Ophelia's virtual OUD care now in-network for Medicaid, dual-eligible Highmark Wholecare members

Ophelia, a virtual provider of opioid use disorder (OUD) treatment, is now in-network for Highmark Wholecare members.

The partnership aims to expand access to OUD care for Highmark Wholecare’s Medicaid and Dual Special Needs Plan members.

Ophelia has been part of Highmark Health’s network in Pennsylvania since 2021, serving 2.9 million commercial members, now extending to 360,000 additional members. Ophelia works with 13 Medicaid plans overall. 

“Pennsylvania has been working to address the opioid crisis for years, with far too many barriers standing in the way of people seeking and receiving life-saving treatment,” Ellen Duffield, president and CEO of Highmark Wholecare, said in an announcement shown in advance to Fierce Healthcare. “Highmark Wholecare’s collaboration with Ophelia is helping course correct this crisis by providing access to comprehensive OUD care that our Medicaid and D-SNP members can receive quickly and safely.” 

In 2021, Pennsylvania experienced nearly 15 drug-related overdose deaths every day, at twice the national average. Synthetic opioids like fentanyl are driving the rise in overdose deaths. Yet 32% of insured Pennsylvanians reside in a zip code with no publicly listed provider who can prescribe buprenorphine, according to Ophelia. 

Paying for OUD treatment can also be tricky. Medicaid reimbursement rates in the state are low, according to Zack Gray, CEO and cofounder at Ophelia. Many providers might not accept Medicaid or commercial insurance. Nationally, a third of Medicaid enrollees with OUD do not receive medications for OUD.

“There’s been a hesitance for providers to open their doors for Medicaid patients because the fee schedule wasn’t well structured to compensate providers treating this population,” Gray told Fierce Healthcare. As a result, Ophelia has chosen to pursue bundled payments. 

“The solution to the problem involves getting slightly creative … by using a bundle to cover wraparound support services that are not explicitly covered in the fee schedule,” Gray said. Those wraparound services include asynchronous clinical care, collaborating with other providers, addressing the social determinants of health and pharmacist and patient education.

Payers in the region are starting to realize that to best serve OUD patients and save money, they must adequately reimburse for treatment, per Gray.

As long as the patient does at least one telehealth visit a month, Ophelia providers get paid the fixed amount.If a patient becomes more expensive, Ophelia does not get paid more.

“It is tied to a service, which makes it feel like fee-for-service, but it’s also inherently value based,” Gray explained. 

In the past, Ophelia would take whatever rate a payer was willing to give, Gray said, committing to proving its effectiveness over time. Since, its real-world data has borne that out. Today, “our model is validated and we can sign bundles day one with health plans.”