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Will new payment model for treating opioid abuse help meet demand for treatment?

The American Medical Association and the American Society of Addiction Medicine on Monday advocated for a new way to reimburse physicians who treat patients for opioid use disorder, hoping it will help meet the increasing demand for medication-assisted therapies.

The new alternative payment model, called Patient-Centered Opioid Addiction Treatment, would give providers an initial, one-time payment to cover the costs associated with evaluating, diagnosing and planning treatment for a patient, as well as a month of outpatient medication-assisted treatment.

After the initial payment, subsequent reimbursement would come in the form of monthly "maintenance" payments to cover the cost of providing ongoing outpatient medication-assisted treatment, psychological care and social services.


"Medication-assisted treatment is an evidence-based treatment for opioid use disorder, certainly there is no one-size-fit-all approach, but this is an important therapy," said Dr. Patricia Harris, chair of the AMA's Opioid Task Force. "Unfortunately, there are many barriers to patients who need this treatment and having access to this treatment."

More than 63,000 Americans died from opioid addiction-related causes in 2016 alone.

Harris said current provider reimbursement and payment is a major barrier to patients accessing medication-assisted treatment.

In 2016, the Substance Abuse and Mental Health Services Administration started allowing clinicians to treat up to 275 patients with buprenorphine, up from the prior limit of 100 such patients at a time. President Barack Obama that year signed the Comprehensive Addiction and Recovery Act, which allowed nurse practitioners and physician assistants to seek a federal waiver to allow them to prescribe buprenorphine to up to 30 patients a year.

Currently, more than 48,000 clinicians in the U.S. are certified to prescribe buprenorphine, according to SAMHSA, with the vast majority (72%) authorized to prescribe the medication to as many as 30 patients. According to those figures, if all buprenorphine prescribers recognized by the agency were to administer the drug to the maximum number of patients they are allowed, the maximum number of people allowed to get treatment would be just more than 3.1 million. By contrast, about 20.4 million adults needed substance use treatment at some time in 2014, according to SAMHSA.

Clinicians have steered clear of buprenorphine certification or have limited the number of patients they treat due to insufficient reimbursement rates, insurers' prior authorization treatment requirements, limited telemedicine reimbursement, separate billing for medical and behavioral services, and limited payment for non-medical services like transportation.

"The current physician reimbursement structure does not account for all the services that patients with an opioid use disorder need to progress to successful treatment and recovery," said Dr. Shawn Ryan, chair of the AMA-ASAM Alternative Payment Model Working Group, in a written statement. "While we know that a combination of medication and psychosocial support systems is the evidence-based standard for treatment, we continue to find that patients are not able to access treatment due to limited or non-existent insurance coverage."

Under the model endorsed by the AMA and ASAM, patients would receive outpatient treatment using either buprenorphine or naltrexone. They would also have to receive psychological or counseling therapy services as well as care coordination to provide social support or other medical services as needed.

A physician would only qualify to receive payment under the payment model if they were part of an opioid addiction treatment team where they would be contracted to deliver all three types of services.

Teams would consist of a physician or healthcare professional certified to prescribe buprenorphine and naltrexone, a physician who specializes in addiction medicine, a healthcare professional certified to provide psychological treatment or counseling, and a nurse or social worker with experience in helping opioid use disorder patients with their non-medical needs, such as providing social service resources.

Under the payment structure, a patient taken to the emergency department for a drug overdose could then be referred to a physician practice, organization or unit inside the same hospital where they could assessed and then put on a treatment plan. Currently, many patients who go to the ED for an overdose end up waiting in a hospital detox unit to stabilize while the provider seeks to refer them to an outside treatment facility. If there are no treatment facilities available, a hospital has few other options but to discharge the patient.

Harris said over the coming weeks the group that developed the model will take and review feedback about the concept with the hope of gaining interest from physician practices and insurers for participation in a pilot demonstration.

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