January 2019 HOW TO PAY FOR IT MAT in Community Health Centers H ealth centers in California have increasingly While this funding has been crucial to expanding the focused on designing approaches to identify availability of MAT, health centers are still grappling and treat substance use disorder. One such with how to sustain these programs if grant funding approach is medication-assisted treatment, which ends. Reimbursement for MAT services is challeng- includes the use of Food and Drug Administration- ing, in large part, because health centers are paid a approved medications in combination with bundled rate for clinician visits under the prospective counseling and behavioral therapies.1 payment system (PPS). Services must be provided by a “Federally Qualified Health Center (FQHC) prac- To integrate medication-assisted treatment (MAT) titioner,” and not all medical professionals involved into primary care, health centers must engage in MAT are included in this definition (e.g., certified providers and staff, design the clinical model, alcohol and drug counselors, registered nurses).3 determine how to identify patients, redesign work- flow, and promote cross-discipline coordination. To Complicating reimbursement is the one-visit rule help pay for the expenses associated with these that prevents California health centers from being activities, the US Health Resources and Services paid for both physical health and behavioral health Administration’s Substance Abuse Service Expansion services delivered on the same day. In addition, the offered a grant program, and in federal fiscal year PPS bundled rate is inclusive of wraparound services 2016, 36 California health centers each received (e.g., care coordination), which may be more inten- between $300,000 and $400,000. Building on this sive for MAT patients and are viewed as critical to the investment, the Department of Health and Human success of delivering MAT in primary care.4 Services announced in June 2018 that an addi- tional $350 million would be available to support Funding concerns remain central as policymakers MAT implementation. Health centers are eligible for and health care providers gain a better understand- three categories of funds: $100,000 in base funding, ing of how to expand access to MAT in primary care. $150,000 in one-time funding to support infra- This paper summarizes five funding approaches structure investments, and $250 per MAT patient health centers may wish to consider and offers exam- reported in 2017.2 ples where available. Federally Funded FEDERALLY FUNDED MAT EXPANSION: PRO AND CON MAT Expansion Funds can be used to pay for team member salaries that are central to many MAT clini- Startup Funds from Health Plans In 2017 and 2018, California received $240 million as cal delivery models (e.g., substance abuse Partnership HealthPlan and Central California counselor, licensed vocational nurse) but part of the federal 21st Century Cures Act to support whose time would not otherwise be eligible for Alliance for Health have training incentives MAT expansion throughout the health care system. reimbursement under the PPS. Funds can also be ranging from $500 to $1,000. Inland Empire California is using these funds to add new MAT used to pay for care for uninsured patients. Health Plan offers stipends to support sub- access points in primary care clinics, mental health stance use disorder (SUD) certification for Current funding is only available through behavioral health providers. clinics, jails, residential treatment facilities, hospitals, September 2020, and future funding has not emergency departments, and other locations. Health been announced. Documentation requirements Consider contacting other local health plans centers can apply for funding to cover staffing and for care of under- and uninsured patients can be for support. start-up costs, as well as receive training and techni- time-consuming. cal assistance as part of a learning collaborative. Health centers may also opt to participate in the state’s hub-and-spoke program, which builds rela- Training and Start-Up TRAINING AND START-UP: PRO AND CON tionships with opioid treatment programs (previously Several sources for financial assistance or incentives Where available, these funds offer a valuable known as methadone clinics) and offers coverage for can support clinical education or program start-up opportunity to support new MAT programs. New federal funding (through the SUPPORT for some uncompensated care (e.g., treatment services costs. One-time financial incentives to offset time Patients and Communities Act, signed into law for uninsured and underinsured patients). Funds in spent away from clinical practice to undergo training on October 24, 2018) is expected to extend MAT this program can be used to pay for MAT team mem- required to prescribe buprenorphine (waiver training) funding through 2021 or beyond. ber staffing and training, as well as select program is the most commonly available support. costs. Only certain health plans offer funds targeting program start-up and clinician training. Clinicians