7/26/2016
Behavioral Health Financing, Medicaid and Collaboration In Challenging Times
Mitchell Berger, MPH Office of Policy, Planning, and Innovation, SAMHSA
Today’s Discussion
• A. SAMHSA and Leading Change • B. Health Coverage, Medicaid/CHIP and Behavioral Health • C. SAMHSA Block Grants • D. SAMHSA Response to Public Health Crises: Medication Assisted Treatment (MAT) and Opioids • E. Enhancing Partnerships and Collaboration
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A. SAMSHA Leading Change 2.0 Strategic Plan
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A. Leading Change 2.0
• Six Strategic Initiative areas: Health Care and Health Systems Integration (HCHSI); Prevention; Trauma and Justice; Recovery Support; Health Information Technology; Workforce Development • For HCHSI Goals include fostering integration, providing support to states on Medicare and Medicaid and financing mechanisms, supporting parity, increasing “coverage and access for those in need”
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B. Health Coverage: Reasons for Not Receiving Mental Health Services in the Past Year among Adults Aged 18 or Older with a Perceived Unmet Need for Mental Health Care Who Did Not Receive Mental Health Services, by Mental Illness Status: Percentages, 2014
AMI-any mental illness SMI-serious mental illness Slide 5
B. Health Coverage: Reasons for Not Receiving Illicit Drug Use Treatment or Alcohol Use Treatment among People Aged 12 or Older Who Felt They Needed Treatment: Percentages, 2011 2014 Combined
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B. Background: Health Coverage
• Total coverage: 49% employer based; 19% Medicaid, 13% Medicare, 10% uninsured; 6% non group (e.g., Marketplace); 2% other public. About 32.3 million non elderly (ages 18 64) Americans total lack health insurance. Total US Population: 316 million • Up to 15.9 million of 32.3 million non elderly uninsured eligible for Medicaid and the Marketplaces. Of these, about half eligible for Marketplace (tax credits)(22 percent) or Medicaid/CHIP (28%) • Others ineligible due to immigration status (15 percent), income (12 percent), employer sponsored insurance offer (15 percent) or coverage gap in non expansion states (9 percent) • 2.9 million in coverage gap
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B. ACA insurance coverage
• 20 million uninsured adults have gained health coverage incl. Medicaid and the Marketplace between October 2013 Feb. 2016 (individuals may move between coverage options) • Estimated 8.9 million non elderly white adults, 3 million African Americans, 4 million Hispanics have gained coverage • Uninsured rate drop from 20.3 percent to 11.5 percent as of first quarter 2016 • 2.3 million young adults gain coverage due to provisions allowing adults 19 25 to remain on parent/guardian coverage through age 26 • More than half of uninsured are persons of color, including African Americans (14 percent) and Hispanics (34 percent) • Uninsurance rate declined 18.2 percent to 10.1 percent in Medicaid expansion states; 23.4 to 16.1 percent in non expansion states Slide 8
B. Background: Medicaid
• Medicaid is a Joint State Federal Entitlement program anyone meeting eligibility requirements can enroll • Federal participation/federal medical assistance percentage (FMAP) ranges from 50 percent to 74 percent for each state • 72.5 million total now enrolled in Medicaid and Children’s Health Insurance Program • Children’s Health Insurance Program (CHIP) established 1997, now covers roughly 8.1 million low income children above cut off for Medicaid. 35 million children in Medicaid/CHIP. • About 15 million person increase in enrollment since Oct. 2013 • Increase in enrollment of 35 percent (~12.7 million) in Medicaid expansion states vs. 11 percent (~2 .26 million) in non expansion states
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B. Medicaid Expansion Status Source: NASHP/RWJF
As of May 2016: 19 states are not expanding Medicaid to cover those up to 138% of the Federal Poverty Level; 26 states (including D.C.) are expanding, 6 are using alternative expansion strategies
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B. Medicaid and Behavioral Health
