Tag Archives: Medicaid

Why Isn’t Housing Deemed “Medically Necessary” in SUD Treatment?

I shock friends and colleagues from time to time by telling them that, “Did you hear…. from now on, insurance is no longer going to cover the cost of a hospital stay associated with any medical procedure, and that the costs of room and board while in post-surgical recovery all must come out of pocket.”

The look of incredulity and anger on their faces is priceless.

I entertain the discussion for a while and let it play out, enjoying listening to all of the justifications why that is abhorrent public policy (and equally bad health care).

Only afterwards, I take the time to tell them that, while I was joking, that it really isn’t a joke when it comes to mental health, behavioral health, and addiction treatment; that after detoxification (and for the lucky few, inpatient residential treatment), that the vast majority of people entering the drug and alcohol treatment space will be forcibly placed by their insurance carriers into an outpatient program but will not cover the necessary costs of a properly trained and supervised recovery residence.

At this point in my experience in this space, I am no longer surprised when they start to try to make a distinction.

However, in a news report that was admittedly surprising to me, HHS Secretary Alex Azar said in prepared remarks (as reported by ModernHealthcare.com) that Medicaid may soon allow hospitals and health systems to directly pay for housing, healthy food or other solutions for the “whole person.”

What?!?!

“What if we gave organizations more flexibility so they could pay a beneficiary’s rent if they were in unstable housing, or make sure that a diabetic had access to, and could afford, nutritious food,” Azar said in a speech supported by the Hatch Foundation for Civility and Solutions and Intermountain Healthcare.

Azar said the Center for Medicare and Medicaid Innovation is looking “to move beyond existing efforts to partner with social services groups and try to manage social determinants of health as they see appropriate…. If that sounds like an exciting idea … I want you to stay tuned to what CMMI is up to.”

“We believe we could spend less money on healthcare—and, most important, help Americans live healthier lives—if we did a better job of aligning federal health investments with our investments in non-healthcare needs,” he said.  According to ModernHealthcare.com, Azar didn’t elaborate on when the model would be launched, but the program could help Medicaid enrollees who need housing.

Granted, the discussion related mostly to seniors, medically-necessary improvements to homes, and home health care visits:

“These interventions can keep seniors out of the hospital, which we are increasingly realizing is not just a cost saver but actually an important way to protect their health, too,” Azar said. “If seniors do end up going to the hospital, making sure they can get out as soon as possible with the appropriate rehab services is crucial to good outcomes and low cost as well. If a senior can be accommodated at home rather than an inpatient rehab facility or a [skilled nursing facility], they should be.”

Azar was focusing on the agency’s approach to social determinants a day after it was announced that CMS would begin allowing states to cover a broader range of mental health services under Medicaid.

Specifically, CMS would consider Medicaid demonstration waivers (referred to as a §1115 waiver) covering short-term stays for acute care provided in psychiatric hospitals or residential treatment centers in return for states expanding access to community-based mental health services (these proposals would waive the so-called institutions for mental diseases (IMD) exclusion, a section of the Medicaid law (within the Social Security Act) that prohibits the use of federal Medicaid funding for most inpatient psychiatric services).

“It is the responsibility of state and federal governments together, alongside communities and families, to right this wrong,” Azar said. “More treatment options are needed, and that includes more inpatient and residential options that can help stabilize Americans with serious mental illness.”

However, Azar is speaking to psychiatric illness, not Substance Use Disorders, which appear to remain the “ugly stepchild” of health care, generally.

Back in 2014, the State of Illinois asked the Centers for Medicare and Medicaid Services (CMS) for permission to spend $60 million in Medicaid funding to help vulnerable enrollees find and maintain stable housing, joining New York and counties in Minnesota and California in efforts to try to add housing to the list of healthcare services offered to chronically ill Medicaid patients.

Under the waiver, Illinois wanted to offer managed-care plans incentive payments for enrollees specifically with mental illness or substance abuse disorders to successfully find temporary or permanent stable housing.

New York unsuccessfully sought $75 million from the CMS to develop housing capacity for high-cost Medicaid enrollees. The state ended up removing the request from its pending Medicaid waiver. But New York continues to seek $75 million to help chronically homeless, mentally ill or otherwise vulnerable adults live independently. Assistance—including counseling, employment aid, legal and budget help and case management—would be directed at those with high Medicaid costs.

At the present time, CMS determined that waivers cannot be used to pay outright for housing. Instead, these state programs can pay for assistance in finding housing, providing home modifications, and educating beneficiaries about tenant rights.

However, CMS has paid rent for Medicaid beneficiaries in the past through grant programs. The “Money Follows the Person” (MFP) demonstration project that was launched in 2008 transitioned Medicaid enrollees from an institutional setting back into the community. 43 states including California, Texas, New Jersey, Ohio, New York, Georgia and the District of Columbia participated in the grant program. Florida opted out.

By the end of 2016, there were 9,995 participants. In 2008, 289 people participated in the demonstration, according to federal data.

