Appendix to Position Statement 33: Substance Use Disorders
The President’s Commission on Combatting Drug Addiction and the Opioid Crisis issued a report on November 1, 2017, that contained 56 recommendations, covering a wide spectrum of potential improvements in substance use disorder prevention, screening, early intervention, and treatment, many of which are reflected in this and other MHA position statements.
MHA’s Recommendations to the Commission
MHA offered the following two recommendations as input into the Commissions’ report:
Recommendation 1: We need to add substance use screening and remission measures to quality measurement initiatives, such as the CMS-AHIP Core Quality Measures Collaborative.
Quality measurement in health care does not reward effective substance use treatment. While American doctors do what is right out of concern for the people they serve, our payment system does very little to reinforce this. By changing the way we measure success in substance use treatment, we can energize health care’s role in the opioid crisis.
In depression, for example, there is a quality measure for screening and a quality measure for achieving remission at one year. These quality measures incentivize doctors to identify problems early and make sure that people are getting effective care.
In substance use, we have a screening measure, but it is not often used as part of quality measurement. Without a quality measure of screening, we don’t reward busy doctors for screening for substance use. There are no quality measures of substance use remission at one year being used. Without a quality measure of remission at one year, doctors are only expected to screen and refer. They do not get credit for staying on top of condition management and seeing that the treatment is ultimately effective.
To address the opioid crisis, we need to do a better job rewarding providers for their role – we need to add substance use screening and remission measures to quality measurement initiatives, such as the CMS-AHIP Core Quality Measures Collaborative.
Recommendation 2: Pilot and Scale new Maternity Care Bundled Payment models.
Current fee-for-service health care payments incentivize low-value, high-cost care to treat substance use through obstetrics.
While there are many points of intervention in the opioid crisis, none is perhaps so critical as at conception. Maternity care offers a point of health care contact for families with opioid dependencies, and provides an opportunity to break possible intergenerational cycles while dramatically reducing mid- and long-term costs.
The Administration has an opportunity to catalyze American health care innovation in maternity care amidst the opioid crisis by piloting and scaling new maternity care bundled payment models.
In our suggested model, providers (e.g., the obstetrics clinic) would screen for substance use and related stressors (see the kinds of questions on the Survey of Well-Being of Young Children’s Family Questions). Payers (in many instances, Medicaid) would estimate how much the maternity care episode and early years of the child’s life are likely to cost them if none of these issues are taken care of – i.e. the status quo.
If the obstetrics practice is able to intervene and stop the substance use and mitigate related stressors by six months postpartum (the end of the maternity care episode), the payer would then share some of the estimated savings.
The governmental savings that could result from this approach are significant, and range from reducing the need for neo-natal care intervention to avoiding long-term care and support costs for children exposed to substances during pregnancy. Maternity care bundled payments for reducing perinatal substance use and related stressors can be a key intervention in the opioid crisis, and good health care practice generally.
Commission Recommendations Aligned with MHA’s Position Statement
The following recommendations, as edited in bold type, are specifically endorsed by MHA as part of this position statement, recognizing that advocacy and funding will be necessary to make this ambitious agenda a reality:
- Mandate federal leadership in the development and implementation of training programs for health care providers and educators to screen at-risk patients and primary, secondary and college students for substance use and mental health issues, such as “Screening, Brief Intervention and Referral to Treatment” (SBIRT) programs;
- Mandate that HHS, CMS, the Substance Abuse and Mental Health Services Administration (SAMHSA), the VA, and other federal agencies incorporate quality measures that address addiction screenings and treatment referrals to ensure that all health care providers are screening for SUDs and know how to appropriately counsel and refer people for effective treatment;
GUIDELINES AND LICENSING
- Mandate federal leadership in the development and implementation of a national curriculum and standard of care for all opioid prescribers, to supplement the CDC guidelines that are specifically targeted to primary care physicians;
- Mandate that the DEA to require that all prescribers desiring to be relicensed to prescribe opioids show effective participation in an approved continuing medical education program on opioid prescribing;
PRESCRIPTION DRUG MONITORING (PDMP) ACT
- Support the proposed Prescription Drug Monitoring (PDMP) Act to mandate states to share data and directs DOJ to fund the establishment and maintenance of a data-sharing hub, to mandate PDMP data integration with electronic health records, overdose episodes, and SUD-related decision support tools, and to remove legal barriers and ensure inclusion of overdose/naloxone deployment data;
- Remove pain survey questions entirely on patient satisfaction surveys, so that providers are never incentivized for offering opioids;
- Modify rate-setting policies that discourage the use of non-opioid treatments for pain, such as certain bundled payments that make alternative treatment options cost prohibitive for hospitals and doctors, particularly those options for treating immediate post-surgical pain;
- Encourage adoption of process, outcome, and prognostic measures of treatment services endorsed by the National Outcome Measurement and the American Society of Addiction Medicine (ASAM);
REMOVE REIMBURSEMENT AND POLICY BARRIERS
