Treatment & Recovery

SAFE Takes analyzes and assesses the federal recommendations and proposals made by the White House and National Governors Association.

SAFE Takes reflects our analysis and assessment of the progress made in each of the recommendations made by the President’s Commission (Commission) on Combatting Drug Addiction and the Opioid Crisis (November 2017) and the National Governors Association’s (NGA) Recommendations for Federal Action to End the Nation’s Opioid Crisis (January 2018). The following SAFE Takes focuses on government action pertaining to treatment and recovery.

Legend

RECOMMENDATIONS S.A.F.E. TAKE
NGA: Congress should align 42 CFR Part 2 with the Health Insurance Portability and Accountability Act (HIPAA) to bring substance use disorder (SUD) info with other types of health data.

 

STATUS
Little Movement
 
There are two sides to this – data sharing can save lives. However, without strong privacy protection, it can adversely affect one’s livelihood in and after recovery. Proceed with caution. We wrote about this as legislation was being introduced, however, it did not make it into the final version of H.R. 6, SUPPORT for Patients and Communities Act.
RECOMMENDATIONS S.A.F.E. TAKE
Commission #4: The Department of Education should collaborate with states (Dept. of Ed) on student assessment programs, such as Screening, Brief Intervention, and Referral to Treatment (SBIRT) to identify at-risk youth who may need treatment.

 

STATUS 

Little Federal Progress

 

Schools are leary of doing any assessments on kids. They don’t want to be held responsible for knowing something about a child and not addressing it. Assessment in schools by school staff is rare. However, school districts do not need to wait for the Department of Education to implement SBIRT – there is a free tool available (CRAFFT Screening Tool
RECOMMENDATIONS S.A.F.E. TAKE
NGA: The Administration should expedite approval of Medicaid Institute for Mental Diseases (IMD) waivers. Congress should enact legislation creating an exception to IMD exclusion for those receiving SUD treatment.

 

STATUS 
Steady Progress
 

Waivers can currently be requested for opioid use disorder but not for broader substance use disorder. As part of the Department of Health and Human Services effort to combat the ongoing opioid crisis, on November 1, 2017, the Centers for Medicare & Medicaid Services (CMS) issued guidance describing additional flexibilities to help states improve access to, and quality of, SUD treatment through Medicaid section 1115 demonstrations.

The Medicaid Innovation Accelerator Program (IAP) is available to support Medicaid agencies interested in strategic design support to develop their section 1115 SUD demonstration proposals and implementation plans. For more information, visit IAP SUD Individualized Technical Support Opportunities.

H.R. 6, SUPPORT for Patients and Communities Actprovides the option to cover care in IMDs, which may otherwise not be reimbursed, for treatment of SUD for patients aged 21-64 during fiscal years 2019-2023. However, this is still not a permanent solution.

RECOMMENDATIONS S.A.F.E. TAKE

NGA: Health & Human Services (HHS) should strengthen federal oversight and ensure the Mental Health Parity and Addiction Equity Act (MHPAEA)/parity violations do not limit access to substance use disorder (SUD) treatment. 

Commission #33:  HHS, The Centers for Medicare and Medicaid Services (CMS), the Indian Health Service (IHS), Tricare, the Drug Enforcement Agency (DEA), and the Veterans Administration (VA) should remove reimbursement and policy barriers to SUD treatment, such as patient limits, that limit access to any forms of FDA-approved medication-assisted treatment (MAT), counseling, inpatient/residential treatment, and other treatment modalities, particularly fail-first protocols and frequent prior authorizations. All primary care providers employed by the above-mentioned health systems should screen for alcohol and drug use, and provide treatment within 24 to 48 hours, directly or through referral. 

Commission #35: Because the Department of Labor (DOL) regulates health care coverage provided by many large employers, the Commission recommends that Congress provide DOL increased authority to levy monetary penalties on insurers and funders, and permit DOL to launch investigations of health insurers independently for parity violations. 

Commission #36: Federal and state regulators should use a standardized tool that requires health plans to document and disclose their compliance strategies for non-quantitative treatment limitations (NQTL) parity. HHS, in consultation with DOL and Treasury, should review clinical guidelines and standards to support NQTL parity requirements.

 

STATUS

Uncoordinated

 

There is a lot of confusing messaging from the government about parity rules and enforcement, healthcare insurance coverage for inpatient treatment, and substance use. Congress has been making progress on some areas, but overall, government action on this front shows a lack of coordinated effort.
RECOMMENDATIONS S.A.F.E. TAKE

NGA: Expand access to evidence-based SUD and mental health services for justice-involved populations. Specifically, medicaid coverage for medicaid-eligible individuals who are incarcerated pending disposition or nearing release. CMS should grant states (under 1115 authority) partial waivers of inmate exclusion otherwise barring states form receiving federal Medicaid funding in these circumstances. 

