Industry Voices—How value-based contracts in Medicaid can promote opioid addiction recovery

Vermont’s Medicaid program recently saw its spending on urine toxicology testing rise six-fold in three years, reaching $15 million dollars in 2018.
On the surface, this rise in spending reflects a positive trend: more patients are receiving life-saving treatment for opioid use disorder. But, does all this testing truly help the patient? Does frequent laboratory toxicology testing promote recovery?
My opinion, and that of an increasing number of addiction medicine professionals, is no. Many of those $15 million taxpayer dollars could be put to better use and state Medicaid agencies can encourage more effective treatment through value-based contracts with providers. 
Urine toxicology testing does have a role in the management of opioid use disorder. For example, it is helpful (but not necessary) in establishing the diagnosis and is useful for identifying co-occurring substance use disorders. Additionally, testing can reduce the diversion of medication and help promote patient accountability. But too many providers overemphasize the results of urine drug testing at the expense of building a trusting rapport with patients. 
Engagement between a doctor and patient is critical: Research shows that patients with opioid use disorder who leave treatment early face increased risk of terrible outcomes (death, overdose, relapse, hospitalizationHIV  and Hepatitis C, to name a few). Doctors are not parole officers and should not behave as such. Modern best-practices in addiction medicine emphasize keeping patients in treatment despite co-occurring addictions, imperfect medication adherence—behaviors that doctors are fishing for with unnecessary, punitive testing.
Recognizing this, the National Quality Forum encourages doctors to keep their patients with OUD engaged in treatment for a minimum of six months. More recent research suggests 15 months or longer should be the minimum target. Doctors with practice styles and policies that foster trust and promote treatment retention often find that frequent laboratory toxicology tests become irrelevant (e.g., when my patient tells me he is using cocaine, I don’t need testing to confirm that any more than I would need a chest x-ray to confirm his complaint of a cough).
While I am encouraged to see that more patients are accessing treatment for opioid use disorder, I am troubled by the quality of the treatment implied by the volume of laboratory toxicology testing. 
The other unfortunate reality driving the volume of toxicology testing is traditional fee-for-service reimbursement. Amazingly, most Medicaid fee schedules pay more for a 30-second laboratory toxicology test than they do for 60 minutes with a counselor or 30 minutes with a doctor. Upside-down economics like this incentivize over-utilization of line items that drive revenue, even if they don’t drive recovery. This dynamic has led to well-documented over testing and profiteering in the pain medicine industry, and some actors in the addiction medicine industry are following suit. 
Instead of over-relying on testing, my practice offers medications for addiction treatment with group therapy and one-on-one counseling. This approach gives more sustained engagement, in part, by helping members cope with stress and deal with broader needs, including housing and employment. 
My practice also prefers to enter into value-based-contracts with payers, including Medicaid. Under these arrangements, Medicaid pays physicians only if patients achieve certain outcomes (like abstinence, retention in treatment, or reduced hospitalization).
It doesn’t matter how many tests we order or encounters we bill for—we are only reimbursed if patients recover. Value-based arrangements like these align incentives between providers, payers and patients. As such, they encourage doctors to examine their routine practices to ensure every action they take drives the best patient outcomes for the lowest cost (not surprisingly, we have found that frequent laboratory urine testing is not such a practice). 
Unfortunately, we find that state Medicaid agencies and Medicaid managed care organizations can sometimes be hesitant to enter into such value-based contracts. And that is understandable as the shift from fee-based to bundled payments can be complex and time-consuming. But the cost of foregoing this transition is increasingly too great and is a missed opportunity for patients and taxpayers alike. 
The opioid epidemic is finally getting the attention it needs and funding is finally beginning to flow into the addiction medicine space. Spending on treatment of opioid use disorder will dominate the budgets of state Medicaid agencies for years to come and appropriately so. With the nation’s addiction medicine infrastructure in its infancy, the structure and philosophy of reimbursement arrangements being designed today will influence the quality of care that is delivered for the foreseeable future.
We call upon legislators and Medicaid administrators to spend taxpayer dollars wisely and promote recovery, discourage profiteering and drive high-quality care by engaging in value-based contracts. The health of the public and the health of the fledgling addiction medicine industry will be better for it. 
Gus Crothers, M.D., is the national medical director at Groups Recover Together and a board-certified specialist in Addiction Medicine. He also serves on the board of the Maine College of Health Professions and the Maine Opioid Clinical Advisory Committee.