California’s MAT Expansion Project has funding to would benefit from additional educational and Current funding must be spent by September 2020; support clinicians getting waiver training as well as training beyond what is required to receive the new federal funding is expected, but details are program start-up funds.5 Some Medi-Cal managed X-waiver. Federal funding is typically released one year at a time, and the program require- unavailable at the time of publication. care plans also offer start-up funds (see box). ments change. Prescribers seeking a waiver to prescribe buprenor- phine — known as the X-waiver — can access no-cost training, as well as other clinical training opportunities, through the MAT expansion website.6 For example, the Providers Clinical Support System offers free waiver trainings for physicians, nurse prac- titioners, and physician assistants. California Health Care Foundation 2 AA Flipped visits. Health centers using this model AA Medication management. Some health centers Visit Design leverage a nonbillable Medi-Cal provider (e.g., have added the medication management of SUD As health centers design MAT programs, some nurse, medical assistant, addiction counselor) to to their general array of clinical services covered look to existing payment models and then struc- see patients for counseling, care coordination, or by Medi-Cal managed care plans.7 This stream- ture their programs accordingly. Options that health both. This visit is concluded with a clinician face- lined model is similar to managing other chronic centers may want to consider include shared medi- to-face encounter. This face-to-face visit serves diseases (e.g., diabetes), where the costs of med- cal appointments, flipped visits, drop-in visits, and as the billable encounter. However, in order to ical assistants performing panel management integrating medication management. Here are comply with California regulations, the visit must tasks are built into the PPS rate or managed descriptions of each: be medically necessary and documentation must care payment. Behavioral health services, where justify the billing code. available, are completed by Medi-Cal providers AA Shared medical appointments. Also known (e.g., licensed clinical social workers) and are as group visits, shared medical appointments AA Drop-in services. When arrangements are made also included in the PPS rate. Where behavioral typically include a brief educational presentation with the local Medi-Cal managed care plan, health services are not available, patients may be from a clinician or expert, participant discussion, health centers can offer drop-in services for referred to virtual behavioral health services or to and a clinician encounter. This approach can patients assigned to their clinic for primary care recovery and self-help groups. Buprenorphine is be used for induction (new starts), maintenance and for patients assigned elsewhere. This model provided through home induction,8 which does (medication refills), or to review a preset cur- can provide a bridge for patients starting treat- not require additional clinic time. riculum. Shared medical appointments enable ment in the hospital or emergency department clinicians to efficiently see a larger number of (ED) until they can be established with a primary VISIT DESIGN: PRO AND CON patients in a relatively short amount of time, care provider or at a higher level of care (e.g., an while also providing peer support to patients. opioid treatment program). Some Medi-Cal man- Implementing these visit designs generally does not require major infrastructure changes beyond Either the clinician can lead the visit, or the aged care plans have established a mechanism adjusting appointment systems and workflow. visit can be led by another trained member of to pay for MAT services delivered by waivered They maximize clinician time and also encour- the care team. Under current California FQHC providers on a fee-for-service basis (billing an age all staff to work at the top of their license. regulations, health centers can get reimbursed evaluation and management code) for patients Bringing patients in more often (e.g., for monthly group visits) provides additional support for for each group visit participant only if the group who are not assigned to that clinic for primary patients. Offering drop-in services expands visit is coupled with an individual face-to-face care. If the patient is enrolled in Medi-Cal, the access to MAT. encounter. This visit can take place before, clinic can also bill the visit at the PPS rate. Health after, or during the group visit. In the latter centers choosing this model will need to either Additional staff training is likely required, particularly in health centers that don’t already case, patients would be pulled out of the group work with the patient to direct them toward a have MAT programs and flipped/group visits in individually and rejoin once the encounter was source of ongoing care after MAT stabilization or place. Depending on the structure of the group complete. Health centers should ensure that ask the