- Mandate HHS/CMS, the Indian Health Service (IHS), Tricare, the DEA, and the VA to remove reimbursement and policy barriers to SUD treatment, including those, 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;
TREATMENT WITHIN 24 HOURS
- Mandate that all primary care providers employed by the above-mentioned health systems screen for alcohol and drug use and, directly or through referral, provide treatment within 24 to 48 hours;
COVER TRUE COSTS
- Mandate that 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;
PARITY -- DOL JURISDICTION OVER ERISA PLANS
- Because the Department of Labor (DOL) regulates health care coverage provided by many large employers under ERISA, Congress should 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;
PARITY -- STANDARDIZED TOOL FOR PARITY ENFORCEMENT
- Require that federal and state regulators mandate use of a standardized tool for parity enforcement that requires health plans to document and disclose their compliance strategies for non-quantitative treatment limitations (NQTL) parity, including stringent prior authorization and medical necessity requirements;
PARITY -- REVIEW CLINICAL GUIDELINES AND RATES
- Mandate that HHS, in consultation with DOL and Treasury, review clinical guidelines and standards to support NQTL parity requirements and that private sector insurers, including employers, review rate-setting strategies and revise rates when necessary to increase their network of addiction treatment professionals;
MEDICATION ASSISTED TREATMENT
- Mandate that 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;
- Mandate that DOJ broadly establish federal drug courts within the federal district court system; States, local units of government, and Indian tribal governments should apply for drug court grants established by 34 U.S.C. § 10611; Individuals with an SUD who violate probation terms with substance use should be diverted into drug court, rather than prison;
- Expand the use of recovery coaches, especially in hard-hit areas;
- Mandate federal health systems and encourage insurance companies and state payers to expand programs for hospital and primary case-based SUD treatment and referral services and prioritize addiction treatment knowledge across all health disciplines; adequate resources are needed to recruit and increase the number of addiction-trained psychiatrists and other physicians, nurses, psychologists, social workers, physician assistants, and community health workers and facilitate deployment in needed regions and facilities.
- Revise regulations and reimbursement policies to allow for SUD treatment via telemedicine.
- Encourage regulatory changes to allow Emergency Medical Technicians (EMT) to administer naloxone, including higher doses to account for the rising number of fentanyl overdoses;
- Encourage HHS to develop new guidance for Emergency Medical Treatment and Labor Act (EMTALA) compliance with regard to treating and stabilizing SUD patients and provide resources to incentivize hospitals to hire appropriate staff for their emergency departments;
RECOVERY SUPPORT SERVICES AND FAMILY PRESERVATION
- Encourage HHS to implement guidelines and reimbursement policies for Recovery Support Services, including peer-to-peer programs, jobs and life skills training, supportive housing, and recovery housing;
- Encourage 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 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;
- Encourage the Office of National Drug Control Policy (ONDCP), which reports directly to the President, https://www.whitehouse.gov/ondcp , the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Department of Education (DOE) to 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;
- Encourage the ONDCP, federal partners, including DOL, large employers, employee assistance programs, and recovery support organizations develop best practices on SUDs and the workplace. Employers need information for addressing employee alcohol and drug use, ensure that employees are able to seek help for SUDs through employee assistance programs or other means, supporting health and wellness, including SUD recovery, for employees, and hiring those in recovery;
- Encourage the ONDCP, federal agencies, the National Alliance for Recovery Residents (NARR), the National Association of State Alcohol and Drug Abuse Directors (NASADAD), and housing stakeholders to 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;
DECOUPLE FELONY CONVICTIONS AND ELIGIBILITY FOR BUSINESS/OCCUPATIONAL LICENSES
- Encourage the ONDCP to work with the DOJ, DOL, the National Alliance for Model State Drug Laws, the National Conference of State Legislatures, and other stakeholders to develop model state legislation/regulation for states to decouple felony convictions and eligibility for business/occupational licenses, where appropriate;
ESTABLISH GOALS FOR PAIN MANAGEMENT AND ADDICTION RESEARCH (BOTH PREVENTION AND TREATMENT)
- Encourage federal agencies, including HHS (National Institutes of Health, CDC, CMS, FDA, and the Substance Abuse and Mental Health Services Administration), DOJ, the Department of Defense (DOD), the VA, and the ONDCP, to engage in a comprehensive review of existing research programs and establish goals for pain management and addiction research (both prevention and treatment);
- Encourage Congress and the Federal Government provide additional resources to the National Institute on Drug Abuse (NIDA), the National Institute of Mental Health (NIMH), and National Institute on Alcohol Abuse and Alcoholism (NIAAA) to fund the research areas cited above; NIDA should continue research in concert with the pharmaceutical industry to develop and test innovative medications for SUDs and OUDs, including long-acting injectables, more potent opioid antagonists to reverse overdose, drugs used for detoxification, and opioid vaccines;
- Encourage CMS, FDA, and the United States Preventative Services Task Force (USPSTF) implementation a fast-track review process for any new evidence-based technology supporting SUD prevention and treatments;
- Encourage commercial insurers and CMS to fast-track creation of Healthcare Common Procedure Coding System (HCPCS) codes for FDA-approved technology-based treatments, digital interventions, and biomarker-based interventions;
- Encourage NIH to develop a means to effectively evaluate behavior modification apps for effectiveness;
- Encourage the FDA to establish guidelines for post-market surveillance related to diversion, addiction, and other adverse consequences of controlled substances.