Payment & Delivery Models

Wider use of proven treatment is goal of opioid-use disorder APM

Andis Robeznieks , Senior News Writer

Increasing the use of, and access to, medications proven to be effective in treating opioid-use disorder is the purpose behind a new alternative payment model that supports coordinated delivery of medical, psychological and social services to the patients who need them.

The Patient-Centered Opioid Addiction Treatment (P-COAT) model was developed by the American Society of Addiction Medicine (ASAM) and the AMA, and is designed to support and facilitate coordination between treatment providers. Historically, payments for these services has been segregated and payment has been lacking for services such as phone calls and emails to coordinate treatment between patients, primary care physicians, specialists, outpatient treatment programs and emergency departments.

“Arbitrary limitations on effective, comprehensive treatment are stymying physician efforts to treat patients with opioid-use disorder,” said AMA Opioid Task Force Chair Patrice A. Harris, MD. “This new tool will remove a brick in the wall that prevents patients from accessing needed treatment.”

Surge in opioid-use disorder

The P-COAT concept paper cites a Blue Cross Blue Shield Association report noting that there has been a 493 percent surge in opioid-use disorder (OUD) diagnosis between 2010 and 2016. But, despite its proven clinical effectiveness, the use of medication-assisted therapy (MAT) to treat OUD has increased only 65 percent—meaning the rate of diagnoses rose eight times as quickly as the rate of MAT use.

New treatment starts for MAT have nearly doubled from 44,000 in December 2015 to 82,000 in Decembers 2017. But heroin- and fentanyl-related deaths continue to increase at a “staggering rate,” Dr. Harris said in response to news of a 22 percent nationwide drop in opioid prescribing between 2013 and 2017.

“These statistics again prove that simply decreasing prescription opioid supplies will not end the epidemic,” she added. “We need well-designed initiatives that bring together public and private insurers, policymakers, public health infrastructure, and communities with the shared goal to improve access and coverage for comprehensive pain management and treatment for substance use disorders.”

An estimated 2.5 million patients could benefit from MAT with medications such as buprenorphine, but physicians are required to obtain special certification before they are allowed to prescribe it. There are 45,000 physicians who hold the proper certification, but 72 percent are limited to treating 30 patients and it is estimated that 40 percent of certified physicians do not write any buprenorphine prescriptions at all, according to January 2018 data from the Substance Abuse and Mental Health Services Administration.

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ASAM is a member of the AMA Opioid Task Force, which recommends reducing the stigma of opioid-use disorder and enhancing access to treatment as one of its goals for physicians.

The P-COAT concept paper notes how a major hurdle to accessing treatment has been the poor integration of MAT as a pharmacy benefit into a complicated and fragmented insurance coverage and payment structure for behavioral health benefits.

Many insurance plans have not provided sufficient coverage for services related to OUD. When coverage is provided, it is often through a separate insurance plan or is more limited and requires higher out-of-pocket spending by patients.

“While we know that a combination of medication and psychosocial support systems is the evidence-based standard for treatment, we continue to find that patients are not able to access treatment due to limited or non-existent insurance coverage,” said Shawn Ryan, MD, chair of the AMA-ASAM APM Working Group and ASAM’s Payer Relations Committee.

The P-COAT model is designed to increase the number of patients who can successfully manage their condition while also reducing health care spending on costs associated with OUD, such as emergency department visits and hospitalizations.

It’s hoped that the release of P-COAT concept “will begin a national conversation with insurers and policymakers about what it takes for successful treatment and recovery,” Dr. Ryan said.

Anyone interested in participating in P-COAT can submit their contact information using this form.

The lack of financial support for non-face-to-face care-coordination activities was noted in an AMA letter to leaders of the U.S. House Ways and Means committee. The committee then highlighted these concerns in a white paper analyzing suggestions they received for future opioid-related legislation and policy.

Physicians are invited to be part of this conversation on the AMA End the Opioid Epidemic microsite. The AMA wants doctors to share their stories and suggestions about the role of medical education in ending the epidemic, worthwhile training programs they attended, their experiences with state prescription drug-monitoring programs, and the steps they’ve taken to reduce stigma and increase access to naloxone.

The AMA offers online CME to expand your understanding of the opioid epidemic. Explore educational content such as "A Primer on the Opioid Morbidity and Mortality Crisis: What Every Prescriber Should Know."