patient to contact their Medi-Cal man- or flipped visit, some health centers may find the model’s scheduling changes and workflow documentation is sufficient to justify the billing aged care plan to change their assigned primary disruptive, particularly in group visits led by a codes that are used. care provider. staff member and where patients are seen one by one during the group portion of the visit. In addition, physical space requirements for group visits may present a challenge for some. How to Pay for It | MAT in Community Health Centers 3 Value-Based Payment therapy; complementary medicine) for six months, AA Patient-Centered Opioid Addiction Treatment Alternative Payment Model. The American Methodologies because a pilot determined that overall costs were lowered beyond the cost of the intervention and that Society of Addiction Medicine proposed an Value-based payment is increasingly used to acknowl- patient outcomes improved. Michigan’s Spectrum alternative payment model13 that includes two edge improvements to quality and can support the Health established a case rate with the Complex components: a one-time payment to cover the costs of team-based care; however, PPS regulations Care Clinic, identifying the most frequent users of costs of MAT induction and a lower monthly present challenges to health centers interested in ED services and providing integrated behavioral and fee to cover the bundled costs associated with pursuing value-based payment opportunities. Health physical health care for a population with a high inci- ongoing treatment. Ongoing treatment services centers should conduct due diligence about which dence of SUD. include medication management, psychological additional reimbursement care is considered to be in treatment, and social services. Payments would addition to, rather than duplicative of, PPS rates. The In 2015, El Dorado County Community Health Center be adjusted based on patient complexity, as California Primary Care Association has done exten- began working with a Medi-Cal plan to explore the well as on provider performance on a range sive research on these issues and can be a resource feasibility of a case rate to deliver MAT using a team- of measures (e.g., quality, spending, outcome to health centers interested in learning more. based approach. Preliminary data analysis showed measures). that the program yielded savings due to reduced ED The National Council for Behavioral Health defines and inpatient use, and that such savings were suf- AA Enhanced payments. In 2017, the Central a “case rate” as a single payment to cover the cost ficient to cover increased costs associated with MAT California Alliance for Health established the of a case based on an outcome decided upon by a delivery.11 El Dorado and the health plan are continu- Enhanced Primary Care Pain Management pro- payer.9 Rates reflect the average cost for a defined ing to explore the feasibility of establishing a case gram to increase the number of providers who episode of care. For MAT, this episode of care typi- rate. offer MAT to Medi-Cal members.14 The program cally includes initial consultation and any follow-up allows waivered clinicians to receive enhanced MAT services. The benefit to providers offering MAT In addition to enhanced and case rates, some alter- payment for initial and follow-up consultative is that a case rate is likely to more accurately reflect native payment models have been designed but are evaluation and management services related the intensity of services and team-based approach not widespread. Examples include: to opioid use.15 These payments require prior to care delivery as compared to the standard PPS authorization and are also subject to other rate. In addition, this model was credited with the AA Addiction Recovery Medical Home. Proposed requirements. The Central California Alliance rapid expansion of MAT in primary care in France by Leavitt Partners and the National Council on for Health piloted this payment with private and contributed to a 79% drop in heroin overdose Alcohol and Drug Dependence,12 this model providers because FQHCs could not accept the rates.10 offers a phased approach to payment: fee- payment outside of the PPS system. for-service payments during prerecovery and Case rates have proven successful in non-FQHC stabilization, capitation during recovery initiation While value-based payment programs provide settings. For example, Inland Empire Health Plan and active treatment (including a component greater flexibility to integrate behavioral health care contracted with the Desert Pain Clinic and provided a based on achievement of quality scores, with a approaches — additional services, varying appoint- case rate to cover all services (e.g., medical manage- bonus threshold), and lower capitation amounts ment types, virtual visits, and communication — early ment, including transition from high-dose opioids once patients are in recovery and need fewer state efforts to explore these systems in California to buprenorphine; behavioral therapy; physical services. FQHCs have been put on hold at the time of