Medication Assisted Treatment for Substance Use Disorders and the DMC-ODS Pilot Program Technical Assistance Webinar for Counties September 1, 2016

Presentation Overview Background MAT and the DMC-ODS Pilot Program Required vs. Optional MAT Narcotic Treatment Program Considerations Additional MAT Opportunities Rate-Setting MAT Outside of the DMC-ODS Pilot Program Medi-Cal Fee-for-Service / Pharmacy Los Angeles County Approach Questions and Discussion

Acronym Key FFS: Fee-For-Service MAT: Medication Assisted Treatment NRT: Narcotic Replacement Therapy NTP: Narcotic Treatment Programs OBOT: Office-Based Opioid Treatment OTP: Opioid Treatment Programs OTS: Opioid Treatment Services SUD: Substance Use Disorder TAR: Treatment Authorization Request

Medication Assisted Treatment What is medication assisted treatment (MAT)? MAT is the use of prescription medications, in combination with counseling and behavioral therapies, to provide a whole- person approach to the treatment of substance use disorders. Research shows that a combination of MAT and behavioral therapies is a successful method to treat substance use disorders. There are various “doors” through which Medi-Cal beneficiaries in need of MAT may access treatment.

Medi-Cal Coverage of MAT DMC-ODS Pilot Program Standard Drug-Medi-Cal Program Other Opioid (Narcotic) Treatment Program (methadone, buprenorphine, naloxone, disulfiram) Narcotic Treatment Program (methadone or LAAM if available and prescribed) Medi-Cal Fee-For-Service Medical Benefit (physician administered) (buprenorphine, injectable naltrexone – with TAR) Additional MAT (all medications for SUD) Naltrexone Treatment (oral for opioid dependence) Medi-Cal Pharmacy Benefit (buprenorphine, naloxone, injectable naltrexone-with TAR, disulfiram, acamprosate- with TAR) Medication services as a component of Withdrawal Management Narcotic and non-narcotic drugs (other than methadone) used for outpatient heroin or other opioid detoxification services.

MAT and the Drug Medi-Cal Organized Delivery System Pilot Program

MAT and the DMC-ODS Pilot Program Required MAT Services Optional Additional MAT Services Narcotic Treatment Program (NTP) Services NTPs are required to provide access to methadone, buprenorphine, naloxone, and disulfiram to DMC-ODS patients o DHCS sets rates for NTP services Medication Services as a component of Withdrawal Management (counties required to cover 1 level of WM) All FDA-approved medications for SUD (except methadone) Includes the utilization of long-acting injectable naltrexone at DMC facilities, including NTPs Counties propose interim rates for additional MAT outside of a NTP setting, including buprenorphine, disulfiram, naloxone, and long-acting injectable naltrexone

Narcotic Treatment Programs and the DMC-ODS Covered Medications. NTPs are required to offer and prescribe medications to beneficiaries covered under the DMC-ODS formulary, including: Methadone Buprenorphine Disulfiram Naloxone Treatment Components. The components of NTP are: Intake Individual and Group Counseling Patient Education Medication Services Collateral Services Crisis Intervention Services Treatment Planning Medical Psychotherapy Discharge Services

Narcotic Treatment Programs and the DMC-ODS Narcotic Replacement Therapy. Per HSC 11839.2, a NTP patient must be receiving narcotic replacement therapy, which includes methadone and buprenorphine. Naloxone. While NTPs may offer forms of buprenorphine that contain naloxone in the formula, this is not a replacement for naloxone. Naloxone (by itself) is used to treat a narcotic overdose in an emergency situation. 10

Additional MAT under the DMC-ODS Optional Coverage. Pilot counties may choose to cover Additional MAT, which includes all FDA-approved medications for SUD in any DMC setting. This includes residential facilities with DHCS approval to provide incidental medical services. Treatment Components. Components of Additional MAT include: Ordering Prescribing Administering Monitoring

Examples of Additional MAT Counties are encouraged to increase MAT services by exploring the use of the following interventions: Extend NTP/Opioid Treatment Programs (OTPs) to remote locations using mobile medication units and contracted pharmacies, which may have onsite counseling and urinalysis. Implement medication management protocols for alcohol dependence, including naltrexone, disulfiram, and acamprosate. Alcohol maintenance medications may be dispensed onsite in NTPs/OTPs or prescribed by providers in outpatient programs. Provide ambulatory alcohol detoxification services in settings such as outpatient programs, NTPs/OTPs, and contracted pharmacies.