Commission #37: The Commission recommends the National Institute on Corrections (NIC), the Bureau of Justice Assistance (BJA), the Substance Abuse and Mental Health Services Administration (SAMHSA), and other national, state, local, and tribal stakeholders use medication-assisted treatment (MAT) with pre-trial detainees and continuing treatment upon release. 

 

STATUS

Needs Funding, Culture and Attitude Change

 

The most lethal time for any opioid user is the two weeks after release from jail or prison. Social and environmental factors as well as a decreased tolerance both increase vulnerability for return to use and overdose.

The move to allow for Medication Assisted Treatment (MAT), also known as pharmacotherapy, for incarcerated individuals has been very slow,  mostly due to funding, concerns over diversion of prescription medicine for illicit use within the facilities, and a general misunderstanding of the role of these medications and their effectiveness for longer term treatment of SUD. Even if inmates have access to MAT/pharmacotherapy, those with felony charges are not eligible for medicaid coverage upon release until their probation is complete, creating a dangerous gray area.

Public-Public and Public-Private partnerships must be formed in most cases so the correctional facility can make a warm handoff of medical services to the local managed care organization (MCO/Medicaid provider) or county health department. In 2016 Rhode Island launched a first of its kind program in the country to provide medically assisted substance abuse treatment for incarcerated individuals, as well as transition programs to connect with treatment providers upon release. Rhode Island is currently the only state that mandates the use of all three evidenced-based opioid withdrawal medications (Vivitrol, Suboxone, and Methadone).

All of these systems mentioned are working on incorporating MAT/pharmacotherapy into their programs and making it available to current incarcerated offenders. H.R. 6, Support for Patients and Communities Act requires Health and Human Services to convene a stakeholder group to report on best practices for states on this topic. This is an important, but tiny step in an area critical to impacting this crisis.

RECOMMENDATIONS S.A.F.E. TAKE
NGA: Health and Human Services should revise Medicare coverage requirements to cover methadone at community outpatient treatment programs.

 

STATUS 
Complete
 
H.R. 6, SUPPORT for Patients and Communities Act expands Medicare coverage to Opioid Treatment Providers and does not limit the coverage to methadone only. This is a big win for senior citizens using Medicare who struggle with opioid use disorder. However, there are still many barriers for Medicaid clients, who have to pay out of pocket for treatment in these programs.
RECOMMENDATIONS S.A.F.E. TAKE

NGA:  The Health Resources and Services Administration (HRSA) should expand definition of approved sites where primary care providers can be reimbursed for providing medication assisted treatment (MAT) and other behavioral health interventions to include substance use disorder (SUD) treatment facilities.

Commission #34: Health and Human Services (HHS) review and modify rate-setting (including policies that indirectly impact reimbursement) to better cover the true costs of providing SUD treatment, including inpatient psychiatric facility rates and outpatient provider rates.

 

STATUS
Needs More Work
 
H.R. 6, SUPPORT for Patients and Communities Act works to increase the number of providers who can treat SUD with MAT. However, reimbursement rates will impact how many qualified providers actually provide the treatment, and it doesn’t seem to address that. Once improved reimbursement demonstrates positive impact in the field then the rate will be justified. SAMSHA-HRSA promotes the use of integrated care for treatment of substance use disorder with tools and resources.
RECOMMENDATIONS S.A.F.E. TAKE
Commission #32: Adopt process, outcome, and prognostic measures of treatment services as presented by the National Outcome Measurement and the American Society of Addiction Medicine (ASAM).

 

STATUS 

Slow Progress

 

Yes! We need more money for research of evidence based practices and recovery supports that work. Policies for outcome measurements have to be adopted by insurers, providers, healthcare systems, and government to enable real change in treatment models.
RECOMMENDATIONS S.A.F.E. TAKE
Commission #39: The federal government should partner with appropriate hospital and recovery organizations to expand the use of recovery coaches, especially in hard-hit areas. Insurance companies, federal health systems, and state payers should expand programs for hospital and primary case-based SUD treatment and referral services.

 

STATUS 
Progress at State Level
 
Great recommendation – doable and affordable. The model can save lives and money. Rhode Island – RI-CARES – was one of the first states to use recovery coaches in the emergency room (ER). They are collecting data about their work and now other states are adopting this practice. This model can be utilized in any ER.
RECOMMENDATIONS S.A.F.E. TAKE
Commission #40:  The Commission recommends the HRSA prioritize addiction treatment knowledge across all health disciplines.