California Health Care Foundation 4 publication. The California Primary Care Association notes that payments to health centers for services Drug Medi-Cal Organized DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM: PRO AND CON need to be congruent with applicable laws, regula- tions, and guidance. Until the California Department Delivery System DMC-ODS offers another pathway for health centers in participating DMC-ODS counties to of Health Care Services (DHCS) issues guidance on In 2017, an additional pathway to payment for be paid for providing MAT, including reimburse- how case rates impact PPS rates, FQHCs should not MAT was established as part of the Drug Medi-Cal ment mechanisms for drug and alcohol counselors and other SUD services. proceed with these options. Organized Delivery System (DMC-ODS). DMC-ODS operates as a voluntary county-level pilot program Some counties may not choose to pay for MAT and is designed to expand, improve, and reorga- provided outside of opioid treatment programs. VALUE-BASED PAYMENT METHODOLOGIES: PRO AND CON nize Medi-Cal’s system for treating people with SUD. While expanding access to treatment for patients, Alternative payment models recognize that As of November 2018, 40 counties had submitted DMC-ODS contracts may introduce administra- the traditional method of paying for services in tive complexity; the California Primary Care implementation plans and of these, 22 counties have Association describes contractual, legal, and health centers doesn’t reflect the true costs of providing MAT, and that reimbursing for MAT at launched their DMC-ODS programs.17 Participating other concerns for health centers to consider. 21 a higher rate is still cost-effective. MAT has been counties must cover MAT offered by opioid treat- In addition, some health centers have expressed shown to lower rates of hospitalizations and ED concern about adequacy of payment rates. ment programs. These counties also have the option visits, cutting health care expenditures by more than 50%.16 to cover MAT delivered in other settings, including through contracts with health centers; however, MAT Few alternative payment methodologies for in other settings must be paid for with county funds. MAT have been implemented in California. In Payment rates are developed by each county and addition, case rates can be complicated for health centers, as it is considered payment for therefore vary.18 medical services and therefore is included in PPS rate calculations. No Medi-Cal managed DHCS notes that health centers that opt to pro- care plan in California has yet to establish this vide MAT within the DMC-ODS must do so outside payment model with FQHCs. their PPS rate and may need to undergo a DHCS scope-of-services PPS rate-setting change.19 Health centers can access the change request form on the DHCS website.20 However, a rate-setting change is not required if the health center can demonstrate there is no overlap between Drug Medi-Cal and PPS. Additional guidance is available in the California Primary Care Association’s Leveraging Federally Qualified Health Centers in California’s Behavioral Health Care Continuum (PDF). How to Pay for It | MAT in Community Health Centers 5 Conclusion California has launched a concerted effort to inte- grate MAT into all health care touchpoints, including primary care, hospitals, EDs, mental health clinics, residential treatment facilities, jails, and other set- tings.22 Although federal and state investment has enabled health centers to design programs, sus- About Center for Care Innovations About the Foundation taining them requires payment that reflects the true CCI — the Center for Care Innovations — trans- The California Health Care Foundation is dedicated costs of care delivery. forms care for vulnerable populations by inspiring, to advancing meaningful, measurable improvements teaching, and spreading evidence-based practices in the way the health care delivery system provides California’s work to address the opioid crisis has laid and innovation among the organizations that serve care to the people of California, particularly those the foundation to enable better identification and them. CCI is a vital source of ideas, best practices, with low incomes and those whose needs are not management of SUD. Other states have done simi- and resources for California’s health care safety net. well served by the status quo. We work to ensure lar work and may serve as a model for policymakers that people have access to the care they need, when and health plan partners. For example, the Maryland CCI carries out its mission by designing and imple- they need it, at a price they can afford. Department of Health established a bundled pay- menting programs, providing training and technical ment for MAT that includes a range of services (e.g., assistance, and building learning networks to share CHCF informs policymakers and industry leaders, in-person meetings, drug ordering and adminis- best practices for health care safety net organizations. invests in ideas and innovations, and connects with tration, drug screens, etc.), along