How segregated payments keep comprehensive substance use disorder care out of reach

Despite an overall drop in opioid prescribing over the past decade, opioid-related overdose deaths have continued to rise.

At the same time, some data show opioid use disorder diagnoses have spiked at a much higher rate than the use of medications for opioid use disorder (MOUD). Only 11% of people with opioid use disorder receive medications, and women and Black and Hispanic people have disproportionately lower access.

Experts argue these trends show decreasing prescriptions of opioids is not enough to end the epidemic. Rather, they call on a cross-industry effort, taking a long-term view of prevention and widening access to treatment. Many barriers to getting there remain.

Enforcing parity 

The first federal parity law was passed in 1996 and was expanded in 2008, demanding that most plans equitably cover behavioral health as physical health, like substance use disorder treatment. Some states have stronger parity laws, which trump federal parity requirements. But enforcement has been spotty. 

“It’s no secret to anyone that health insurers violate state and federal parity laws,” Bobby Mukkamala, M.D., chair of the Board of Trustees and Task Force on the Overdose Epidemic at the American Medical Association (AMA), said in an AMA webinar on removing barriers to care in February. “And they’ll continue to do so unless they’re held accountable.” 

Payers’ historic lack of compliance accelerated national calls for stricter enforcement as high up as President Barack Obama’s task force on mental health parity. Payers, meanwhile, demanded more clarity around requirements. In 2021, additional legislation was passed with an update that America's Health Insurance Plans acknowledged as one national standard (PDF). But earlier this year, the Department of Labor (DOL) found payers are still not complying with the new requirement. 

“These are big complex corporations that have huge compliance departments. That can’t be an excuse,” said Michael Conway, commissioner of the Colorado Division of Insurance, in the AMA webinar. “We’re paying money to these entities to make sure that they’re providing the care that we need. Parity is a huge component of that.”

The DOL recently beefed up its own parity enforcement capabilities. 

Telehealth as treatment—to be, or not to be

Enabling telehealth for treatment of opioid use disorder has been shown to have positive outcomes, particularly for rural communities. Some studies suggest a link between telehealth expansion and access to MOUD.

Since the pandemic eased many restrictions around the delivery of tele-treatment, stakeholders have urged lawmakers to make those changes permanent, like requiring reimbursement for opioid use disorder tele-treatment. But not every state will preserve pandemic-era waivers.

Pennsylvania recently announced it will roll back its allowance of telemedicine, including for prescribing buprenorphine.

“These waivers, issued by almost every state, provided critical access to OUD treatment amidst the backdrop of a worsening opioid epidemic in America,” Bicycle Health CEO and founder Ankit Gupta told Fierce Healthcare. “At a time when more Americans are struggling than ever before, It is irresponsible to take away these waivers without sufficient time for patients to taper off medication, find new local providers and figure out how to move forward.”

Manatt Health is tracking ongoing telehealth-related regulatory changes state by state. 

Payment innovation: a bumpy road

Addiction is a chronic disease. Its treatment can involve physical and behavioral care components like medication and counseling. Yet these benefits are often not integrated among payers, explained Brenda Jackson, a consultant on reimbursement strategy in substance use and mental health. 

Many states and payers contract with managed behavioral health care organizations, effectively carving out those services from physical health. Plans like Blue Cross North Carolina have added behavioral health as a benefit, aiming for most of its network primary care practices to deliver integrated care by the end of this year. Taking on additional risk in a value-based care model is another way to improve access and outcomes. 

Medicare, to which the parity law does not currently apply, does not cover all levels of care for addiction treatment, like intensive outpatient or residential treatment programs or practitioners like licensed counselors or peer counselors. As a result, hundreds of thousands of Medicare beneficiaries cannot access treatment in these facilities. 

“It just gets extremely complicated extremely quickly if the providers themselves can’t just bill for the medication,” Jackson told Fierce Healthcare. “You have to cut through a lot of turf and silos and confusion even to get people to recognize what the issue is.”

Researchers have also criticized barriers to treatment like prior authorization and called out block grant funding for deepening the segregation of substance use disorder treatment from the rest of healthcare. To help address the disparate system, in 2018, the American Society of Addiction Medicine and the AMA launched an alternative payment model to support coordination between providers of medical, psychological and social services to patients. 

The introduction of G codes by the Centers for Medicare & Medicaid Services allowed for bundled services to be reimbursed. Many commercial payers include these codes in their fee schedules, but some may never adopt them, according to Jackson. Recognizing the importance of their widespread implementation, Bicycle Health has been pushing payers to include the codes on their fee schedules.

“We don’t want to change our model just to fit the billing criteria,” Gupta said. 

In California, mental health is already carved out by some payers; substance use disorder is additionally carved out by the state’s Drug Medi-Cal program. Though theoretically a good payment model for accounting for all levels of care, the payment system is complex, with at times onerous enrollment criteria that vary county to county, according to Gupta. When Bicycle Health tried to join the Drug Medi-Cal program in Los Angeles, pages of requirements and dozens of confusing questions kept the provider from enrolling, Gupta said.

Benefits are further complicated for patients on Medi-Cal, for which Bicycle Health can only provide care during the first month they are with the plan. After that, members get assigned to a managed care organization, which may not necessarily approve the provider’s treatment as a benefit. They tend to argue that substance use disorder benefits are to be administered by the Drug Medi-Cal program, Gupta said. To avoid dropping patients mid-treatment, Bicycle does not market its Medi-Cal benefit. Gupta is hopeful about the future; the benefit is currently being reorganized by the state. 

Some payers say they are listening. “Provider partnerships are an extremely important component of what we do to improve access to care for our members,” said Anthem’s business solutions director Eric Bailly, who supports the company’s substance use disorder strategy. Anthem partnered with Bicycle Health even before the onset of COVID-19, during which "telehealth became necessary overnight." 

Back in 2018, the payer collaborated with other stakeholders to pilot an alternative payment model incentivizing providers to focus on long-term recovery through bundled payments. That model was among a number of Anthem initiatives that have helped boost access to holistic opioid treatment. 

The bundled payments approach, according to Bailly, recognizes the need for complex care on the road to recovery. While it’s not entirely a value-based model, Bailly acknowledged, it’s payment innovation, with the potential to build toward a value-based contract down the line once trust is established.

Bailly hopes the industry will move toward a comprehensive population health management approach.

Instead of separate entities managing separate components of one’s care, “have everybody work together as one team," he said.