- The American Society of Addiction Medicine (ASAM) and the American Medical Association (AMA) recently unveiled an alternative payment model that aims to improve care and reduce costs associated with opioid use disorder.
The new alternative payment model, known as the Patient-Centered Opioid Addiction Treatment (P-COAT), restructures how physicians are paid to provide office-based, outpatient medication-assisted treatment for patients with opioid addictions.
“The current physician reimbursement structure does not account for all the services that patients with an opioid use disorder need to progress to successful treatment and recovery,” explained Shawn Ryan, MD, MBA, ABEM, ABAM, FASAM, Chair of the AMA-ASAM APM Working Group and ASAM’s Payer Relations Committee. “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.”
Medication-assisted treatment is key to treating opioid use disorder. However, the use of the treatment is limited because of existing physician reimbursement and coverage structures.
Over 45,000 physicians are certified by the Substance Abuse and Mental Health Services Administration to prescribe buprenorphine as part of a medication-assisted treatment plan for opioid use disorder. But about 40 percent of them do not write prescriptions for buprenorphine.
Physicians face challenges with prescribing medication-assisted therapy because many insurance plans do not offer adequate coverage for the full treatment plan or plans offer coverage through additional plans.
The current reimbursement system exacerbates the challenges with prescribing medication-assisted treatment for opioid use disorder. According to AMA and ASAM, reimbursement issues include:
• Payments for Evaluation and Management (E&M) services do not cover the time a provider needs to diagnose an opioid use disorder and create a treatment plan with the patient
• E/M service payments require face-to-face encounters with patients and do not support telephone, email, or other electronic communications with patients
• Limited payment structure does not allow primary care physicians and addiction specialists to communicate electronically to help primary care offices diagnose and treat opioid use disorder
• Reimbursement for behavioral health services to primary care and addiction specialist practices do not cover the costs of care, and credentials needed for billing for these services are unrealistic
• Payers usually do not reimburse for technology-based treatment and recovery support tool use, remote monitoring, and/or services used in conjunction with outpatient treatment for opioid use disorder
• Prior authorization requirements for medications and outpatient services disrupt timely, effective care
• Medical billing for substance use disorder services too complex
These reimbursement challenges result in higher healthcare costs and utilization, the industry groups argued. Patients who cannot access proper treatment for opioid use disorder increase costs by making frequent visits to the emergency department and experiencing inpatient admissions for their addiction. Patients with opioid use disorder also face longer hospital stays and hospital readmissions.
In addition, limited reimbursement structures for office-based outpatient treatment promotes more expensive hospital care. Lack of financial support results in higher spending on inpatient/residential programs and intensive outpatient services.
To curb spending and redirect opioid use disorder care to less costly settings, ASAM and AMA developed an alternative payment model to support office-based opioid addiction treatment involving the use of buprenorphine or naltrexone consistent with the ASAM Criteria or other equivalently evidence-based standards.
In addition to offering office-based outpatient use of either buprenorphine or naltrexone, practices must also have appropriate outpatient psychological and/or counseling therapy services and care coordination between care management, social support, and other necessary medical services.
Practices can partner with other providers to deliver all three required services. The combination of providers either in the practice or outside of it will be known as the Opioid Addiction Treatment Team.
The P-COAT model will reimburse practices that are part of an Opioid Addiction Treatment Teams under the following payment structures:
• Initiation of Medication-Assisted Treatment: one-time payment to support evaluation, diagnosis, and treatment planning, as well as the initial month of outpatient medication-assisted treatment
• Maintenance of Medication-Assisted Treatment: monthly payments to cover the costs of ongoing outpatient medication and psychological treatment and social services
AMA and ASAM noted that practices must meet minimum care quality requirements to receive the reimbursements under the alternative payment model. Key requirements include documentation of opioid use disorder diagnosis, screenings using a validated tool for substance abuse disorders, face-to-face visits to establish treatment plan, and coordination with other addiction-related services.
Payers will also adjust reimbursement to qualifying practices based on care quality, health outcome, and spending performance. Practices will be assessed for the percentage of patients who filled and used the medications prescribed, the percentage of patients who demonstrated compliance with the treatment plan, risk-adjusted average number of opioid-related emergency department visits per patient, and other measures.
In addition to the two payment structures, practices can also qualify for add-on payments for the use of technology-based treatment and recovery support tools. These payments will incentivize practices to use remote patient monitoring, communication and counseling for chronically ill patients, and psychotherapy for opioid use disorder patients.
AMA and ASAM intend for the alternative payment model to help payers and physicians engage in new ways of providing high-quality, cost-efficient care for opioid use disorder. The industry groups also revealed that the model could qualify as an Advanced Alternative Payment Model (APM) under MACRA to promote improved opioid addiction care.
“Arbitrary limitations on effective, comprehensive treatment are stymying physician efforts to treat patients with opioid use disorder,” said Patrice A. Harris, MD, MA, Chair of the AMA Opioid Task Force. “This new tool will remove a brick in the wall that prevents patients from accessing needed treatment. Eventually, this wall will be torn down. Until then, we must continue fighting for our patients and remove arbitrary barriers to care.”
Physician practices and payers interested in joining a pilot test of P-COAT can submit their contact information to the AMA and ASAM here.