1. ADDRESSING THE OPIOID EPIDEMIC: Virginia MEDICAID Perspective on expanding access to addiction treatment and decreasing Inappropriate opioid prescribing
Katherine Neuhausen, MD, MPH
Chief Medical Officer
Virginia Department of Medical Assistance Services
Medicaid and Behavioral Health Agency Approaches to Opioid Use Disorder: Identifying the Problem and Implementing the Solution.

2. Medicaid Members with Substance Use Disorder Diagnosis
Source: Department of Medical Assistance Services – claims/encounter data (November 3, 2016).
Circles # of Medicaid recipients whose claims/encounter data included an addiction related diagnosis.

3. Communities Impacted by Addiction
Source: Department of Medical Assistance Services – claims/encounter data (November 3, 2016) and 2010 U.S. Census Bureau Population.
Circles % of Medicaid recipients whose claims/encounter data included an addiction related diagnosis respective to the total population in that zip code.

4. Addiction and Recovery Treatment Services (ARTS) Benefit
Changes to DMAS’s Substance Use Disorder (SUD) Services
for Medicaid and FAMIS Members approved in Spring 2016
Expand short-term SUD inpatient detox to all Medicaid /FAMIS members
Expand short-term SUD residential treatment to all Medicaid members
Increase rates for existing Medicaid/FAMIS SUD treatment services
Add Peer Support services for individuals with SUD and/or mental health conditions
Require SUD Care Coordinators at DMAS contracted Managed Care Plans
Organize Provider Education, Training, and Recruitment Activities 1 2 3 5 4 6
The Medicaid covered substance use disorder program is changing in response to the Governor and Virginia General Assembly passing this benefit in response to the opioid crisis.
These are the six major components of the changes to the SUD benefits.

5. Transforming the Delivery System for Community-Based SUD Services
All Community-Based SUD Services will be Covered by Managed Care Plans
A fully integrated Physical and Behavioral Health Continuum of Care
Magellan will continue to cover community-based substance use disorder treatment services for fee-for-service members
ARTS
Inpatient Detox
Residential Treatment
Partial Hospitalization
Intensive Outpatient Programs
Opioid Treatment Program
Office-Based Opioid Treatment
Case Management
Peer Recovery Supports
In 2015 close to 70% of members were served in managed care. With the implementation of MLTSS, this will close to 90% served in managed care.
To fully integrate physical and behavioral health services for individuals with SUD and expand access to the full continuum of services, DMAS plans to “carve in” non-traditional SUD services into Managed Care for members who are already enrolled in plans. The only service currently covered by managed care is inpatient detoxification.
Non-traditional services that will be “carved in” include Residential Treatment, Opioid Treatment (medication and counseling component), Substance Abuse Day Treatment, Crisis Intervention, Intensive Outpatient Treatment, and Substance Abuse Case Management.
Magellan will continue to cover these services for those Medicaid members who are enrolled in FFS
Effective April 1, 2017 except for Peer Supports which will be effective July 1, 2017.
Providers will need to become enrolled and credentialed with the managed care plans beginning 4/1/17. Majority of members are covered by managed care and most when the Managed Long Term Services and Supports (MLTSS) is implemented.
Effective April 1, 2017
Addiction and Recovery Treatment Services (ARTS)
Peer Recovery Supports effective July 1, 2017

6. ASAM Level of Care Placement Department of Behavioral Health License4
Medically Managed Intensive Inpatient
Acute Care General Hospital (VDH license)
3.7
Medically Monitored Intensive Inpatient Services (Adult)
Medically Monitored High-Intensity Inpatient Services (Adolescent)
Inpatient Psychiatric Unit
Acute Freestanding Psychiatric Hospital
Substance Abuse (SA) Residential Treatment Service (RTS) for Adults/Children
Residential Crisis Stabilization Unit
Medical Detox License required for all
3.5
Clinically Managed High-Intensity Residential Services (Adults) / Medium Intensity (Adolescent)
3.3
Clinically Managed Population-Specific High-Intensity Residential Services (Adults)
Inpatient Psychiatric Unit (3.5) )/Required for co-occurring enhanced programs
SA RTS for Adults (3.3 or 3.5) and Children (3.5)
SA and MH RTS for Adults and Children (3.3 or 3.5)/Required for co-occurring enhanced programs
Supervised RTS for Adults (3.3)
3.1
Clinically Managed Low-Intensity Residential Services
MH & SA Group Home Service for Adults and Children (Required for co-occurring enhanced programs)
2.5
Partial Hospitalization Services
2.1
Intensive Outpatient Services
SA or SA/Mental Health Partial Hospitalization (2.5)
SA Intensive Outpatient for Adults and Adolescents (2.1) 1
Outpatient Services
0.5
Early Intervention
N/A; All Licensed Providers
Opioid Treatment Program (OTP)
Opioid Treatment Program
Office-Based Opioid Treatment (OBOT)
N/A; Physician Offices
We worked very closely with our sister agency – the Department of Behavioral Health and Developmental Services to develop this crosswalk looking at how each level of ASAM aligned with the licenses administered and regulated by the Department of Behavioral Health