 

STATUS

Slow Going

 

Psychiatric/medical academic programs have an average of 8 hours of total education for students about substance use disorders.  Information in this area should be much more available and more intensive for health care providers. Medical schools, boards, and healthcare systems can all help make this a reality today.
RECOMMENDATIONS S.A.F.E. TAKE
Commission #46: The Commission recommends that HHS implement guidelines and reimbursement policies for Recovery Support Services, including peer to peer programs, jobs and life skills training, supportive housing, and recovery housing.

 

STATUS 
On the right track
 

These recovery support services were included in the first piece of legislation called CARA (Comprehensive Addiction Recovery Act), however, they were not funded. Some states have added recovery coaches to their formulary but it is hit and miss. When someone successfully stops misusing, but can’t find employment, or housing, or a community of support, they are more likely to re-engage in misuse. Recovery Support Services are part of treatment.

H.R. 6, SUPPORT for Patients and Communities Act requires HHS to issue best practices for recovery housing, and to identify common indicators in fraudulent recovery housing operators. The Building Communities of Recovery program was reauthorized and modified by the law to include peer support networks and funding for community organizations focused on long-term recovery support services. H.R. 6 also requires HHS to establish a National Peer-Run Training and Technical Assistance Center for Addiction Recovery Support to facilitate expansion of comprehensive recovery support programs in communities, as well as provide a program to support transition to independent living and return to the workforce.

RECOMMENDATIONS S.A.F.E. TAKE

NGA:  Health & Human Services (HHS) should issue guidance encouraging universal screening of pregnant women as part of comprehensive obstetric care. HHS should also issue comprehensive standards for treating neonatal abstinence syndrome.

Commission #47: HHS, the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Administration on Children, Youth and Families (ACYF) should disseminate best practices for states regarding interventions and strategies to keep families together, when it can be done safely (e.g., using a relative for kinship care). These practices should include utilizing comprehensive family centered approaches and should ensure families have access to drug screening, substance use treatment, and parental support. Further, federal agencies should research promising models for pregnant and postpartum women with substance use disorders (SUDs) and their newborns, including screenings, treatment interventions, supportive housing, non-pharmacologic interventions for children born with neonatal abstinence syndrome, medication-assisted treatment (MAT) and other recovery supports.

 

STATUS 
Moving Forward
 

When screening laws lead to separation of families with a charge of “neglect and abuse,” the safety and health risk increases for mothers and children. The opioid crisis has caused a dramatic increase in the number of children in foster care. Communities and states must ask (if children can be kept safe with their parents); does investment in finding ways to keep families together and healthy make more fiscal and emotional sense than foster care?

H.R. 6, SUPPORT for Patients and Communities Act has several provisions to improve care for infants with neonatal abstinence syndrome and their mothers – an important step in reducing the impact of this crisis to next generations. The law includes a study to identify gaps in Medicaid coverage for pregnant and postpartum mothers, clarification for states on provision of Medicaid to infants with NAS, and provision of support for their mothers. It also provides funding for HHS to test a “recovery coach” program for parents with children in foster care, along with an increase of funding to increase capacity for family-focused residential treatment.

RECOMMENDATIONS S.A.F.E. TAKE
Commission #48: The Office of National Drug Control Policy (ONDCP), SAMHSA, and the Department of Education (DOE) should identify successful college recovery programs, including “sober housing” on college campuses, and provide support and technical assistance to increase the number and capacity of high-quality programs to help students in recovery.

 

STATUS 

Needs Funding

 

Great idea but there has been no money for this. Technical assistance and services for Collegiate Recovery Programs has not previously been funded by the federal government and there is no current legislation to support it.

RECOMMENDATIONS S.A.F.E. TAKE
Commission #51: ONDCP, federal agencies, the National Alliance for Recovery Residences (NARR), the National Association of State Alcohol and Drug Abuse Directors (NASADAD), and housing stakeholders should work collaboratively to develop quality standards and best practices for recovery residences, including model state and local policies. These partners should identify barriers (such as zoning restrictions and discrimination against MAT patients) and develop strategies to address these issues.

 

STATUS 

Consistent Progress

 

NARR has done a great job to move this initiative forward with support from many partners. Standards have been developed and housing all over the country is implementing better quality according to these standards. Continued work must be done but work to date must be applauded and recognized. In May 2018, the National Council for Behavioral Health and NARR partnered in creating a Recovery Housing Toolkit to help state policy makers move forward.