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Drug overdose deaths climbed 30% to more than 90,000 during the pandemic year, largely driven by synthetic opiates like fentanyl, government data showed. The statistic is devastating by itself, but made even more alarming by the fact that many providers of medication assisted treatment (MAT) say they're bleeding cash, and struggling to attract and retain staff.

MAT is the standard of care for opioid use disorder, and involves medications, such as buprenorphine and methadone, in combination with counseling. However, the financial challenges of providing such services plagued providers and were felt especially hard by opioid treatment programs that serve large numbers of Medicaid patients.

In Rhode Island, the state's largest non-profit, outpatient provider for opioid treatment, CODAC, continues to see losses when it comes to Medicaid reimbursement.

CODAC's average cost of substance use treatment is $79.33 for a 45-minute session and $99.16 for a 60-minute session, Linda Hurley, president and CEO of CODAC, told 乌鸦传媒. However, it takes a loss on those sessions for all carriers but one, according to data from a sample of more than 250 of its patients.

When it comes to Medicaid reimbursement, the losses are especially steep. On average, CODAC sees a loss of $30.42 for a 45-minute session, and $27.54 for a 60-minute session. On average, for managed care organizations that Medicaid contracts with, losses are as high as $27.47 for a 45-minute session, and $22.02 for a 60-minute session.

"We are about as efficient as we can possibly be," Linda Hurley, president and CEO of CODAC, told 乌鸦传媒. However, "we continue to be undercompensated."

Access to Care

Opioid treatment programs need to be paid so they can sustain themselves and grow to meet rising demand, Hurley said. For people who are in treatment for opioid use disorder, there is a much lower rate of overdose death, she said.

Shawn Ryan, MD, who serves on the American Society of Addiction Medicine's board of directors and as vice chair of the organization's legislative advocacy committee, concurred.

"It is so important that reimbursement is adequate for people to be able to keep their doors open," Ryan told 乌鸦传媒. Currently, there is "more need than we've ever had before."

Prior to the pandemic, the National Survey on Drug Use and Health indicated that more than 20 million Americans ages 12 and older needed treatment for substance use disorder, but only about 4.2 million received any form of treatment or services, according to an email from an ASAM spokesperson.

The organization cited Medicaid as the largest and most significant source of coverage and funding for addiction treatment in the country. It covers 35% to 50% of MAT services for opioid use disorder in states hit hardest by the epidemic, as well as all medications for the condition and related services.

The spokesperson told 乌鸦传媒 that addiction medicine physicians have noted that generally low reimbursement rates in Medicaid can make it challenging to sustain operations at an outpatient addiction medicine practice or opioid treatment program.

"There is a critical need for more robust billing, coding, and payment systems for addiction medicine practices under Medicaid both to sustain business operations of current practices and to incentivize physicians to enter the field of addiction medicine, including through accredited fellowship training," the ASAM spokesperson added.

Greater reimbursement has always been a need, but has become increasingly urgent, Allegra Schorr, president of the Coalition of Medication Assisted Treatment Providers and Advocates of New York State, told 乌鸦传媒 earlier this year.

Last year, opioid treatment programs adapted quickly to battling two public health crises at once, but saw the rise of telehealth, an increase in supply expenses, and an uptick in demand at the same time, Schorr previously said. The goal has been to make MAT as convenient for patients as possible, but that requires adequate payment.

Staffing Woes

Medicaid reimbursement is traditionally much lower than any other insurance, and lower than what is needed to pay overhead, Will Cooke, MD, a family physician in Indiana who provides medication assisted treatment, told 乌鸦传媒.

That can create an incentive to not take care of people, especially those with complex needs, he said.

In general, physicians went into medicine because they have compassion and want to help. "But you also have an obligation to keep your doors open," Cooke said. "If your office closes, you can't help anybody."

"It really shouldn't be like that," he said.

Cooke said he believes there are many more providers that would be interested and willing to treat people with opioid use disorder and other substance use disorders if services were better reimbursed.