Though that grant program expired on September 30, 2016, the authorizing legislation required that the Secretary of HHS provide for a national evaluation of the MFP demonstration and submit a final report to the president and Congress that presents the findings and conclusions of this evaluation.  That report can be found here.

The report concluded:

MFP also provides strong evidence of success at improving the quality of life of participants. After transitioning to the community, participants experience increases across all seven quality-of-life domains measured, and the improvements are largely sustained two years post-transition. The changes in the quality of life that occur when participants move to the community are remarkable and important indicators that this demonstration has had positive impacts on participants’ lives. Estimating the value of the quality-of-life improvements reported by MFP participants would be extremely difficult, and any dollar value placed on these improvements would not adequately reflect what it means for people with significant disabilities when they can live in and contribute to their local communities.

This reads like it was taken verbatim from The American Journal of Community Psychology’s 2013 study on “The Role of Recovery Residences in Promoting Long-Term Addiction Recovery Outcomes.”

However, it was not, and the need for more-than-adequate sober living accommodations for people in recovery from addiction should be at the top of the list when it comes to health care public policy.

As I said before, we would never make a heart surgery patient go find a hotel to recover in and we would never let insurance carriers refuse to pay for such accommodations.

Let’s hope that HHS Secretary Azar is picking up the mantle from his predecessor and continuing to move addiction treatment health care into the full medical health care continuum, rather than to accept society’s generalized and simplistic view that addicts choose to be addicts, and we should not spend valuable resources on saving their lives.

“We can support both inpatient and outpatient investments at the same time,” Azar said. “Both tools are necessary and both are too hard to access today.”

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Legal Action Center’s Response to President’s “Initiative to Stop Opioid Abuse and Reduce Drug Supply and Demand”

Yesterday in New Hampshire, President Trump outlined his administration’s three-pronged plan for addressing the opioid epidemic. While the strategy includes certain components critical to expanding access to evidence-based addiction care, it lacks specificity on health approaches and falls well short of the comprehensive public health response needed to address a crisis that is currently claiming the lives of over 175 Americans each day. Further, the plan’s emphasis on the failed punitive policies is out of step with what we know from decades of public health and public policy data.

One stated goal of the President’s “Initiative to Stop Opioid Abuse and Reduce Drug Supply” is to “expand access to evidence-based addiction treatment in every State, particularly MAT for opioid addiction”, a critical need which we strongly endorse. The Legal Action Center supports certain additional tactics outlined in the President’s plan to “increase availability of the life-saving overdose reversal drug Naloxone, to expand access to residential SUD treatment and to improve treatment options for people within the criminal justice system, and looks forward to hearing the details of their operationalization.

However, the President’s proposal does not sufficiently address the reality that bringing an end to the opioid epidemic is dependent on a significant federal investment to strengthen and expand the national system of care for all substance use disorders. Many communities, especially in rural areas, have a complete dearth of qualified addiction treatment providers. Strengthening the existing addiction care workforce and developing expertise in the rest of the healthcare system to help prevent and treat addiction also is critically needed. Addressing this gap in coverage will require both short and long term investments and policies that align with the goal of expanded access to effective community-based prevention, treatment and recovery supports. The 2010 Affordable Care Act, for the first time in history, included coverage of substance use disorders as an Essential Health Benefit, and the 2008 Mental Health Parity and Addiction Equity Act requires insurers to cover mental health and addiction services at a level that is equal to coverage of medical and surgical services. The federal government should be working with States to enforce the Parity Act, and to ensure that all insurers, including Medicaid, Medicare and commercial plans, are covering all evidence-based services – including all three FDA approved addiction medications – at par with other health conditions.

Good access to Medicaid is critical to achieving the goal of expanded access to substance use disorder care. This includes expanding – rather than restricting– Medicaid eligibility, which provides coverage for millions of Americans who struggle with substance use disorders. The Legal Action Center strongly supports and has long advocated for making residential substance use disorder care more accessible to people enrolled in Medicaid by repealing the IMD exclusion and CMS issuing waivers until Congress changes the law. At the same time, the initiative’s stated goal of expanding access to evidence based treatment cannot be achieved if the Administration continues to take regulatory actions to weaken the Medicaid program through severe funding cuts and enrollment restrictions such as work requirements and lockout provisions. The administration must stop taking actions to limit people’s ability to get Medicaid if it is serious about stemming the opioid crisis.

Similarly, the Legal Action Center strongly supports the need to link people struggling with addiction in the criminal justice system to the care they need, but this action must include people with all forms of substance use disorder, not just opioid use disorder as proposed by the President’s Initiative. We agree with, and have long advocated for, diverting as many people with addiction away from the criminal justice system and connecting them to treatment. We encourage the administration to support diversion as early in the process as possible and to consider use of other home and community-based settings. We also urge the Administration to ensure that there is good access to evidence-based harm reduction approaches, including syringe-exchanges and safe consumption facilities, as well as all three FDA-approved addiction medications and residential treatment.

