June 2019 HOW TO PAY FOR IT MAT for Hospitalized Patients C alifornia has made significant investments California Bridge resources are available to any hos- to address the nationwide opioid epidemic. pital in the country, regardless of participation in the These efforts include a broad range of activi- collaborative.3 ties under the umbrella of the state’s State Opioid Response grant, also known as the Medication Expanding access to treatment for MAT in hos- Assisted Treatment Expansion Project.1 While efforts pitals is timely, given how often hospitals treat are multifaceted, improving access to medications patients with OUD. The rate of opioid-related hos- for addiction treatment (MAT) for patients with opioid pital admissions in California increased by more than use disorder (OUD) is a major focus.2 FDA-approved 50% between 2008 and 2017 (from 122 to 215 per medications for the treatment of OUD consist of vari- 100,000 population).4 Opioid-related hospital admis- ous formulations of methadone, buprenorphine, and sions typically include a primary medical, surgical, or naltrexone. Improving patient access to MAT is being psychiatric diagnosis with a secondary diagnosis of accomplished through projects to enhance educa- OUD. The primary diagnosis may be a consequence tion, training, and mentoring for providers; conduct of OUD (e.g., endocarditis, osteomyelitis) or may be information and media campaigns; and expand the unrelated to the underlying OUD. numbers of programs and providers in primary care, inpatient, residential, jail, and other care settings. While hospitalized patients often have medical and surgical complications of substance use disorder, As one component of the state’s opioid work, the few hospitals have systems in place to treat the California Bridge program received more than $12 underlying addiction.5 Buprenorphine and metha- million to support expansion of MAT in emergency done — the most common OUD medications — are departments and acute inpatient hospital settings. considered the gold standard for evidence-based As of March 2019, 31 hospitals received California treatment and can be easily started and maintained Bridge grants and joined a learning collaborative in inpatient settings by either hospitalists or hospital- to expand access to treatment through the design based addiction medicine consultation services. and implementation of MAT programs. Many This paper describes how MAT is reimbursed in AA 99251–99255: New or established patient acute inpatient settings, addressing three areas for initial inpatient consultation service Hospital Costs payment: AA 99356: Prolonged consultation, inpatient Hospitals are reimbursed for facility costs separately AA Professional services — setting, first hour from professional services. In California, these costs how clinicians are reimbursed are typically reimbursed on a per diem basis or AA 99357: Each additional 30 minutes beyond through a diagnosis-related group (DRG) method- AA Hospital costs the first hour ology.9 MAT-related services — such as counseling AA Pharmacy costs associated with AA 99238–99239: Hospital discharge day provided by a social worker — would be included in the medication management, 30 minutes or less; hospital the DRG payment. discharge day management, more than The paper assumes that patients begin these medi- 30 minutes As with professional services, adding OUD as a cations while hospitalized, but it does not address diagnosis may increase the patient’s acuity and, as ongoing community-based care once patients are In their documentation, providers would add OUD a result, the case mix index (CMI). A higher CMI discharged. Providers who offer MAT in inpatient to the list of diagnoses; this addition could trigger indicates a more complex and resource-intensive settings should have systems in place to arrange for higher payment by increasing acuity or by docu- caseload10 and may increase reimbursement accord- such ongoing care. Options for community linkages menting the increased time it takes to manage the ingly. As with professional services, the potential can include community health centers, substance patient. Whether the acuity increases depends on for increased reimbursement would depend on the use disorder treatment clinics, specialized hospital the individual patient’s medical condition and insur- patient’s medical condition and insurance coverage. discharge MAT clinics (also known as Bridge clin- ance coverage. ics), Opioid Treatment Programs (formerly called methadone clinics), and telemedicine. Information Some hospitals supplement MAT in inpatient set- Pharmacy Costs on reimbursement for MAT provided in other set- tings by including counseling and support services In an inpatient setting, MAT is paid for in the same tings can be found in How to Pay for It: MAT in provided by social workers, peer counselors, sub- manner as all other medications. The pharmacy Community Health Centers and How to Pay for It: stance use navigators, and related providers. Such purchases medications, often through wholesale MAT in the Emergency Department. services may include Screening, Brief Intervention, drug contracts. Once purchased, medications are and Referral to Treatment (SBIRT), which is a com- typically reimbursed by health plans using a per Professional Services mon approach to understand the severity of a substance use disorder, increase patient awareness, diem payment. This per diem is essentially a case rate that covers any medication that a patient may Inpatient MAT uses the same set of Current and connect patients to treatment.7 Costs associated need over the course of admission, regardless of Procedural Terminology (CPT) codes that are used with SBIRT and other counseling activities are not cost. Upon discharge, a patient would use an out- for other inpatient admissions, whether provided by typically billable as a separate professional service patient pharmacy to fill subsequent prescriptions. a hospitalist or as a consult. The CPT codes include:6 during hospitalization. However, if physician services Increasingly, commercial and Medi-Cal health plans include prolonged face-to-face counseling, the CPT allow buprenorphine prescriptions for addiction AA 99221–99223: New or established patient codes listed above can also be used for time-based diagnoses without prior authorization.11 For patients initial hospital