• Represents roughly 30 percent of total mental health spending (est. $179 billion as of 2014) • Represents roughly 25 percent of total substance use disorder spending (est. $31 billion as of 2014) • As many as 20 percent of Medicaid beneficiaries have a behavioral health diagnosis • 3 million children in Medicaid for reasons other than disability and child welfare had a behavioral health diagnosis • Persons with behavioral health diagnoses represent a high portion of Medicaid expenditures (at least 2 3 times higher expenditures than those without such diagnoses); High prevalence of comorbidities such as heart diseases, diabetes, smoking • Role in supportive housing, helping homeless persons • Role of collaborative chronic care approaches, some with peer specialist roles • Carve out managed care models that promote specialization and accountability versus carve in models that promote integrated care • Opportunities at state level to provide input on contracts with MCOs
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B. Background: Medicaid and Mental Health (MH) Spending
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B. Background: Medicaid and Substance Use Disorder (SUD) Spending
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B. Coverage gap Medicaid expansion
•Medicaid expansion may increase access to services •Expansion may help meet mental health/substance abuse needs •Supports rural hospitals and others serving indigent •ASPE/SAMHSA cite study in 2016 brief; “low income adults with serious mental illness are 30% more likely to receive treatment if they have Medicaid coverage.” • SAMHSA estimate of 5.3 million persons with behavioral health disorder (any mental illness or substance use disorder) potentially eligible for Medicaid expansion, more than 2.6 million live in states that have not expanded Medicaid/undecided •Reduced income and racial/ethnicity disparities in coverage •Medicaid expansion can help reduce out of pocket spending for mental health services and other needs •Linked to reduced expenses in criminal justice and disability costs and improved employment productivity Slide 14
B. Opportunities for Impact CMS Regulations
• Medicaid Parity Regulation Medicaid Managed Care, Children’s Health Insurance Program and Alternative Benefit Plans (Final, March 2016) • Medicaid and Children's Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, and Revisions Related to Third Party Liability (Final, May 2016) • Proposed Rule: Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies (Nov. 2015) • Final Rule: Mechanized Claims Processing and Information Retrieval Systems (December 2015): Following ACA, HHS provided additional funds for improved Medicaid eligibility and enrollment systems. Funding will now be extended. • Final Rule with Comment Period: Methods for Assuring Access to Covered Medicaid Services (Nov. 2015): Access Monitoring Review Plans must address key areas: primary care, physician specialists, behavioral health, pre and post natal obstetrics (including labor and delivery), and home health services; input from stakeholders on rate changes and access. • Opportunities: Review Federal Register and Regulations.gov
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B. Mental Health Parity and Addiction Equity Act (2008)
• ASPE estimated ACA will expand parity protection for 30 million with existing coverage for mental health/substance use disorders and provide new protections for 32 million • 2013 Commercial Parity regulation applies to non Federal governmental plans with more than 100 employees, group health plans of private employers with more than 50 employees and individual market health plans • Medicaid Parity Regulation Medicaid Managed Care, Children’s Health Insurance Program and Alternative Benefit Plans (Final March 2016, Proposed April 2015) • Rule estimated by CMS to impact 23 million enrolled in Medicaid managed care, children’s health insurance program and alternative benefit plans • Medicaid parity and commercial plans as closely aligned as feasible • Medical/surgical and MH/SUD services classified in four areas inpatient, outpatient, pharmacy and emergency areas of classification (includes long term care services) • Improve availability of medical necessity criteria • Applies parity to both quantitative limits (e.g., visit limits) and non quantitative treatment limitations(e.g., prior authorization, medical necessity) • Includes examples to improve understanding and compliance • SAMHSA working with stakeholders to identify public and private coverage parity gaps and develop parity outreach materials
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Parity
• White House Mental Health and Substance Use Disorder Parity Task Force report to President due Oct. 2016 • Includes HHS, Labor, Justice, VA, DOD • Listening sessions held April June • Public can provide comments • See http://www.hhs.gov/about/ agencies/advisory committees/parity/
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B. Medicaid Managed Care
