Medicaid: Paving the Path to Recovery

By Jennifer Ryan, Vice President; Tanya Schwartz, Director, Medicaid Policy; and Molly Brassil, Director, Behavioral Health Policy

One would need to be completely “off the grid” to not be aware of the opioid crisis that has overtaken the country. Alarming and heart wrenching stories about the surprising range of victims of the substance use epidemic top the news headlines on a daily basis. The death rate due to drug overdoses has exceeded car accidents as the leading cause of death among adults under age 50 – since 2000, the rate of overdose deaths involving opioids (opioid pain relievers and heroin) has increased by 200%.

In his critically acclaimed book about the origins of the opioid crisis, Dreamland, Sam Quinones credits a surprising confluence of events – a particularly industrious group of young men from a small region in Mexico in the 1990s; the unbridled proliferation of OxyContin by legitimate and not-so-legitimate doctors in the early 2000s; and the loss of sense of community in middle America in the 21st century – with creating a public health crisis that local, state, and federal officials cannot seem to get under control.

“This epidemic involved more users and far more death than the crack plague of the 1990s or the heroin plague of the 1970s, but it was happening quietly.  Kids were dying in the Rust Belt of Ohio and the Bible Belt of Tennessee.  Some of the worst of it was in Charlotte’s best country club enclaves… Via pills, heroin had entered the mainstream.”

–Sam Quinones, Dreamland

States are taking the lead in developing innovative Medicaid-based approaches to substance use disorder (SUD) treatment and prevention using the Section 1115 waiver authority. Harbage Consulting is proud to have worked with four states – California, West Virginia, Minnesota and Alaska – to design and implement these programs.

West Virginia’s SUD Continuum of Care

On October 10, 2017, the State of West Virginia received approval from the Centers for Medicare & Medicaid Services (CMS) to provide a continuum of care designed to treat substance use issues among the state’s Medicaid population. Harbage Consulting is proud to have worked with West Virginia from the beginning to design a continuum of care for enrollees, draft the Section 1115 waiver application and implementation plan, and assist the state in negotiating the waiver with CMS.

The state’s initiative seeks to reduce the overdose death rate in West Virginia – the highest in the nation – to increase access to and utilization of appropriate SUD treatment services and improve care coordination across the treatment and recovery continuum.

Relying on the American Society of Addiction Medicine (ASAM) criteria, a nationally recognized, comprehensive set of guidelines for the placement, continued stay, and transfer or discharge of patients with SUD, West Virginia’s Medicaid program will cover the following new services:

  • Use of the widely-accepted Screening, Brief Intervention, and Referral to Treatment (SBIRT) screening tool to identify SUD treatment needs;
  • Inpatient withdrawal management services for individuals with severe withdrawal issues as they discontinue substance use;
  • Methadone treatment, administration and monitoring of it and related counseling;
  • Residential treatment services for residents in an institutional care setting of any size, including facilities that meet the definition of an institution for mental diseases (IMD);
  • Recovery support services to prevent and treat relapse, including counseling provided by peer recovery coaches;
  • Expanded care coordination services to help individuals navigate the available substance use treatment and recovery support services; and
  • An initiative to make naloxone widely available and to increase awareness across the state.

Certain services, such as coverage of Methadone, will be implemented on January 1, 2018. Other services, such as residential treatment, peer recovery support, and withdrawal management services will be implemented on July 1, 2018.  We hope that enhancing access to SUD treatment in West Virginia will save the lives of many of their residents.

California’s “Drug Medi-Cal Organized Delivery System”

California was the first state to receive approval of a Medicaid SUD waiver in 2015, The Drug-Medi-Cal Organized Delivery System, and we have been supporting the state as well as county governments in navigating the challenging process of implementing the new program and ensuring that an adequate provider network is in place to meet the growing demand.  The waiver program includes an expansion of services to offer a more complete continuum of care to Medi-Cal beneficiaries, and grants counties more control over service delivery, including selective provider contracting and interim rate-setting.

The continuum is largely modeled after the levels of care defined in the ASAM criteria. One of the most significant shifts under the program is that residential treatment is covered for all Medi-Cal beneficiaries based on medical necessity (no longer limited to perinatal women) in facilities of any size (no longer limited to 16 beds). As of October 2017, seven counties have implemented the new SUD treatment services under the waiver program and 33 others have submitted plans to implement, reaching nearly 95% of California’s Medi-Cal population.

Beyond Medicaid: More Work Still Needed

While there is so much more work to be done, Harbage Consulting is hopeful that state Medicaid agencies will continue to lead the way in combatting this crisis that is universally affecting their residents. However, the Medicaid program is only one lever in the broader system – in order for long-term progress to be made, the public and private sectors, state legislatures, and the advocacy community will need to come together to implement broad-based, coordinated strategies that will not only focus on treating SUDs and preventing overdose deaths, but stem the tide of addiction before it starts.

Stay tuned for our next blog on how the SUD epidemic is impacting youth in California.