with separate changemakers to create a more responsive, patient- reimbursement for MAT induction, medication For more information, visit centered health care system. management, and individual and group counsel- www.careinnovations.org. ing.23 Similarly, Maine has a Medicaid waiver that For more information, visit www.chcf.org. includes a per-member-per-month payment on top The Authors of fee-for-service payment. A range of professionals Sandra Newman, MPH, LSN Health Strategy (e.g., nurse care manager, opioid dependency clini- Tammy Fisher, MPH, Center for Care Innovations cal counselor, peer recovery coach) are included in the multidisciplinary care team.24 As such payment models proliferate, the hope is that California will continue to innovate to ensure that all patients who rely on MAT can access these services. In the mean- About This Series time, many community health centers are making it The California Health Care Foundation commis- work with existing funding streams. sioned How to Pay for It, a series of short papers that focuses on reimbursement mechanisms for strategies that advance integration of behavioral health and medical care. California Health Care Foundation 6 Endnotes 1. “Medication-Assisted Treatment,” Substance Abuse and 11. J. Bachman, personal interview, August 3, 2018. 23. Meryl Schulman et al., “Exploring Value-Based Payment Mental Health Services Administration, last modified to Encourage Substance Use Disorder Treatment in 12. Addiction Recovery with Medical Home — Alternative February 7, 2018, www.samhsa.gov. Primary Care,” Center for Health Care Strategies, Payment Model: Incentivizing Recovery. Not Relapse., June 2018, www.chcs.org. 2. 2018 Expanding Access to Quality Substance Use FY Leavitt Partners and Facing Addiction with NCADD, Disorder and Mental Health Services (SUD-MH) Funding 2018, www.incentivizerecovery.org (PDF). 24. State-by-State Health Home State Plan Amendment Opportunity: Frequently Asked Questions (FAQs), Matrix, Centers for Medicare & Medicaid Services, 13. Patient-Centered Opioid Addiction Treatment (P-COAT): Health Resources and Services Administration, 2018, September 2018, www.medicaid.gov (PDF). Alternative Payment Model (APM), American Society of bphc.hrsa.gov (PDF). Addiction Medicine, 2018, www.asam.org (PDF). 3. The Centers for Medicare & Medicaid Services defines 14. Medication Assisted Treatment, policy no. 404-1731, FQHC practitioners as including physicians, nurse Central California Alliance for Health (CCAH), practitioners, physician assistants, certified nurse March 24, 2017, www.ccah-alliance.org (PDF). midwives, clinical psychologists, clinical social workers, or certified diabetes self-management training / medical 15. Provider Manual, 2018, CCAH, July 1, 2018, nutrition therapy provider. www.ccah-alliance.org (PDF). 4. Roger Chou et al., Medication-Assisted Treatment 16. Frances L. Lynch et al., “Costs of Care for Persons with Models of Care for Opioid Use Disorder in Primary Care Opioid Dependence in Commercial Integrated Health Settings (Rockville, MD: Agency for Healthcare Research Systems,” Addiction Science and Clinical Practice 9, no. 1 and Quality, December 2016), www.ncbi.nlm.nih.gov. (August 14, 2014): 16, doi:0.1186/1940-0640-9-16. 5.California MAT Expansion Project 2.0 State Overdose 17. “County Plans & Contracts: Counties Participating in Response (SOR) Funding, California Department of DMC-ODS,” DHCS, last modified December 12, 2018, Health Care Services (DHCS), n.d., www.dhcs.ca.gov. www.dhcs.ca.gov (PDF). 18. Medication Assisted Treatment for Substance Use 6. “Calendar of Events,” CA Hub and Spoke System: Disorders and the Drug Medi-Cal Organized Delivery MAT Expansion Project, n.d., www.uclaisap.org. System: Frequently Asked Questions, DHCS, June 2018, www.dhcs.ca.gov (PDF). 7. Sarah Brooks (chief, Managed Care Quality and Monitoring Div., DHCS) to all Medi-Cal Managed 19. “Frequently Asked Questions about Medication Care Plans, all-plan letter 15-008, April 16, 2015, Assisted Treatment within Community Clinics and Health www.dhcs.ca.gov (PDF). Centers,” California Primary Care Association. 8. Joshua D. Lee et al., “Buprenorphine — Beginning 20. “Audits and Investigations — Financial Audits: Branch Treatment,” supplement to “Home Buprenorphine/ Cost Report Forms and Documents,” DHCS, last Naloxone Induction in Primary Care,” Journal of General modified September 28, 2018, www.dhcs.ca.gov. Internal Medicine 24, no. 2 (February 2009), doi:10.1007/ 21. Leveraging Federally Qualified Health Centers in s11606-008-0866-8. California’s Behavioral Health Care Continuum, California 9. Case Rate Toolkit, Natl. Council for Behavioral Health, Primary Care Association, November 6, 2017, 2013, www.thenationalcouncil.org (PDF). www.cpca.org. 10. Maria P. Carrieri et al., “Buprenorphine Use: The 22. “The California MAT Expansion Project,” DHCS, last International Experience.” Clinical Infectious modified October 19, 2018, www.dhcs.ca.gov. Diseases 43, Suppl. 4 (Dec. 15, 2006): S197–S215, doi:10.1086/508184. How to Pay for It | MAT in Community Health Centers 7