As congressional Republicans seek to repeal and replace the Affordable Care Act, funding of resources to combat the nation’s growing opioid epidemic has become part of the debate among lawmakers. On the very same day that the Senate introduced its own version of health reform legislation, addiction specialists, beneficiary advocates, Medicaid managed care organizations, physicians and patients convened on Capitol Hill to discuss ways to deliver more integrated and patient-centered care to pregnant women that includes medication-assisted treatment (MAT) when needed. At the same time, panelists at the summit advocated for greater prevention and treatment of neonatal abstinence syndrome (NAS), an opioid withdrawal syndrome that affects newborns and causes lengthy and costly hospital stays.
The number of opioid-related deaths in the U.S. exceeded 33,000 in 2015, an increase of 200% since 2000, according to the U.S. Centers for Disease Control and Prevention (CDC). At the same time, rates of NAS and maternal opioid use are climbing, observes a new report from the Institute for Medicaid Innovation, which hosted the June 22 summit along with the American Society of Addiction Medicine and the March of Dimes. From 2000 to 2009, rates of opioid misuse rose from 1.19 to 5.63 for every 1,000 hospital births each year, while the number of babies born with NAS jumped 300% between 1999 and 2013 in 28 states with publicly available data on opioid addiction.
Although pregnant women who have a substance use disorder are eligible for priority access to MAT, which usually involves either methadone or buprenorphine, only about half of women who need such treatment receive it, observed Mishka Terplan, M.D., professor of obstetrics/gynecology and psychiatry and associate director of addiction medicine at Virginia Commonwealth University. Speaking at the opioid summit, Terplan suggested that this low rate of treatment may be due in part to a lack of access (e.g., shortage of physicians certified to treat opioid use disorder with buprenorphine, a general lack of experience in treating pregnant women with opioid use disorder) and to punitive state policies, given that 44 states can prosecute women for opioid misuse in pregnancy.
David O’Gurek, M.D., an assistant professor with the Lewis Katz School of Medicine at Temple University who spoke on behalf of the American Academy of Family Physicians, argued that MAT must be integrated into behavioral health services available to pregnant women and that the health care system can’t adequately meet the needs of these patients unless care is integrated across multiple lines (e.g., insurance, employers, hospital/health system, pharmacies, public health and community agencies). Moreover, the health care system needs to reassess the ways it treats pain in general and consider prescribing non-opioid pharmacologic therapy for chronic pain, as recommended in 2016 guidelines from the CDC.
Centene Unit Deploys Face-to-Face Approach
To address this problem in Missouri, Centene Corp.’s Home State Health subsidiary operates a case management program that provides wraparound services to pregnant members who are struggling with opioid addiction. Eligible members are identified through available medical and pharmacy data showing a history of narcotic prescription fills or substance use treatment, as well as through referrals from the state’s Comprehensive Substance Treatment and Rehabilitation (CSTAR) program. While all case management provided by Home State has historically been performed telephonically, the MCO felt pregnant members would be better served by face-to-face case management, said Megan Barton, vice president of medical management with the health plan, who also spoke at the summit.
Since Medicaid members tend to move frequently, locating a member is a “collaborative effort” with providers, including pharmacies, and may even involve driving to the most recent address the plan has on file to confirm she lives at that address or speak with a family member who knows where she currently resides, added Barton. Once a member is successfully reached, the in-person meetings can take place anywhere from CSTAR facilities and members’ homes to playgrounds and church parking lots, wherever “a member can get the best experience and build a trusting relationship” with the plan representative, she observed.
The case manager first conducts a comprehensive assessment, looking for any barriers the patient may face that are preventing her from making healthy decisions and what social supports are needed, and formulates an individualized care plan that could include facilitating enrollment into specialized local programs that provide MAT and linking them to community resources. The program involves frequent contact and support, and case managers may even attend medical appointments with the client, all with the goals of guiding them through a healthy pregnancy, increasing the gestational age of the infant at delivery, reducing NICU admissions and hospital stays, and decreasing illicit use of substances such as opioids during and after pregnancy.
A mother of three who was helped by the program explained to summit attendees that she’d struggled on and off with opioid addiction for years after she was prescribed opioids for pain from her second C-section. Home State contacted her after learning that she had been treated for substance use disorder and become pregnant again. When she saw that her insurance company was calling, her initial response was, “‘What do you want?'” she recalled. But once she realized the kind of assistance the case manager would be able to provide, such as initiation of MAT during pregnancy and temporary housing that did not involve having to be separated from her children, that case manager quickly became her “best friend,” the mother attested.
Barton said the program has about 125 members enrolled at any given time, and about 20 (half of its case management team) nurses offer face-to-face assistance to these pregnant women. She added that the MCO is currently looking to enhance the program through peer support.
Because of the siloed way care is currently provided to pregnant Medicaid beneficiaries — resulting in the delivering hospital, for instance, not knowing the patient has been receiving MAT, or the pediatrician not knowing about the mother’s opioid use history — case managers like the ones working with Home State have “become the glue between all the parts of the system,” attested Paul Jarris, M.D., chief medical officer with the March of Dimes Foundation. Jarris argued that states need to work with all stakeholders and parts of the health care system to create more “seamless handoffs” that result in healthier pregnancies, shorter hospital stays and fewer cases of NAS.
Symptoms of NAS include extreme irritability and feeding problems and are not commonly recognized by pediatricians. NAS costs about $66,700 per stay, and leads to hospital stays averaging 16.9 days, compared to an average two-day hospital stay for newborns without NAS. Moreover, NAS amounted to total hospital charges of $1.5 billion in 2012, of which Medicaid paid $1.2 billion and private insurance covered $200 million.
MCOs such as Pittsburgh-based Gateway Health have been collaborating with the Pennsylvania Dept. of Human Services (DHS) to establish coordinated care clinics that can provide MAT, counseling and social service support through a team-based approach. Working with all behavioral health and physical health MCOs in the state, local behavioral health providers and social supports, DHS in 2014 piloted the first clinic with the Magee Women’s Hospital of UPMC. With Gateway playing a leadership role, the health plans agreed on a common shared savings model to help fund the first few years of the program and developed a per-member per-month payment methodology that bundled payment for services not typically included in the Medicaid fee schedule, explained Steven Szebenyi, M.D., chief medical officer for Gateway, who also spoke at the summit.
The pilot resulted in more than 50% of patients completing the program and led to lower rates of NAS. Gateway in 2016 launched a similar program with Allegheny Health Network that shows early signs of success and plans to develop additional programs across the Pittsburgh area. And DHS continues to work with the MCOs on establishing another 20 programs across the state, added Szebenyi.