• More than 70 percent of Medicaid enrollees now are served by managed care arrangements compared to 8 percent in 1992 • “45.9 million (or 73.5 percent of all Medicaid beneficiaries) accessed part or all of their Medicaid benefits through Medicaid managed care” in FY 2013 • Expansion of Medicaid managed long term services and supports (20 states compared to 8 in 2004) • 4.3 million children enrolled in CHIP (or about 81 percent of all separate CHIP beneficiaries) enrolled in MCOs in FY 2013 • Medicaid and Children's Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, and Revisions Related to Third Party Liability (Proposed June 2015; Final, May 2016) • Promotes delivery reform efforts and reflects Affordable Care Act changes • Notes expansion of Medicaid managed long term services and supports (20 states in 2014 compared to 8 in 2004 • Managed care Medicaid plans now in 41 states • Carve out managed care models that separate behavioral health services versus carve in models • Opportunities at state level to provide input on contracts Slide 18 with managed care
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B. Medicaid Managed Care
• Revised appeal and grievance procedures streamline • Care Coordination role of care coordinators, health risk screening in 90 days for new patients, coordination of care between Medicaid settings and community and social support services • Assurances of Adequate Capacity and Service must certify annually • Network Adequacy standards time and distance standards for Behavioral health (mental health and substance use disorder), adult and pediatric, specialist, hospital, pharmacy, primary care and OBGYN providers • IMD “State may make a monthly capitation payment to an MCO or PIHP for an enrollee aged 21 64 receiving inpatient treatment in an Institution for Mental Diseases[ ]so long as the facility is a hospital providing psychiatric or substance use disorder inpatient care or a sub acute facility providing psychiatric or substance use disorder crisis residential services, and length of stay in the IMD is for a short term stay of no more than 15 days during the period of the monthly capitation payment” • States can support medical homes, HIEs, access • CMS to develop quality rating system for managed care plans • Monitoring and compliance Slide 19
B. Medicaid Policy: Letters to State Medicaid Directors and Informational Bulletins
• Subregulatory guidance from CMS to State Medicaid Directors • Key associations often copied • SAMSHA, HRSA, NIH, CDC and others may be directly involved in development or have input • Ex. 2015, CMS, SAMHSA, NIH, Coverage of Early Intervention Services for First Episode Psychosis in the Medicaid program • 2015, CMS, New Service Delivery Opportunities for Individuals with a Substance Use Disorder (1115 waiver) • 2015, SAMHSA CMS, Coverage of Behavioral Health Services for Youth with Substance Use • 2014, CMS, NIH, CDC, SAMSHA, Medication Assisted Treatment for Substance Use Disorders • Opportunities: Look at these letters and can use for discussion with Medicaid, state mental health agency, etc. Slide 20
B. Medicare
• 55 million beneficiaries (16 percent of population) • Includes over 65, disabled and those with end stage renal disease • Uninsurance rate for those over 65 is roughly 2 percent; in 1963 was 48 percent • No current parity regulations; Does not cover long term care • Covers inpatient, outpatient mental health services, home health, substance use treatment • 190 life time limit on inpatient hospitalization in psychiatric hospitals (Change proposed in Proposed FY 2017 budget) • 26 percent of beneficiaries in general and 37 percent of disabled beneficiaries may have mental health condition • 2008 law increased reimbursement for outpatient mental health services so similar to other conditions Slide 21
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B. Medicaid 1115 Waivers
• Demonstration Waivers Innovative efforts to expand eligibility, cover services not typically covered by Medicaid, enhance delivery system. States can receive matching federal funds for approved waivers • HHS can waive many Medicaid requirements but must (in HHS’ view) enhance Medicaid program objectives • As part of waivers, states may be able to save money and reinvest savings in other coverage and delivery efforts • Can be broad or target certain populations • States can receive matching federal funds but overall must be budget neutral to federal government • Approved for initial time period and renewable • 5 states studied by GAO (CA, MA, NY, VT, OR) operated 150 separate programs under 1115 waivers • Ex. Telemedicine demonstration (NY), supported employment (OR), workforce training and recruitment (NY, CA), state funded Medicaid community mental health rehabilitation (VT) Slide 22
