There are big changes coming up for opioid treatment programs (OTPs) and other substance use disorder (SUD) programs in New York State. Starting next year, the longstanding fee-for-service Medicaid reimbursement system will be replaced by managed care; also starting next year, new insurance legislation to protect SUD patients is expected to be enacted.
Henry Bartlett, executive director of the Committee of Methadone Program Administrators (COMPA) of New York State, the trade association of OTPs, is in a position to know more than most observers about the plans for Medicaid managed care, private insurance, and OTPs.
Of one thing he is sure: OTPs will definitely be covered by Medicaid. Whether and how they will be covered by private insurance plans, either in the subsidized marketplace plans or other commercial plans, is unclear. But managed Medicaid, which is run by private companies but paid for by the state, will cover OTPs.
But the change from fee-for-service, in which OTPs are paid for what they provide, to managed care, in which an insurance company may restrict care in certain cases, raises questions. Although COMPA has advocated against onerous utilization review, in which the OTP has to continually justify a patient’s stay in treatment, there is “no guarantee” that this won’t happen, said Mr. Bartlett. COMPA has also advocated against any time limits in treatment.
Working closely with the New York State Office of Alcohol and Substance Abuse Services (OASAS), COMPA is trying to make sure the transition is as smooth as possible for OTPs and their patients. “We were asked by OASAS, how we should be measured in the world of managed care,” said Mr. Bartlett. “COMPA spent a lot of time hashing that out, and we developed a paper that we sent to OASAS that includes our statement of principles and how we think OTPs should be looked at.” In particular, COMPA stressed that care should be individualized. Furthermore, measurement of success should be based on reducing or eliminating the use of opioids, not other drugs. “We should focus on reducing secondary drug use only when that use becomes problematic to the patient or when it creates dysfunction,” he said. “In other words, OTPs should not be penalized if patients are using marijuana or other secondary drugs if that use is not problematic.”
The response from OASAS to COMPA has been positive. “They said they would use our paper when they work with DOH [the Department of Health] to develop contracts with managed care.” Mr. Bartlett is optimistic that the contracts will end up reflecting COMPA’s suggestions. “But until I see the written contracts, I won’t know for sure.”
New York will continue to be a state that is generous with Medicaid in terms of SUD treatment. “But things are going to change under managed care, because they will require additional authorizations,” he said. Asked whether this will affect patients, Mr. Bartlett said that “if OTPs have burdensome reporting requirements imposed on them, or burdensome reauthorization requirements, it will cost money. Money spent on administrative requirements is not available to be spent on direct patient care. Ironically that could end up negatively impacting both the quantity and quality of patient care,” he said.
The Private Sector
How OTPs will be treated by non-Medicaid health plans is another question. In the past, most have simply refused to consider paying for medication-assisted treatment (MAT) in OTPs. But under the Affordable Care Act and the Mental Health Parity and Addiction Equity Act, it’s not so clear that they can do so. There are many people with health insurance who could benefit from MAT but would have to pay for it out of pocket.
COMPA is working with the Albany-based New York Health Plan Association (HPA), which represents all insurance plans in the state. The president and CEO, Paul F. Macielak, is learning about OTPs, which are a very unusual kind of provider to the mainstream world of health insurance. COMPA has told them what OTPs are, the regulatory basis for their existence, and why it is so hard to obtain methadone outside of an OTP.
But this is not without challenges. A number of drug-free programs are also going to Mr. Macielak saying that health plans should be sending people with opioid addiction to them. In the end, insurance companies are going to be evaluating treatment options based on outcomes.
“They don’t want bad outcomes,” said Mr. Bartlett of insurance companies and health plans. Patients who are sent to drug-free treatment and relapse are the most expensive ones. These patients “show up in emergency rooms, in hospitals, and that’s what insurance companies care about,” he said. OTP patients, on the other hand, are treated effectively so that they have fewer long-term—and costly—medical problems.
It’s virtually impossible to find out what plans cover OTPs, as this is generally set up plan-by-plan.
That’s where two new bills recently agreed to by Gov. Andrew M. Cuomo and the legislature come in. Under these bills, announced on June 18, insurance companies will have to utilize an assessment tool that is approved by the Office of Alcoholism and Substance Abuse Services (OASAS). In another provision, insurance company staff who decide what level of care a patient should have must be experienced in SUD treatment.
In addition, if an insurance company does not approve a certain treatment, another bill will require that the insurance company pay the provider as long as there is an appeal in process. That means that a new patient in crisis will still have treatment paid for, at least until the appeal is upheld.
But this insurance legislation originally didn’t look good for OTPs. Initially, the bill said that insurance companies are required to pay for any level of care approved by an addiction professional. This was troublesome, because it meant that a professional whose philosophy was opposed to MAT could say the patient needed drug-free treatment.
“I went to the legislature and said, ‘Do you know what you’re on the verge of passing here? A CASAC who works for a drug-free program can bind an insurance company to a level of care even if the evidence does not show that the level of care is appropriate for a specific patient.’” (CASACs are Credentialed Alcoholism and Substance Abuse Counselors.) That shouldn’t be the measure used by insurance companies, who instead should be required to use an independent instrument, said Mr. Bartlett. Ultimately, that is what the bill—which still has not been signed—says.
And COMPA ended up getting help from, of all people, the health plans. The health plan administrators (HPAs), of course, didn’t want any legislation. “Some insurance companies were being unreasonable by requiring patients to fail first at one level of care before authorizing another level of care,” said Mr. Bartlett. “But the other side was being just as unreasonable by saying any “addiction professional” could make a level of care determination which would trump the insurance company.”
The “middle ground” is one that is being followed now—an independent tool that is evidence based. I’m guessing HPA views this as the lesser of two evils,” Bartlett said. “Being required to pay for all treatment recommended by any addiction professional would be far worse, by their reckoning, than being required to abide by an independent tool.”
Meanwhile, Allegra Schorr, president of COMPA and vice president of the West Midtown Medical Group in New York City, sent out an e-mail to the COMPA board saying that OTPs in New York should be proud of themselves for getting this changed.
Under the previous wording, “a CASAC-T with no understanding of addiction medicine could conclude that a chronic long-term opiate addict with multiple, failed attempts at drug-free treatment should once again be treated in a drug-free residential setting and the insurance company would have had to pay for that level of care,” Ms. Schorr wrote. “We believe such language would have been very disadvantageous for OTPs.” (CASAC-T is an advanced certification requiring additional education in areas such as psychopharmacology, alcohol, and drugs.)
COMPA deserves the credit for getting this language changed, said Ms. Schorr, noting that the language used by OASAS in announcing the plan states that insurers will be required “to use recognized, evidence-based and peer-reviewed clinical review criteria, approved by the State Office of Alcoholism and Substance Abuse (OASAS), when making decisions regarding the medical necessity of treatment.” This language is “virtually identical to what COMPA proposed,” she said. “This is no small victory, and it’s the kind of thing that we don’t much trumpet. We shouldn’t forget that without COMPA’s efforts in this and countless other areas, the landscape in which we operate would be far more hostile.”
There are about 120 OTPs and 40,000 OTP patients in New York.
COMPA’s recommendations that were sent to OASAS are available online at: http://staging3.atforum.com/documents/COMPASuggestionsManagedCareContracts.pdf