Meryl Schulman, MPH

June 11, 2018

Across the US, it is nearly impossible to open a newspaper and not find an article about the opioid epidemic. Its impact is ubiquitous — families, communities, and states all feel its effect. Opioids, however, are not the only addictive substance impacting Americans. While the rate of overdose deaths related to opioid pain relievers and heroin increased by 200 percent from 2000-2014, excessive alcohol use continues to be a leading cause of preventable death. A clear gap in treatment remains for people with any substance use disorder (SUD) — drug or alcohol — with only one in 10 ever receiving specialty treatment.

To address this treatment gap, a comprehensive approach including primary care is needed. As the foundation of the health care system, primary care plays an important role in screening and treating SUDs. Furthermore, primary care is uniquely positioned to address comorbidities (e.g., lung disease, hepatitis C, and cardiovascular disease) that are common among people with SUDs. While SUD and physical health services have historically been siloed, recent efforts support opportunities for states, health plans, and providers to integrate care. The Affordable Care Act (ACA), for example, requires most health plans to cover 10 essential health benefits, including SUD services and mental health treatments. The ACA also gives states the authority to create health homes to coordinate care for Medicaid beneficiaries with multiple chronic conditions, including SUDs and mental illness.

Value-Based Payment Levers to Support SUD Screening and Treatment

In addition to the above reforms, payers have a variety of levers that can be used to encourage the integration of SUD screening and treatment in primary care settings. Value-based payment (VBP) is already being adopted by states and health plans to improve health care quality and reduce costs, although most commonly for physical health conditions. While not exclusive to primary care, a recent Health Affairs blog post underscored the importance of VBP as part of broad strategy to address the opioid epidemic. More recently, a new brief, Exploring Value-Based Payment to Encourage Substance Use Disorder Treatment in Primary Care, developed by CHCS and the Technical Assistance Collaborative and supported by the Melville Charitable Trust, explores how states and health plans are using financial levers to encourage SUD treatment in primary care. Examples include:

  1. Using incentive payments to encourage primary care providers (PCPs) to become eligible to prescribe SUD medications. For example, Partnership HealthPlan of California, a Medi-Cal (Medicaid) managed care organization (MCO), implemented a one-time $500 incentive payment for PCPs who become waivered to prescribe buprenorphine. Similarly, Central California Alliance for Health (CCAH) offers newly waivered physicians and mid-level providers a $1,000 bonus payment to help grow its network’s capacity to manage patients’ SUDs with maintenance medications.
  2. Providing enhanced payments to support increased care coordination and care management of patients with SUDs. For example, CCAH allows PCPs, as well as physician assistants and nurse practitioners working under them, to bill on a fee-for-service basis for initial and follow-up consultative evaluation and management services when providing medication-assisted treatment (MAT) to members with opioid use disorder (OUD) or those on high doses of opiate medications for chronic, non-cancer pain management. These payments are in addition to the capitated rates that CCAH’s contracted providers receive. Similarly, through Virginia’s Addiction and Recovery Treatment Services program, the state’s Medicaid program offers enhanced payments to select providers (including PCPs) working with individuals with OUD receiving MAT. The state recognizes that traditional payment rates can be insufficient when it comes to providing comprehensive SUD treatment in primary care.
  3. Implementing pay-for-performance arrangements to encourage and monitor SUD services in primary care. UPMC For You, a Medicaid MCO in Pennsylvania, uses a pay-for-performance model for PCPs who are prescribing SUD medications and who meet specific quality measures. In addition, Partnership HealthPlan in Northern California rewards PCPs who perform an average of at least one urine toxicology screen annually for patients prescribed opioids for 90 days or more. This allows providers to track whether or not patients are taking pain medications as prescribed and to see if they are using any illegal substances. The Oregon Health Authority uses incentive and challenge pools to encourage its Coordinated Care Organizations to meet key target measures, like alcohol or drug misuse screenings.
  4. Exploring more advanced risk-based VBP arrangements to support SUD. Geisinger Health Plan is using a retrospective bundled payment for select providers, including PCPs, who are treating patients with buprenorphine or Vivitrol (naltrexone). While the plan currently does not tie payment to quality, it is exploring this option. New York State is committed to tying 80 percent of payments to value by the end of its Delivery System Reform Incentive Payment program waiver period. To help meet these requirements, Community Health Independent Practice Association is piloting an integrated primary care bundled payment that holds providers accountable for 14 physical and behavioral health conditions, including SUDs. Similarly, Maimonides Medical Center and Mount Sinai Health Partners are participating in a two-year pilot of the payment model, Total Care for Special Needs Populations. In these pilots, providers assume responsibility for the total cost of care of individuals with serious mental illness and/or SUDs. Given that spending for Medicaid beneficiaries with a behavioral health diagnosis—including those with SUDs—is nearly four times higher than for those without, providers in this pilot have a strong business case to better manage care and comorbidities for this population.

An Evolving VBP Strategy to Address SUDs in Primary Care

As is evident from the above examples, many states and health plans have already adopted innovative payment approaches to build provider and network capacity to address SUDs in primary care. Others, however, are in the early stages of developing more sophisticated VBP arrangements to support SUD treatment. Moving forward, health plans and providers will have the opportunity to build on this work with the release of a new alternative payment model, Patient-Centered Opioid Addiction Treatment (P-COAT). Created by the American Medical Association and the American Society of Addiction Medicine to improve access to medications for treating OUD through appropriate financial support, P-COAT allows office-based opioid treatment providers offering MAT using buprenorphine or naltrexone to receive separate bundled payments for the initiation and ongoing maintenance of MAT. Given this momentum, as well as the Centers for Medicare & Medicaid Services’ interest in payment models for SUD and opioid use, it is likely that VBP arrangements for SUD in primary care will continue to be explored.

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Heidi Gustafson

Do these incentives create room for authentic peer recovery supports? If incentives are attached to success I would hope that funding be available to contract for these services thru existing Recovery Community Organizations. They are evidence based services and greatly increase successful outcomes by increasing life achievements and abstinence.

Meryl Schulman, CHCS

Great question. Our environmental scan specifically focused on how value-based payment arrangements can be used to encourage SUD treatment in primary care settings. Therefore, we did not look at models that target community-based supports. However, we agree that community-based recovery supports and peer-led services in particular are critical resources for many individuals. Please stay tuned for new CHCS resources on this topic in the near future.

Marie Verna

Great ideas coming from the states. I’m happy to know that “integration” of behavioral and physical healthcare involves not only treatment, research and workforce development, but also redesigned payment systems. Let’s make sure we get the outcomes right when defining value. There’s only way to do that: Ask consumers what’s valuable to them.

Lyn Farr

Seems like a great move. Don’t forget youth as you address the issue.