B. Medicaid 1115 waivers and Health Coverage
• As of May 2016, 6 states have approved 1115 waivers for Medicaid expansion type programs: Arkansas, Iowa, Indiana, Michigan, New Hampshire, Montana. • Others in process/transitioning or discussing such approaches include Kentucky, Arizona, Ohio, Louisiana • May include Healthy Savings Accounts, monthly enrollment fees or cost sharing for those above 100 percent federal poverty level and, in some cases, 50 100% of poverty level • May be penalties/disenrollment for nonpayment of fees • Some include healthy behavior incentives (Ex. Health risk assessments, reduction of premium for meeting goals) • Premium assistance: Ark., MI and NH use Medicaid funds to pay premiums for Marketplace plans; Iowa and Indiana provide premium assistance to those receiving employer sponsored insurance • Proposals to link insurance to work requirements/job searches But Indiana and PA do use state funds to foster employment Slide 23
B. Section 1332 State Innovation Waivers
• Some approaches under 1115 or which CMS in past rejected may be eligible in 2017 for 1332 waivers • Under 1332, HHS may waive provisions of ACA in state applying to: Qualified health plans and Marketplaces; tax credits/cost sharing subsidies; Individual and employer shared responsibility payments (mandates) • Ex. Could have late enrollment penalty instead of individual mandate; use private Marketplace(s) instead of state/federal Marketplace, allow additional persons to purchase coverage • Cannot waive nondiscrimination, no lifetime/annual limits, preexisting condition requirements • Coordinate 1332 process with current 1115 waivers • Several states reported to have interest (e.g., VT, CA, HI, CO) • Some states using 1115 for Medicaid expansion could consider
as well Slide 24
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B. Section 1332 State Innovation Waivers
• State waiver must show state plan: • Will cover the same number of persons as without waiver (i.e., under ACA Title 1/Marketplaces)(Comprehensive coverage) • Same minimum benefits (Scope of coverage) • Equivalent affordability of coverage and protections against out of pocket expenses • Won’t increase federal deficit (deficit neutrality) • State must as part of application show process for obtaining public input, including public hearings, and budget info • Monitoring, compliance and reporting requirements
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B. Section 1332 State Innovation Waivers
• Coverage refers to minimum essential coverage • Minimum essential coverage Includes Marketplace plans, employer sponsored coverage, Medicaid, Medicare Part A and B, Tricare • Comparable refers not just to overall number but also impact on minority and vulnerable populations such as low income, elderly, persons with serious health conditions • Also must ensure there are not more gaps or discontinuities in coverage • Waiver application must include modeling and demographics Slide 26
B. Section 1332 State Innovation Waivers
• Affordability “state residents' ability to pay for health care and may generally be measured by comparing residents' net out of pocket spending for health coverage and services to their incomes.” • CMS will consider affordability on average and how waiver will impact spending relative to their income • Will consider impact on vulnerable populations such as elderly, low income, those with serious health issues • Must have similar protections against excessive cost sharing • Need supporting data and modeling Slide 27
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B. Section 1332 State Innovation Waivers
• Comprehensiveness “scope of benefits provided by the coverage as measured by the extent to which coverage meets the requirements for essential health benefits (EHBs)” in Marketplace or Medicaid • “[E]valuated by comparing coverage under the waiver to the state's EHB benchmark, selected by the state (or if the state does not select a benchmark, the default base benchmark plan)” • Under waiver scope number of residents with coverage must be as comprehensive in all 10 EHB categories as without the waiver • CMS will evaluate impact on low income, elderly, chronically ill and other vulnerable persons • Must have analysis and modeling data
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B. Section 1332 State Innovation Waivers
