Medical Associations Propose New Payment Model for Opioid Addiction Treatment

Recognizing that the current payment structure for physicians who provide outpatient opioid addiction treatment is not working, the American Medical Association (AMA) and the American Society of Addiction Medicine (ASAM) have come up with an alternative payment model.

In a recently released 39-page brief, the two medical associations suggest that those treating patients addicted to opioids receive a one-time, upfront fee to reimburse them for cost of evaluating, diagnosing and establishing a treatment plan for patients, along with a month of outpatient medication-assisted treatment. Additional monthly payments would then be made for continued medication, psychological care and social services.

In each of the two phases, higher amounts would be paid for patients with more complex needs that require more intensive supervision and services. Within each phase of care, add-on payments would be available for practitioners who use treatment and recovery support tools, such as remote patient monitoring for patients with chronic conditions, communication and counseling for patients with chronic conditions, and psychotherapy.

Dubbed the Patient-Centered Opioid Addiction Treatment Payment, or P-COAT, the plan is only designed to support office-based opioid treatment (OBOT) using buprenorphine or naltrexone, consistent with the ASAM criteria or other equivalently evidence-based standards mutually agreed to by the payer and provider for Level 1 or Level 2 outpatient services.

A physician practice could only receive P-COAT payments if it was part of an organized Opioid Addition Treatment Team (OATT) that could deliver or contract to deliver the following:

  • Office-based outpatient medical treatment using either buprenorphine or naltrexone
  • Appropriate outpatient psychological and/or counseling therapy services
  • Appropriate coordination of services, such as care management, social support, and other necessary medical services to treat the patient’s condition

Federal law requires practitioners to have specific education to be certified to prescribe buprenorphine as part of a medication-assisted treatment (MAT) for opioid use disorder that also includes behavioral therapy and other supportive services.

As of January, it’s estimated that more than 45,00 physicians have been certified to provide these services. Although that number has increased significantly, as the opioid epidemic has grown, 72 percent of physicians who are certified are limited to the number of patients they can treat (30). The rest are certified to treat up to 100 or 275 patients.

In outlining its new payment proposal, the medical associations point to a laundry list of problems that exist with the current system including:

  • Evaluation & Management (E/M) services payments are insufficient to support the time a physician or a qualified healthcare professional takes to identify and diagnose an opioid use disorder and to develop a treatment plan;
  • E/M services payments require face-to-face visits with patients and there is limited support for telephone, email, or other electronic communications with patients;
  • There is a limited payment structure available to enable primary care physicians/clinicians and addiction specialists, other than psychiatrists, to communicate by phone or email to help the primary care practitioners to diagnose and develop effective treatment plans for opioid use disorder;
  • Payments for services delivered by behavioral health services agencies do not require coordination with medical therapies delivered by physician practices;
  • Payments for behavioral health services delivered by primary care and addiction specialist practices are generally inadequate to cover costs, and the credentials required for billing are often unnecessary and unrealistically high;
  • Insurers do not yet pay for technology-based treatment and recovery support tools, remote monitoring and/or services that are used in conjunction with standard outpatient treatment for opioid addiction;
  • Most insurers do not pay for transportation, housing, or other non-medical services that patients may need to succeed in addiction treatment;
  • Prior authorization requirements for medications and intensive outpatient services make it difficult to deliver timely, effective treatment to patients;
  • Billing for substance use disorder services is highly complex and continues to evolve with passage of federal and state legislation.

Physicians interested in pursuing this model can go here.

Treating patients with opioid addiction takes more than a magic bullet, it takes time. This payment model recognizes that, along with need for a team approach and appropriate reimbursement.

Although still in the early stages, it’s never too late to consider how this might impact your practice should the plan be adopted. The Health Law Offices of Anthony C. Vitale can help you to determine the additional proposed reimbursement you may be entitled to and how to maintain compliance should the final reimbursement rules and regulations take effect.

Material presented on the Health Law Offices of Anthony C. Vitale's website is intended for information purposes only.

It is not intended as professional advice and should not be construed as such.