Additional MAT at NTP Settings Dual DMC Certification. A NTP provider can enroll with the DHCS Provider Enrollment Division to offer Additional MAT. This would result in a dual DMC certification for the NTP and Outpatient Drug Free (ODF) modalities. Examples. If a county chooses to provide Additional MAT services, vivitrol can be administered at a NTP site. The beneficiary would receive that service as part of the outpatient program, not the NTP. That beneficiary could also access counseling at the NTP site, but they would be receiving ODF counseling, not NTP counseling.

Additional MAT at Non-NTP Settings MAT in Outpatient and Residential Settings. Counties may choose to expand MAT in outpatient, IOT, and residential settings under the ODS. Residential facilities must first have DHCS approval to provide incidental medical services. Examples. Vivitrol can be administered at an outpatient, IOT, or residential site. A state TAR is not required; however, counties may choose to impose a TAR at the county level. Buprenorphine can be expanded with a SAMHSA Data 2000 waivered physician along with counseling services. Counties may pay DMC physicians to prescribe, order, and monitor the medications while the prescription is filled by the pharmacy.

DMC-ODS Provider Requirements Care Coordination. Counties must require, through contract, that providers have procedures and protocols in place to assure care coordination and linkages to other services and supports for beneficiaries receiving MAT. Communication with Physicians. Provider staff must maintain regular communication with the physicians of the clients who are prescribed these medications, unless the client chooses not to consent to signing a 42 CFR part 2 compliant release of information for this purpose.

Rate-Setting NTP Services under the DMC- ODS Additional MAT under the DMC- ODS State sets rates according to standard NTP rates methodology. Counties propose interim rates for additional MAT covered under the pilot program (ordering, prescribing, administering, and monitoring). Counties are encouraged to utilize the state’s medication rates.

MAT Outside of the Drug Medi-Cal Organized Delivery System Pilot Program

Coverage of MAT Outside of the DMC-ODS Standard Drug-Medi-Cal Program (non-pilot counties) Other (all counties) Narcotic Treatment Program (methadone or LAAM if available and prescribed) Medi-Cal Fee-For-Service Medical Benefit (Physician-Administered) (buprenorphine and injectable naltrexone-with TAR) Naltrexone Treatment (oral for opioid dependence) Medi-Cal Pharmacy Benefit (buprenorphine, naloxone, injectable naltrexone-with TAR, disulfiram, acamprosate-with TAR) Narcotic and non-narcotic drugs (other than methadone) used for outpatient heroin or other opioid detoxification services.

MAT Services Outside of Drug Medi-Cal Medi-Cal Fee-for-Service Medical Benefit. SUD treatment providers may offer certain MAT services by enrolling physicians as Fee-For-Service (FFS) providers and adhering to various registration and other regulatory requirements. Medi-Cal Pharmacy Benefit. If a FFS physician does not administer the drug and instead writes a prescription for the medication to be dispensed or administered at a pharmacy, the drug cost is covered under the Pharmacy Benefit.

Medications Covered Medications. Medications covered by Medi-Cal that may be prescribed by an appropriately registered and enrolled FFS physician include: Buprenorphine Long-Acting Injectable Naltrexone (All beneficiaries when administered by a FFS physician as a medical benefit; only covered for certain criminal-justice involved populations when administered at a pharmacy) Naloxone Disulfiram Acamprosate Other FDA-approved medications for SUD on Medi-Cal formulary o Excluding Methadone. Methadone is only available to Medi-Cal beneficiaries through a certified NTP. 20

Authorization Requirements Buprenorphine. Does not require a Treatment Authorization Request (TAR). Injectable Naltrexone. Always requires a TAR whether billed as a medical claim by physicians or as a pharmacy benefit. Is only covered as pharmacy benefit for certain criminal-justice involved populations. Naloxone. Does not require a TAR, except for the auto- injector formulation and the intranasal device formulation. Disulfiram. Does not require a TAR. Acamprosate. Requires a TAR.