A patient with hypertension may come in three or four times a year for 20 minutes with some labs to review, he said. However, for a patient with substance use disorder, nurses may need to make calls, peer recovery specialists may need to be on staff, and drug screens may need to take place.

There may be more time and resources needed, and providers may be spending more overhead and getting reimbursed the same, he said.

Hurley said that one of CODAC's biggest hurdles is attracting staff and retaining them once they're trained.

Data from the organization showed that as of 2019, employee turnover rate approached 50% and nearly half of termed employees left after less than a year of service. Exit interviews indicated low compensation and low education reimbursement as the top two reasons for leaving.

However, with current reimbursement rates, even a subtle increase in the minimum wage could be enough to shut a program down, Hurley said.

Battling Stigma

Providers and advocates believe stigma regarding substance use disorder and the medications most effective in treating it continue to play a role in limiting access to care.

Cooke said that he feels some providers still view patients with substance use disorder as difficult to take on. He added that physicians have treatment that is very effective in helping people overcome their substance use disorder, "but we moralize it and prevent people from getting access to it."

Some people say, "'You're just trading one drug for another,'" he said. "We wouldn't say that to a diabetic."

Hurley described the stigma that persists as "fear," "bias," and "discrimination." She said providers face stigma when it comes to regulation and undercompensation.

"We continue to struggle with it," she said.

Ryan said he believes stigma is at the root of the same government officials' and legislators' refusal to adjust budgets toward substance use disorder treatment.

The issue needs to be met with resources that are "commensurate with the magnitude of the problem," and that's not happening, Ryan said. It's like, "trying to soak up a lake with a napkin."

Though there have been good efforts in several states, there is room for improvement, he said.

"We have not risen to meet this challenge, and have proven that through COVID," Ryan said, noting the more than 90,000 overdose deaths. It's "not for a lack of ability," but for a "lack of will," he added.

Fewer Dollars Everywhere

Matt Salo, executive director of the National Association of Medicaid Directors, told 乌鸦传媒, that while state programs hear from medication assisted treatment providers that they would like reimbursement to be higher, they also hear the same request from other provider groups.

Medicaid reimbursement tends to be lower across the board than Medicare and commercial payers, he said, and it's been that way for decades.

"MAT providers are not unique or singled out, or particularly aggrieved in this," he said. "The challenge is that Medicaid tries to do an awful lot of things for an awful lot of people without enough funding to make everybody happy."

Medicaid costs have been growing faster than state general revenues, he said. One could argue that there could be better access to care and outcomes if Medicaid paid much more, but there just isn't enough money, he added.

When it comes to the question of why states aren't providing more medication assisted treatment, Salo said it's important to manage growth to avoid potential waste, fraud, and abuse, and to maintain quality of care. He said the notion is not specific to MAT.

CMS did not immediately respond to a request for comment.

What Can Be Done

Mark Parrino, president of the American Association for the Treatment of Opioid Dependence, said it's essential to better link regulatory and financial efforts that govern and support providers.

Often the two systems don't communicate with each other, he said, which can hinder efforts to improve access to care.

Providers have also said that both federal and state governments may have a role to play in strengthening reimbursement and expanding access to care.

Though the federal government can't necessarily dictate what states do with their Medicaid programs, they can incentivize them in certain ways, Ryan said.

ASAM pointed to expanding and increasing federal grants, and creating a financial incentive to increase state Medicaid spending on behavioral health services. It also noted that state Medicaid programs and commercial insurers could choose to pay for certain codes like those for initial medical examination and assessment like Medicare does.

"The federal government can offer more access to funding, but the states really have to be the ones to push that down to providers," Cooke said.

Hurley reiterated that tens of thousands of people are dying each year from opioid overdoses without treatment.

"It is so treatable, it is so unfortunate," she said of opioid use disorder. "Let us grow. Pay us, so that we can."

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