• Deficit Neutrality “the projected Federal spending net of Federal revenues under the State Innovation Waiver must be equal to or lower than projected Federal spending net of Federal revenues in the absence of the waiver.” • Estimated effect includes assessment of taxes and other revenue under waiver versus without waiver • Applies both to 5 year period of initial waiver and 10 year budget plan required to be submitted as part of waiver • Appear to be similar to budget neutrality requirement applying to 1115 waivers • Funding: States will receive “the aggregate amount of tax credits or cost sharing reductions that would have been paid had the State not received a waiver” • Determined by HHS and Treasury based on experience of other states participating in Marketplace and tax credits and cost sharing reductions provided in those states Slide 29
B. Section 1332 State Innovation Waivers
• State must as part of application show: • Process for obtaining public input, including public hearings • Application detailing provisions state seeks to waive and plans of state to ensure compliance with requirements • Budget projections and economic analysis • Actuarial analysis and certifications • 10 year budget plan • Impact data and demographic information • Enacted state legislation authorizing waiver
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B. 1332 Innovation Waivers
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B. Health Homes
• As of May 2016, 21 states and District of Columbia have developed 30 models. Some cover SMI/SUD. • Total of roughly 1.3 million enrolled patients
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B. Health Homes
• Intended to coordinate care and treat whole person • Target populations: 2 or more chronic conditions; one chronic condition and are at risk for a second; one serious and persistent mental health condition • Chronic condition may include mental health, substance use, asthma, obesity, heart disease. Others such as HIV/AIDS may be considered by CMS. • Can be geographically limited (e.g., certain counties) • Must include adults and children • CMS is requiring states to consult with SAMHSA as part of CMS review of health home proposals
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B. Health Homes
• Services: Comprehensive care management, Care coordination, Health promotion, Comprehensive transitional care/follow up, Patient & family support, Referral to community & social support services, Health information technology • Funding: 90% enhanced Federal Medical Assistance Percentage (FMAP) for the specific health home services above for 1 st eight quarters • Example: Missouri Primary Care Health Homes; Missouri Community Mental Health Center Health Homes • Health homes supporting other efforts such as State Innovation Models, Medicaid expansion, primary care medical homes outside Medicaid, integration models • Medical neighborhoods with health/medical homes as ‘hubs’
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B. CMS Innovation Models
• CMS Innovation Center founded as part of Affordable Care Act • Supports broad delivery reform in both Medicare and Medicaid • SAMHSA and CMS often discuss how these various models can/should apply to behavioral health. Also an important state/local discussion • Examples of innovative programs: Accountable Care Organizations(ACOs); Primary Care Transformation; Health Care Innovation, Medicaid Emergency Psychiatric Demonstration, Innovation Accelerator Program, Medicare Advantage Value Based Design, Health Care Payment and Learning Action Network, State Innovation Models; Financial Alignment Initiative for Medicare Medicaid Enrollees, Bundled Payments for Care Improvement/episode based payments • Opportunity: Encourage state participation or speak to participating states, use CMS resources online Slide 35
B. Innovation Accelerator Program (IAP)
• Current focus areas include beneficiaries with complex needs (‘super utilizers’), Substance use disorders, physical and mental health integration, long term services and supports • Ex. Physical Mental Health Integration IAP may focus on comorbidities, workforce, use of different settings (FQHCs, schools, community mental health centers), focus on different populations, different models • Provides technical assistance to selected states focusing on such issues as data analytics, quality measures, best practices, new models, innovation • Fits with State Innovation Models
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B. State Innovation Models
• Supports “development and testing of state led, multi payer health care payment and service delivery models” to improve care and efficiency • Two rounds with nearly $1 billion in funding • 34 model design test states (and DC and 3 Territories) and 18 model test states • Ex. Colorado received support for Colorado Framework which includes “integrated primary care and behavioral health services in coordinated community systems” • Ex. New York developing Advanced Primary Care model including value based care, health information tech, behavioral health
