AmeriHealth Caritas Launches Value-Based SUD Pilot With Goal to Take Model Mainstream

Substance use disorder (SUD) treatment has typically been considered separated from other types of health care and paid for out-of-pocket or on a fee-for-service basis, meaning it is often siloed, expensive and incomprehensive. AmeriHealth Caritas is tackling some of those issues with a new value-based payment pilot designed to promote improved, integrated SUD screening and treatment in Washington, D.C.

Its Medicaid managed care plan there is working with the Howard University Faculty Practice Plan to make the Addiction Recovery Medical Home Alternative Payment Model possible. If successful, AmeriHealth Caritas could introduce the model in other areas, according to Yavar Moghimi, chief psychiatric medical officer at AmeriHealth Caritas D.C. 

“We are doing a lot of the foundational work to help set this up as a model that can be easily replicated,” Moghimi told Behavioral Health Business, noting that the opportunity for adoption expands beyond AmeriHealth Caritas itself.

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The organization is also part of the Alliance for Addiction Payment Reform, which aims to build new and better ways to pay for SUD treatment, leading to improved outcomes for patients, payers and health systems by aligning incentives.

“Even within the Alliance for Addiction Payment Reform, which has other large payers … we’re kind of in the lead in terms of getting this off the ground,” Moghimi said. “I think we’re setting the foundation … [to] replicate this in our other AmeriHealth lines of business, and hopefully the lessons we learn will also help the Alliance for Addiction Payment Reform help their other members also launch these programs.”

Headquartered in Philadelphia, AmeriHealth Caritas has a reputation as one of the nation’s most innovative managed care organizations (MCO). It serves more than 5 million Medicaid, Medicare and Children’s Health Insurance Program (CHIP) members through its integrated managed care products, behavioral health solutions, pharmaceutical benefit management and specialty pharmacy services.

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Meanwhile, the Howard University Faculty Practice Plan is home to the individual health care practices of the doctors of Howard University, one of the nation’s oldest and most prestigious historically Black colleges and universities (HCBU). Howard — and its medical practice — are located in D.C.

“The idea is … how do you universally screen for addiction in the entire faculty practice?” Moghimi said, noting that one goal of the pilot is to ensure everyone in the health system gets assessed for SUDs. “And then based on what you find, what’s the appropriate referral?”

AmeriHealth Caritas chose Howard for the pilot for a couple different reasons, Moghimi said.

First, DC is a relatively small locality, and the MCO’s plan there has been successful in doing value-based care with behavioral health providers in the past. Additionally, the opioid epidemic is hitting older, African American men the hardest in D.C., Moghimi said.

Finally, Howard is no stranger to innovation within addiction treatment. Using grants and other mechanisms, the university has integrated peers into the emergency room, brough MAT induction into the ER and built out an addiction fellowship and consult service.

If the pilot works, then both AmeriHealth Caritas and Howard University will benefit by way of shared savings.

“It helps [Howard] to potentially fund some of those ongoing programs,” Moghimi said. “And ultimately it’s helping Howard to think more like a health plan in that they’re thinking about their population, … as opposed to just thinking about each one-off visit.” 

That population-level data gives Howard information on who’s at risk and where they’re presenting within the practice plan, creating opportunities to calculate potentially avoidable costs and better tackle SUD. Additionally, the value-based nature of the model encourages early diagnosis and intervention, as well as follow-up treatment for those with SUD.

“We know that SUDs are chronic, relapsing, remitting conditions, so we should be looking at them as episodes of care — not just the impacts of the substance use, but all of the other complicating factors that lead to this being a very complex, … high cost population for plans and health systems,” Moghimi said.

While he said this is currently AmeriHealth Caritas’ only value-based SUD treatment pilot, the MCO is already working on another value-based program opportunity in a similar realm. It will attempt to fix fragmentation in the SUD treatment industry, according to Moghimi.

“It’ll be looking at the continuum of care of SUD providers and how they’re coordinating care amongst each other,” he said. “The idea is kind of creating a virtual accountable care organization amongst the continuum of SUD providers — basically incentivizing them to coordinate between each other through a shared platform, then ultimately looking at shared outcomes amongst these different providers.”

Moghimi said that kind of accountability is key to improving SUD treatment — and moving toward integrated, holistic, value-based health care.

“I think it’s important for us to have a mix of fee for service and value-based outcomes,” he said. “When I’m trying to have conversations with providers about their quality scores, it’s a whole different conversation when there are dollars behind it.”

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