The Legal Action Center strongly opposes several aspects of the President’s Initiative that focus on punitive approaches. Research has clearly and repeatedly shown that a heightened focus on enforcement does not work to either reduce drug supply or demand, and that the ‘War on Drugs’ disproportionately targeted low-income communities of color and fueled mass incarceration. There is wide agreement among the American public as well as on both sides of the aisle that we need to shift away from a punitive approach to drug policy to a much more effective and less costly approach of treating addiction and supporting effective re-entry policies. There is also robust evidence that the majority of those incarcerated have diagnosed substance use disorders, and that many of them have been incarcerated as a result of criminal activity arising directly from their addiction. This includes those who are convicted of low-level drug dealing to support their addiction. We strongly condemn the suggestion that the death penalty should be sought for drug trafficking, since all evidence shows that such a policy would not reduce drug use, would be very costly and would fall disproportionately on people of color and those without financial means.

While we appreciate the administration’s recognition of the need to develop a plan to address this critical public health emergency and some of its proposals, we urge the Administration to invest sufficient resources to successfully combat the opioid and other substance use epidemic; prioritize proven health responses including expanding health care coverage of substance use disorders and quality prevention, treatment services and medications, evidence-based harm reduction approaches, and recovery supports; and not return to failed punitive policies of the past that did great damage to our country without reducing drug misuse and addiction.

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Will Addiction Treatment Be Eliminated from Obamacare Requirements?

The federal Centers for Medicare & Medicaid Services (CMS) proposed a federal rule late Friday aimed at giving states more flexibility in interpreting the Affordable Care Act’s “Essential Health Benefits” mandate as a way “to lower the cost of individual and small group health plans.”

Perhaps most notably, CMS’ proposed rule would allow states to alter their essential health benefits benchmark plan annually, beginning as early as 2019.

The Affordable Care Act set forth ten (10) categories of essential health benefits, including mental health and substance use disorder treatment.

“Consumers who have specific health needs may be impacted by the proposed policy,” the agency said. “In the individual and small group markets, depending on the selection made by the state in which the consumer lives, consumers with less comprehensive plans may no longer have coverage for certain services. In other states, again depending on state choices, consumers may gain coverage for some services.”

The agency in 2017 proposed standardized health plan options as a way to simplify shopping for consumers on the federally run marketplaces. The CMS said it would eliminate standardized options for 2019 to maximize innovation. “We believe that encouraging innovation is especially important now, given the stresses faced by the individual market,” the proposed rule states.

The Trump administration hopes to relax the ACA’s requirements and provide as much state flexibility as possible through administrative action, following the collapse of congressional Republican efforts this year to make those changes legislatively.

However, the EHB benchmark plans for mental health/substance abuse must comply with the Mental Health Parity and Addiction Equity Act of 2008 (“Parity Act”).

While we do not believe that any state can eliminate or reduce benefits for drug and alcohol treatment, by reducing benefits for other medical health care counterparts, they could strategically and effectively compromise reimbursements, even under the Parity Act.

The 2019 Notice of Benefit and Payment Parameters (PDF), released Friday.

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Pharmacy Benefit Groups Begin to Limit Opioids, Over AMA Objection

Express Scripts, the country’s largest pharmacy benefit manager (PBM), announced plans to roll out a new program nationwide that will limit the number and strength of opioid medications that doctors can prescribe to first-time users.

The program, which will begin on Sept. 1, is being put in place to help reverse the country’s opioid epidemic, according to the Associated Press. President Donald Trump last week said he was prepared to declare a national emergency to combat the deadly opioid crisis.

The move by Express Scripts was met with resistance by the American Medical Association, the largest U.S. organization that represents doctors. It said decisions about prescriptions and treatment plans should be made by doctors and patients, the AP reported.

In a pilot study of more than 100,000 members new to opioid therapy, the company saw a 38% reduction in hospitalizations and a 40% reduction in emergency room visits when compared to a control group during 6 months of follow-up.

The AMA does not support the program’s expansion.

Medicaid has implemented policies such as prescription drug monitoring programs, quantity limits on opioid dispensing, prior authorization requirements, preferred drug lists and patient review and restriction. In 2012, 15% of Medicaid enrollees had at least one prescription opioid claim, and the program paid more than $500 million for more than 34 million claims for opioid drugs.

Cigna also recently announced that it recorded a 12% decline in customers’ use of prescribed opioids in the last year, which it accomplished by leveraging its claims data to detect patterns of misuse and by working with doctors.

Why is the AMA is objecting is left to anecdote, conjecture and speculation.

Saying a “one-size-fits-all” approach regarding the number of prescriptions takes away physician discretion, Patrice Harris, M.D., who chairs the AMA’s Opioids Task Force, told the AP that doctors have already voluntarily reduced opioid prescriptions by 17% and are directing patients to other forms of pain management.

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