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B. Dual eligibles/Financial Alignment
• Roughly 10.7 million dual Medicare Medicaid eligibles as of 2015; More than 40 percent have a mental health diagnosis • 14 percent of enrollees in Medicaid but account for 35 percent of spending; 65 percent of spending for Medicaid long term services and supports • Efforts to coordinate care include CMS Financial Alignment Demonstration and similar state efforts. • Financial alignment of Medicare Medicaid • Demo includes capitated (ex. CA, MI) and fee for service (CO, WA) • Focus areas include care coordination (long term care, behavioral), value based payment, supporting individuals in community (e.g., housing, physical/mental health integration, partnerships, care transitions)
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B. SAMHSA Section 223 Demonstration Program
• 2014 Protecting Access to Medicare Act (PAMA) SAMHSA may support certified community behavioral health clinics • Goal to “support high quality and evidence based practices” through prospective payment system (PPS) • SAMSHA partnering with CMS, ASPE • SAMHSA has issued one year planning grants to 24 states. • These states may apply in Oct. 2016 to be among 8 states eligible for two year demo program in which certified clinics will be eligible for Medicaid funding through PPS. Begins in 2017. • June 2016 SAMHSA and CMS release quality measures tools • Reimbursement equivalent to enhanced federal match in Medicaid CHIP program (65 82%) • Focus on integrated care, primary care, quality, disparities • Must partner with health centers, hospitals, housing, education, Veteran services Slide 39
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B. SAMHSA Health Coverage Resources
• SAMHSA has published National and State of the Prevalence of Behavioral Health Conditions Among the Uninsured Estimates and Behavioral Health Needs Assessment Toolkit (2013) that estimate numbers of persons with behavioral health conditions eligible for Marketplaces and Medicaid (See also July 2015 GAO Report) • Medicaid Handbook: Interface with Behavioral Health Services • Financing Focus newsletter (monthly) • SAMHSA Spending Estimates/Health Financing • SAMHSA HRSA Center for Integrated Health Solutions • SAMHSA supported BHbusiness Plus education of providers about third party billing, enrollment and HIT • Benefits of Medicaid Expansion for Behavioral Health (ASPE/SAMHSA)
• Statistical briefs Slide 40
C. SAMHSA Block Grants
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C. SAMHSA Block Grants
• SAMHSA Leading Change 2.0 Strategic Initiatives include health care and health systems integration, prevention, health info technology, workforce, prevention and recovery • One Goal: “Improve behavioral health outcomes for individuals served by the Mental Health and Substance Abuse Block Grants.” (Integration) • Substance Abuse Prevention and Treatment Block Grant (SABG) and Community Mental Health Services Block Grant (MHBG) programs provide funds and technical assistance to all 50 states, DC, Puerto Rico, the U.S. Virgin Islands, 6 Pacific jurisdictions, and (SABG only) 1 tribal entity • Block Grant funding: $2.140 billion (SABG); $482.57 million (MHBG); Total SAMHSA: $3.4 billion
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C. Block Grant Application
• Block Grant application redesigned to reflect pending impact of ACA and health integration • Now includes both substance use and mental health programs • Advises leveraging Block Grant funds with other funding • Block Grant funds should “support, not supplant, individuals and services that will be covered through the Marketplaces and Medicaid” • Ensure providers enrolled in Medicaid, ensure Marketplace and Medicaid plans include essential health benefits; ensure individuals aware of covered MH/SUD services • Medicaid, commercial health plans and parity • Cites CMS Federal Policy Guidance/letters • Delivery system: Accountable Care Organizations, health homes, waivers/demonstration projects, Health Homes and Medical Homes Slide 43
C. 2014 SAMHSA Block Grant Study
• Included consideration of NASMHPD/NRI survey; review of Block Grant applications and materials; discussions with states • States changing use of Block Grant funds due to ACA. ~28 40 percent of MHBG funds and 19 27 percent SABG funds used for services private plans and Medicaid may cover post ACA • States focusing funds on those who still need support even with Medicaid and Marketplaces (ex.’churning,’ immigrants, those with high deductible plans) • States are funding services that may not be paid for by Medicaid or private coverage • States are focusing on evidence based programs such as supported education/employment, housing and prevention. • States use Block Grants to support vulnerable populations • Both SABG and MHBG have safety net role