inpatient care services billing.8 And while these behavioral health and social requiring ongoing methadone treatment, access to AA 99231–99232: Subsequent hospital care support services could be helpful during an inpatient this medication would be obtained through an opi- stay, they are not required for hospitals offering MAT. oid treatment program. California Health Care Foundation 2 Buprenorphine is relatively inexpensive. One com- monly available out-of-pocket cost estimator showed Looking Ahead: The Author Sandra Newman, MPH, LSN Health Strategy that an eight-milligram sublingual tablet was $1.16 Alternative Payment as of April 2019.12 In contrast, Vivitrol (naltrexone injectable for extended release) was around $1,500. Models About the Foundation Case rates or bundled payments are typically used The California Health Care Foundation is dedicated Conclusion for surgical procedures (e.g., knee replacement) and could be applied to MAT. This rate would include all to advancing meaningful, measurable improvements in the way the health care delivery system provides Although there may not be additional payment costs associated with inpatient medical and addic- care to the people of California, particularly those associated with providing MAT (i.e., the acuity did tion treatment and for an established period of time with low incomes and those whose needs are not not increase), there are other benefits to offering postdischarge. This case rate may better reflect the well served by the status quo. We work to ensure MAT in inpatient settings. First, patients admitted intensity of counseling and peer support services — that people have access to the care they need, when for a primary issue related to their addiction (e.g., provided by either the buprenorphine prescriber or they need it, at a price they can afford. septic arthritis) may begin to experience withdrawal by ancillary providers — that would facilitate starting during the admission. Left untreated, patients may patients on MAT and encouraging them to seek care CHCF informs policymakers and industry leaders, decompensate or leave against medical advice, or postdischarge. invests in ideas and innovations, and connects with may become agitated, requiring sitters or security, changemakers to create a more responsive, patient- which can add costs to the admission. Second, start- The other option to improve payment for hospital- centered health care system. ing treatment for underlying OUD could reduce the based MAT would be to establish new codes, similar length of stay. In turn, reducing length of stay saves to those for advance care planning (e.g., CPT 99497, For more information, visit www.chcf.org. hospitals money because of the method by which 99498).15 These codes enable time-based payment many are reimbursed.13 The associated savings are for communication between providers and the likely greater than the costs associated with deliv- patient and family. Creating new CPT codes and ering MAT. Further, the likelihood of readmission ensuring these codes are reimbursed would require may also be reduced, which can lessen penalties policy changes at the federal level; however, the About This Series for hospitals in some value-based payment arrange- change would serve to recognize the time that MAT- The California Health Care Foundation commis- ments. For example, recent research demonstrated related communication and counseling could take. sioned How to Pay for It, a series of short papers that 30-day and 90-day readmissions were reduced that focuses on reimbursement mechanisms for strategies that advance integration of behavioral significantly for patients taking buprenorphine at health and medical care. the time of hospital admission.14 Finally, stabilizing a patient’s addiction can facilitate treatment of the patient’s other diagnoses and prevent recurrence of preventable conditions (e.g., infection from IV drug use), improving provider and patient experience and potentially improving clinical outcomes. How to Pay for It? | MAT for Hospitalized Patients 3 Endnotes 1.California MAT Expansion Project, accessed May 29, 2019, 11.For more information on coverage of medications www.californiamat.org. for addiction treatment in California, see Medicaid 2.Medications for addiction treatment (MAT) may also be Coverage of Medications for the Treatment of Opioid referred to as medications for opioid use disorder, or Use Disorder: California, American Society of Addiction MOUD. Medicine, accessed April 30, 2019, www.asam.org (PDF). 3.Resources are available on the California Bridge website, 12.This price was based on a 60-day supply estimate www.ed-bridge.org. using GoodRx, calculated on April 30, 2019. 4.HCUP Fast Stats (Oct. 2018), Agency for Healthcare 13.Many hospitals are paid by DRG, a methodology Research and Quality, accessed December 12, 2018, that calculates payments based on a bundle of services, www.hcup-us.ahrq.gov. regardless of length of stay. 5.Honora Englander et al., “Tools to Support Hospital- 14.Jessica L. Moreno et al., “Predictors for 30-Day and Based Addiction Care: Core Components, Values, 90-Day Hospital Readmission Among Patients and Activities of the Improving Addiction Care Team,” with Opioid Use Disorder,” Journal of Addiction Journal of Addiction Medicine 13, no. 2 (Mar. 2019): Medicine (forthcoming), accessed March 8, 2019, 85– 89, doi:10.1097/ADM.0000000000000487. doi:10.1097/ADM.0000000000000499. 6.“Hospital Inpatient Care Services CPT Code Range 15.Frequently Asked Questions About Billing the 99221-99223,” AAPC Coder, accessed March 1, 2019, Physician Fee Schedule for Advance Care Planning coder.aapc.com; Time-based billing can be used for Services, Centers for Medicare & Medicaid Services, these codes. For more information, see Carol Pohlig, July 14, 2016, www.cms.gov (PDF). “Bill by Time Spent on Case,” The Hospitalist 2008, no. 7 (July 2008), www.the-hospitalist.org. 7.“Screening, Brief Intervention, and Referral to Treatment (SBIRT),” Substance Abuse and Mental Health Services Administration, last modified September 15, 2017, www.samhsa.gov. 8.Pohlig, “Bill by Time.” 9.“Diagnosis Related Group (DRG),” HMSA Provider Resource Center, last modified July 13, 2018, hmsa.com. 10.“Open Data Portal: Case Mix Index,” California Health and Human Services, accessed March 8, 2019, data.chhs.ca.gov. California Health Care Foundation 4