Providers Seek Medicaid Reimbursement Hike For Opioid Treatment

Inside Health Policy

July 8, 2021 3:14 pm

Opioid treatment program directors across the country say Medicaid reimbursement in their states isn’t adequate to ensure the highest quality services and some facilities might stop accepting Medicaid if they aren’t paid more — but a representative for Medicaid directors says while most Medicaid providers want more money, OTPs aren’t closing their doors en masse.

Opioid treatment programs (OTPs) are the only settings in the United States where methadone can be distributed to people with opioid use disorder. Other FDA-approved medications for opioid use disorder treatment, buprenorphine and naltrexone, can also be distributed at OTPs.

The SUPPORT Act requires state Medicaid plans to cover medication-assisted treatment (MAT) for all beneficiaries between October 2020 and Sept. 30, 2025. MAT was not a required benefit before the SUPPORT Act, and many states did not previously cover methadone. A CMS spokesperson said CMS may authorize exemptions in the case of a provider shortage. Hawaii, South Dakota, Wyoming, American Samoa, Northern Marianas Islands and Guam are currently exempt from covering MAT under Medicaid.

OTPs are particularly important for treating patients with opioid use disorder, but low Medicaid reimbursement is endemic across addiction medicine, said American Society for Addiction Medicine Chair of Legislative Advocacy Shawn Ryan, president and chief medical officer for a group of OTPs in Ohio.

Some states, like Virginia and Ohio, provide better reimbursement than others, he said. But generally, across the country, “we’re not even close to the gap, right, between population need, and services available, and they’re not going to grow or even be maintained at current level if Medicaid does not look at this very seriously,” Ryan said.

Matt Salo, executive director of the National Association of Medicaid Directors, said essentially every Medicaid provider across the country wants higher reimbursement.

“Literally everybody says that — they don’t go out of business,” Salo said.

Across the country, the number of OTPs increased by 39% between 2003 and 2016, going from 1,067 OTPs to 1,482, according to a Substance Abuse and Mental Health Administration report from 2017. SAMHSA’s website now lists 1,837 OTPs, though numbers vary greatly from state to state.

Medicaid directors describe a tension between ensuring high quality services and increasing provider reimbursement, added Lindsey Browning, program director at NAMD.

“Whenever you see Medicaid, or other payers, sort of opening the door to new services, you sort of see a floodgate of providers come in,” she said. “As a payer and particularly as a public payer, [we’re] wanting to make sure we put the necessary guardrails in place to get the highest quality services.”

But providers say low reimbursement does impact service quality — and in some cases, access to services for Medicaid beneficiaries at all.

Several OTP directors told Inside Health Policy they want and intend to keep treating patients with Medicaid coverage, but low Medicaid reimbursement rates, particularly compared to private insurance or Medicare, are not enough to cover rising costs.

Margaret Rizzo directs an OTP in New Jersey, which did update its rates in 2016 for the first time since 1985, according to Rizzo. But she previously had to cap the amount of Medicaid recipients her clinic could accept.

“We had a waiting list if you had Medicaid to come on to the program, which was devastating,” said Rizzo. “It was a budget buster — we couldn’t afford to treat a patient for $77.50 per month.”

Dave Kneesy, who oversees six OTPs in Florida, said he could easily see a point where Florida clinics stop treating Medicaid beneficiaries.

“We want to take care of as many patients as we can. [But] we got to make a living,” he said.

OTPs that treat large numbers of Medicaid enrollees say their staffing stability suffers. Linda Hurley, president and CEO of Rhode Island’s largest and oldest OTP, said she feels embarrassed to offer low wages to staff, even those with graduate degrees.

With higher Medicaid reimbursement rates, Hurley said she could retain more staff, which in turn would improve the quality of her OTP’s treatment services.

OTP directors say long periods between reimbursement increases provide another hurdle. Kneesy has been treating Medicaid beneficiaries in Florida since 2003, and he’s never seen an increase in reimbursement rates.

There’s no set formula across states for when rates need to be reset, Salo said. If rates for every service were readjusted regularly, he said that’s basically all the state Medicaid agency would do.

However, state Medicaid agencies are still bound by the Medicaid Equal Access Provision and 2015 rules that require states to measure access to a set of Medicaid services for beneficiaries who receive care through a fee-for-service system. The Trump administration proposed to roll back these regulations, but a final rule unwinding them was never released. Mark Parrino, president of OTP trade organization American Association for the Treatment of Opioid Dependence, said he’s not sure how this rule impacts OTPs as MAT didn’t become a required Medicaid benefit until last year, but he’s looking into it. Salo said the rule likely does impact OTPs, though his team isn’t focused on that issue currently.

Typically, though, a crisis like fraud or lack of providers triggers a rate change, as could political pressure from a coordinated group of providers, Salo said.

Some OTP staff are turning their frustration with low and unchanging pay rates into activism. Over the past three and a half years, Hurley has knocked on doors, gone to the statehouse and talked with business leaders and lawmakers to push for higher rates. Kneesy is in the early stages of getting a group of substance abuse and mental health stakeholders together to advocate for better Medicaid rates in Florida.

Self-advocacy was successful for OTPs in New Jersey, Rizzo said. But even with a strong provider network advocating for OTPs, it still took six years for higher rates to go into effect.

Now, it’s been five years since the New Jersey Medicaid rates were raised, and they’re already starting to feel out of date, Rizzo said. But there is talk in New Jersey of aligning the Medicaid rates with Medicare reimbursement rates, a gold standard that many providers say they’d like to see. As of January 2020, Medicare has paid OTPs through a bundled rate. The rate was established in a final rule stemming from the SUPPORT Act. OTPs weren’t recognized as Medicare providers before the final rule.

Allegra Schorr, owner and vice president of an OTP in New York, said she feels there’s a broad lack of understanding about OTPs, which has contributed to allegedly inadequate reimbursement rates. However, she added that New York officials have been quick to respond to OTP needs during the COVID-19 public health emergency and a state plan amendment was recently approved to make an emergency bundled Medicaid rate for MAT permanent.

Jan Kauffman, an OTP director in Massachusetts who’s been working in OTPs since 1973, thinks this lack of understanding is partly due to lack of education and stigma around addiction. Health professional schools need to better incorporate addiction medicine into their core curricula, Kauffman said.

“Until the schools are really training, we’re not going to see stigma diminish,” she said.

There is some evidence the political tide is turning — bipartisan bills to expand addiction medicine education in health professional schools have been introduced in Congress this year.

Ultimately, it comes down to a need to dedicate long-term funding to substance use disorder treatment, Ryan said. He and other policy watchers say this funding should come from Medicare and Medicaid.

President Joe Biden’s fiscal 2022 budget requests $6.6 billion for the Substance Abuse and Mental Health Services Administration’s substance use prevention and treatment programs, and another $2.3 billion for SAMHSA’s State Opioid Response Grants program, among several other requests. But a sustainable treatment model needs to be built around Medicare, Medicaid, commercial payers and other public funding, said Ryan.

Sustainability needs to include Medicaid rate increases for OTPs, said Hurley.