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C. Opportunity: Leverage the Block Grants
• Block Grant funds can complement ACA and Medicaid • Use for services not typically funded by Medicaid • Partnership between Block Grants and SAMHSA funded discretionary grant programs • Collaboration with other state agencies • Synergy between MHBG and SABG • Integrated Planning/Advisory Councils and integration among state programs • Opportunity: Talk with state agency partners about Block Grant
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D. SAMHSA Response to Public Health Crises: Medication Assisted Treatment (MAT) and Opioids
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D. MAT and Opioids
CDC: Drug overdose deaths involving opioids, by type of opioid — United States, 2000–2014
Source: National Vital Statistics System, Mortality file.; CDC MMWR, Jan. 1, 2016, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm
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D. MAT and Opioids
• Medicaid Coverage and Financing of Medications to Treat Alcohol and Opioid Use Disorders, SAMHSA, 2014 • MAT medications for alcoholism approved by FDA include Disulfiram; Naltrexone (oral) Naltrexone extended release (injectable); Acamprosate • For opioids, include Naltrexone (oral); Naltrexone extended release (injectable); Buprenorphine; Buprenorphine Naloxone; Methadone • All Medicaid programs as of 2013 listed Disulfiram and oral Naltrexone on Preferred Drug Lists. Most (50) listed Buprenorphine Naloxone • Only 30 31 listed Acamprosate, extended release Naloxone, Methadone • Only 13 states listed all FDA approved medications • 48 states required prior authorization for Buprenorphine Naloxone • Many states required behavioral therapy documentation for Methadone, extended release Naloxone, Buprenorphine Naloxone. Many states impose quantity limits for Buprenorphine Naloxone • A handful of states (6) had step therapy requirements for extended release Naloxone and 11 had some sort of lifetime limit for Buprenorphine treatment time (e.g., 1 3 years) • Identifies innovative state approaches VT, MD, MA
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D. Background: MAT and Opioids
• 2017 Medicare Part D call letter/advance notice: CMS has required overdose utilization controls and monitoring for acetaminophen and opioids for Part D plans • Reports 47 percent decrease (13753 fewer Part D beneficiaries) identified as “potential opioid overutilizers” 2011 2015 • Efforts (edits) at point of sale to help prevent opioid overutilization; opioid overutilization measures under development; concurrent use of opioids and buprenorphine; opioids and benzodiazepines • Refers to CDC Guideline for Prescribing Opioids for Chronic Pain • Clarifies that Medicare Advantage plans “have the same obligation to cover substance use disorder treatment” as Original Medicare • Part D plans “Currently only buprenorphine, buprenorphine/naloxone, and naltrexone are covered Part D drugs when used for medication assisted treatment (MAT) of opioid use disorder. It is critical that Medicare beneficiaries who are in need of these therapies have appropriate access to these drugs in Part D.” • CMS will monitor tiering and priorSlide authorization49
D. MAT and Opioids
• Jan. 2016 CMS Informational Bulletin for Medicaid, Best Practices for Addressing Prescription Opioid Overdoses, Misuse and Addiction • Medicaid beneficiaries impacted by opioid abuse and misuse prescribed painkillers more than twice as much as non Medicaid beneficiaries; Three to six times more likely to overdose on Rx painkillers • States advised to consider for opioids use of prescription drug monitoring programs, utilization review, use of such strategies as tiering, step therapy and prior authorization, quantity limits • States should educate providers • Increase naloxone (Narcan) use for overdoses by including on preferred drug lists and distributing in community • Access to MAT points to Innovation Accelerator Program (substance use disorders). Barriers to MAT such as use of prior authorization or total lifetime limits on Buprenorphine Naloxone in some states
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D. MAT and Opioids