Provider Requirements Federal Waiver Requirement. Physicians at SUD facilities who have enrolled as FFS providers also need to obtain a federal DATA 2000 waiver (X number). Activities. DATA 2000 waivered (X number) Medi-Cal physicians can order, stock, prescribe, and administer covered medications for treatment of SUD. Setting. Medications may be prescribed / dispensed / administered in the office / clinic setting.

Reimbursement Medical Service. Medications may be prescribed / dispensed / administered in the office / clinic setting. The provider bills the medical service just as any other medical service provided by his / her provider type. Medication Administration. If the FFS physician administers the drug in the office, this is termed a ‘physician administered drug’. The physician is reimbursed for the drug and the administration directly. Coding. FFS Current Procedural Terminology (CPT) codes are used to report physician time for medication management. These codes can be used by physicians and other qualified Medi-Cal healthcare providers. Pharmacy. If the medication is not administered directly to the patient, and the physician writes a prescription for the patient to pick up at a pharmacy for self- administration, the drug cost is covered under the FFS Pharmacy Benefit. o The rate of reimbursement for the drug cost may be found at: http://www.dhcs.ca.gov/provgovpart/pharmacy/Pages/ACAFUL.aspx

Medication-Assisted Treatment in Los Angeles County Gary Tsai, M.D. Medical Director and Science Officer Substance Abuse Prevention and Control

MAT Hubs 3 Primary MAT hubs in LA County Vivitrol (long-acting naltrexone) Buprenorphine

MAT Expansion 2 key areas of focus Training / Culture Change Engaging SUD counselor certifying organizations (CCAPP, CAADE, CADTP) to ensure adequate focus on MAT in their curriculums MAT training for counselors/LPHAs as a part of DMC-ODS preparations Expanding # of MAT prescribers Within primary care, mental health, and SUD provider communities  buprenorphine trainings Utilizing DMC Medical Directors/physicians to the full extent of their expertise and scope of practice Expanding # of MAT hubs

MEDICATION-ASSISTED TREATMENT RESOURCES Case Consultation Support UCSF Clinician Consultation Center for Substance Use Substance use warmline: 855-300-3595 http://nccc.ucsf.edu/clinical-resources/substance-use-resources/ Providers’ Clinical Support System National training and mentorship project to give prescribers the tools to be able to prescribe MAT (http://pcssmat.org/) Buprenorphine Training Resources http://www.samhsa.gov/medication-assisted-treatment/training- resources/buprenorphine-physician-training

MEDICATION-ASSISTED TREATMENT RESOURCES (CONT’D) MAT Guidelines / Protocols (cont’d) ​The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use http://www.asam.org/docs/default-source/practice-support/guidelines-and- consensus-docs/asam-national-practice-guideline-supplement.pdf?sfvrsn=16 http://pcssmat.org/wp-content/uploads/2016/03/PCSS_MAT-Kampman- Guideline-final1.pdf ​Medication for the Treatment of Alcohol Use Disorder: A Brief Guide (SAMHSA) http://store.samhsa.gov/shin/content/SMA15-4907/SMA15-4907.pdf Safe Med LA: LA County’s Prescription Drug Abuse Coalition (www.SafeMedLA.org)

Gary Tsai, M.D. Medical Director and Science Officer Substance Abuse Prevention and Control gtsai@ph.lacounty.gov Thank you!

Questions and Discussion For optimal sound quality, please ensure you are dialed-in using your phone and that you have inputted your audio PIN.

Contact and Resources For questions and / or to be added to the county TA distribution list, please contact dmcodswaiver@dhcs.ca.gov For additional information, please see the DMC-ODS FAQs posted the DHCS website: http://www.dhcs.ca.gov/provgovpart/Pages/Fact-Sheets-and- FAQs.aspx?

Department of Health Care Services Marlies Perez, Division Chief, SUD Compliance, MHSUDS, DHCS Don Braeger, Division Chief, Program, Policy, and Fiscal Division, MHSUDS, DHCS For More Information: http://www.dhcs.ca.gov/provgovpart/Pages/Drug-Medi-Cal- Organized-Delivery-System.aspx

Harbage Consulting Don Kingdon, PhD, Behavioral Health Policy Director don@harbageconsulting.com Molly Brassil, MSW, Deputy Director, Behavioral Health Integration molly@harbageconsulting.com Courtney Kashiwagi, MPH, Senior Consultant courtney@harbageconsulting.com Erynne Jones, MPH, Senior Consultant erynne@harbageconsulting.com