7. Preferred Office-Based Opioid Treatment (OBOT)
Settings and Care Model
CSBs, FQHCs, outpatient clinics psychiatry practices, primary care clinics
Provide Medication Assisted Treatment (MAT) - use of medications in combination with counseling and behavioral therapies that results in successful recovery rates of 40-60% for opioid use disorder compared to 5-20% with abstinence-only models
Supports integrated behavioral health - buprenorphine waivered practitioner with on site behavioral health provider (e.g., psychologist, LCSW, LPC, psych NP, etc.) providing counseling to patients receiving MAT
Payment Incentives
Buprenorphine-waivered practitioner in the OBOT can bill all Medicaid health plans for substance use care coordination code ($243 PMPM) for members with moderate to severe opioid use disorder receiving MAT
Can bill higher rates for individual and group opioid counseling
Can bill for Certified Peer Recovery Support specialists

8. Increases in Addiction Providers Due to ARTS
Addiction Provider Type
# of Providers before ARTS
# of Providers after ARTS
% Increase in Providers
Inpatient Detox (ASAM 4.0)
Unknown
103
NEW
Residential Treatment (ASAM 3.1, 3.3, 3.5, 3.7) 4 78
↑ 1850%
Partial Hospitalization Program (ASAM 2.5) 13
Intensive Outpatient Program (ASAM 2.1) 49 72
↑ 47%
Opioid Treatment Program 6 29
↑ 383%
Office-Based Opioid Treatment Provider 70

9. Before ARTS Medicaid Provider Network Adequacy Residential Treatment
Source: Department of Medical Assistance Services - Provider Network data (March 20, 2017).
Circles # of Medicaid providers included in network adequacy access calculation.
For a zip code to be considered accessible, there must be at least two providers within 30 miles (urban) or 60 miles (rural) driving distance.
Driving distance is calculated by Google services based on the centroid of each zip code.

10. After ARTS Medicaid Provider Network Adequacy ASAM 3. 1/3. 3/3. 5/3
After ARTS Medicaid Provider Network Adequacy ASAM 3.1/3.3/3.5/3.7 Residential Treatment
Source: Department of Medical Assistance Services - Provider Network data (July ).
Circles # of Medicaid providers included in network adequacy access calculation.
For a zip code to be considered accessible, there must be at least two providers within 30 miles (urban) or 60 miles (rural) driving distance.
Driving distance is calculated by Google services based on the centroid of each zip code.

11. Before ARTS Medicaid Provider Network Adequacy Opioid Treatment Program
Source: Department of Medical Assistance Services - Provider Network data (March 20, 2017).
Circles # of Medicaid providers included in network adequacy access calculation.
For a zip code to be considered accessible, there must be at least two providers within 30 miles (urban) or 60 miles (rural) driving distance.
Driving distance is calculated by Google services based on the centroid of each zip code.

12. After ARTS Medicaid Provider Network Adequacy Opioid Treatment Program
Source: Department of Medical Assistance Services - Provider Network data (July ).
Circles # of Medicaid providers included in network adequacy access calculation.
For a zip code to be considered accessible, there must be at least two providers within 30 miles (urban) or 60 miles (rural) driving distance.
Driving distance is calculated by Google services based on the centroid of each zip code.

13. *NEW* Medicaid Provider Network Adequacy Preferred Office Based Opioid Treatment
Source: Department of Medical Assistance Services - Provider Network data (July ).
Circles # of Medicaid providers included in network adequacy access calculation.
For a zip code to be considered accessible, there must be at least two providers within 30 miles (urban) or 60 miles (rural) driving distance.
Driving distance is calculated by Google services based on the centroid of each zip code.