• HHS efforts announced in March 2015 include expanding use of naloxone, training and education including prescriber guidelines, expanding use of medication assisted treatment • CDC supports Prescription Drug Overdose Prevention for States grant program to strengthen prescription drug monitoring programs; developing Guideline for Prescribing Opioids for Chronic Pain • FDA supporting labeling changes (e.g., warnings, safety), abuse deterrent opioids • HRSA provides $94 million to 271 community health centers • Numerous state and local efforts such as prevention efforts, prescribing guidelines, education and outreach, naloxone access, targeted interventions for those at high risk, law enforcement training, statewide task forces • Syringe Services Programs (SSPs): As of May 2015, 228 such programs in 35 states, territories and Indian nations • Consolidated Appropriations Act, 2016 modifies the restriction on use of federal funds for programs distributing sterile needles or syringes for HHS programs. • Funds may be used to support new and existing SSP programs; Funds may be used to support SSP personnel, supplies, testing kits, syringe disposal services, navigation services to link the programs to HIV and hepatitis prevention and treatment services • Funds may not be used to purchase sterile needles or syringes • Overall guidance issued by HHS and targeted guidances by CDC, HRSA and SAMHSA • SAMHSA Block Grants and Minority AIDS Initiative funds Slide 51
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D. MAT and Opioids
• Financing publications with MAT focus; Clinical and education publications (ex. Medication for the Treatment of Alcohol Use Disorder: A Brief Guide – 2015, Opioid Overdose Toolkit: Safety Advice for Patients and Family Members – 2014, Treatment Improvement Protocols, journal articles; opioid use disorder and alcohol use disorder pocket guides); treatment locators • Providers’ Clinical Support System for MAT (http://pcssmat.org/) • 2014 Buprenorphine Summit hosted by SAMHSA, other stakeholder outreach • SAMHSA Targeted Capacity Expansion: Medication Assisted Treatment Prescription Drug Opioid Addiction (MAT PDOA) Grant • SAMHSA oversees opioid treatment programs certification and accreditation process; SAMHSA implements Drug Addiction Treatment Act of 2000 (DATA 2000), which allows certified physicians to prescribe Buprenorphine • SAMHSA issued final rule to allow qualified practitioners who prescribe buprenorphine under a waiver to treat up to 275 patients (up from 100) • SAMHSA Grants to Prevent Prescription Drug/Opioid Overdose Related Deaths; Grants for Electronic Health Record (EHR) and Prescription Drug Monitoring Program (PDMP) Data Integration (7 states)
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E. Opportunity: Partnerships and Engagement in the Broader Public Health System
Civic groups Schools Nursing EMS Neighborhood Homes Community Organizations Nonprofit Centers Organizations
Hospitals Home Health Drug Public Laboratories Health Doctors Treatment Agency Mental Health Law Faith Institutions Enforcement Fire Health Tribal Transit Center Entities Employers Elected Officials Corrections Source: Public Health Practice Program Office, Centers for Disease Control and Prevention , National Public Health Performance Standards Program, User Guide (first edition), 2002. (Current version available at www.cdc.gov/nphpsp )
E. Partner with other entities Ex. Nonprofit Hospitals
• Affordable Care Act, enforced by IRS, now requires nonprofit hospitals to work with public health agencies and others to conduct community health needs assessments (CHNAs) • Must adopt an implementation strategy to address health needs • Must do the assessments every 3 years • Should include consideration of low income/minority populations • May include financial and other barriers to care • Plans must be publicly available • Hospitals can jointly perform their CHNA with other hospitals • Hospitals have flexibility to define their community and identify health needs
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E. Partnerships Local Health Coverage/Safety Net Efforts
• Montgomery Cares (MD) • Hillsborough County (FL) • Healthy San Francisco • My Health LA and other California programs • Fill gaps not full coverage/insurance but may assist those not eligible for Marketplace/Medicaid • Often include network of clinics and volunteer/paid providers • May link to other services • Funded through mix of local, nonprofit, federal, state sources
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Questions/Comments
• Mitchell Berger, Public Health Advisor Office of Policy, Planning, and Innovation, SAMHSA • 240 276 1757 • [email protected]
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