14. Preliminary Findings from VCU Evaluation First Quarter of ARTS Implementation
Treatment rates among Medicaid members with Substance Use Disorders (SUD) increased by 50%
Number of members receiving pharmacotherapy for Opioid Use Disorder increased by 30%
The number of practitioners providing outpatient psychotherapy or counseling to Medicaid members more than doubled:
Treating Opioid Use Disorder (OUD) to 691 practitioners
Treating SUD to 1,603 practitioners

15. ARTS Narrows the Treatment Gap: 50% members with SUD receiving any treatment
Prevalence of members with SUD is likely higher than the estimates in this report because they include only those who have been diagnosed or treated for SUD. 

16. ARTS Narrows the Treatment Gap: 30% members with OUD receiving pharmacotherapy
Prevalence of members with SUD is likely higher than the estimates in this report because they include only those who have been diagnosed or treated for SUD. 

17. Pharmacotherapy for OUD Increasing
ARTS significantly increased the number of Medicaid members receiving pharmacotherapy for OUD in all regions in Virginia.

18. Number of Outpatient Providers Treating OUD More than Doubled
During the first three months, ARTS has reduced the treatment gap for SUD by increasing the number of practitioners providing services for SUD across all regions in Virginia

19. Implementation of CDC Opioid Prescribing Guideline in Medicaid Fee-for-Service and all MCOs
Uniform, Stream-lined Prior Authorization Forms for
All Short acting opioids > 7 days or 90 MME and long-acting opioids
Requires PMP check and urine drug screen
Increase access to Naloxone
Naloxone injection and Naloxone nasal spray (Narcan®) available without PA and no quantity limits
Include non-opioid pain relievers on all MCO formularies without PA
Lidocaine patches
Capsaisin topical gel
SNRIs including duloxetine
Gabapentin and pregabalin (Lyrica®)
NSAIDs including oral and topicals (diclofenac gel)
Baclofen
Tricyclic antidepressants (TCAs)
Buprenorphine patches and buccal film for pain (requires PA)

20. Medicaid Fee-for-Service Opioid Utilization
Decrease in Opioid Rx and Costs After CDC Opioid Prescribing Guideline Implemented 7/1/16
Medicaid Fee-for-Service Opioid Utilization
Total Pills Dispensed
$ Spend
Members with Opioid Rx

21. Medicaid Managed Care Utilization
Opioid Rx and Costs After CDC Opioid Prescribing Guideline Implemented 12/1/16 for New Starts and 4/1/17 for All Members
Medicaid Managed Care Utilization
Total Pills Dispensed
$ Spend
Members with Opioid Rx
17% decrease
18% decrease
7% decrease

22. Patient Utilization Management & Safety (PUMS) Program
PUMS requires Medicaid managed health plans to:
ensure members are appropriately accessing and utilizing services
coordinate member care (including case management)
focus on patient safety
PUMS has six criteria associated with opioid and other controlled substances utilization
PUMS 1 – any member on buprenorphine must be “locked-in” to a preferred Office Based Opioid Treatment provider or in-network buprenorphine waivered practitioner
Virginia’s Prescription Monitoring Program (PMP)
MCO physicians and pharmacists can access the PMP to view member’s controlled substance utilization including cash transactions

23. PUMS Criteria
Buprenorphine Containing Product*: Therapy in the past 30 days – AUTOMATIC LOCK-IN
*Exclude members using Butrans and Belbuca when used for the treatment of pain.
High Average Daily Dose: > 120 cumulative morphine milligram equivalents (MME) per day over the past 90 days
Opioids and Benzodiazepines concurrent use – at least 1) Opioid claim and a 14 day supply of Benzo (in any order)
Doctor and/or Pharmacy Shopping: > 3 prescribers OR > 3 pharmacies writing/filling claims for any controlled substance in the past 60 days
Use of a Controlled Substance with a History of Dependence, Abuse, or Poisoning/Overdose: Any use of a controlled substance in the past 60 days with at least 2 occurrences of a medical claim for controlled Substance Abuse or Dependence in the past 365 days
History of Substance Use, Abuse or Dependence or Poisoning/Overdose: Any member with a diagnosis of substance use, substance abuse, or substance dependence on any new claim in any setting (e.g., ED, pharmacy, inpatient, outpatient, etc.) within the past 60 days.

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Questions
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