SUD Stakeholders’ Call to Payers: Contingency Management Key to Treating Stimulant Use Disorder

Drug overdoses killed a record 93,000 people last year, with the vast majority of those fatalities related to opioids.

However, the opioid epidemic isn’t the only drug-related crisis sweeping the country. Stimulant use is also on the rise, with deaths attributable to those drugs increasing 10-fold between 2009 and 2019. And, in 2020, overdose deaths involving cocaine and psychostimulants such as meth increased 26.5% and 34.8%, respectively, according to the CDC.

From a regulatory standpoint, opioid use disorder (OUD) tends to overshadow stimulant use disorder, as it affects more people. But still, stimulants caused more than 20,000 overdose deaths in 2020. Plus, stimulant use disorder can’t be mitigated by medication-assisted treatment, which is largely considered the gold standard for opioid use disorder (OUD).

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Instead, an incentive-based treatment called contingency management has proven to be the best course of action for stimulant use disorder. But despite strong evidence that the practice improves patient retention, care transitions and outcomes, relatively few behavioral health providers offer the treatment.

“One of the huge barriers to implementing or expanding access to contingency management is the fact that we don’t have billing code for it, even though we have billing codes for cognitive behavioral therapy (CBT),” Eric Gastfriend, CEO of DynamiCare Health, told Behavioral Health Business. “And there’s actually more evidence for the effectiveness of contingency management in addiction treatment than CBT.”

Boston-based DynamiCare Health is a technology platform that uses contingency management to help patients kick their substance use disorders (SUDs). It partners with addiction treatment programs, health systems, accountable care organizations (ACOs) and health plans to reward SUD patients for hitting certain positive treatment milestones. Rewards come in the form of deposits onto a smart debit card, which can’t be used for cash withdrawals, bars or liquor stores.

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Gastfriend co-founded the company with his father back in 2016. His argument isn’t against the coverage of CBT. Instead, his point is that contingency management should be covered, too — and that the practice won’t gain widespread traction until providers can afford to offer it.

“We have codes for CBT, and that’s what every treatment program does,” he said. “There’s no billing code for contingency management, so no one does it because it’s not reimbursable.”

BrightView Health — a DynamiCare client — is one of the few SUD treatment providers currently offering contingency management as part of its programming. It’s using grants to help make the practice affordable, according to Shawn Ryan, president and chief medical officer at BrightView.

He said the company has been doing contingency management for most of its seven-year history. Before it partnered with DynamiCare, that meant doing things the “manual way” and giving out tickets for prize drawings based on factors such as therapy attendance.

The evidence surrounding contingency management is what originally sold Ryan on the practice: Research has shown that contingency management significantly boosts retention, with one study showing a 49% retention rate for contingency management patients, compared to 35% in a standard care group. Additionally, the practice leads to longer bouts of consecutive abstinence for patients, research indicates.

“If you want your patients to have the best chance of recovery, it should be part of your program, period,” Ryan told BHB. “Go to the insurance companies and [regulators] and ask them: ‘Why not? We know this works. It’s well researched. We need every tool in the toolbox.’”

Still, stigma puts the practice out of reach for many providers, he said. Even if they don’t subscribe to that stigma themselves, many payers do — and incentive programs cost money to implement.

“I’ve had very tough conversations with some different folks, whether it be regulators, payers or providers, who will say stigmatizing things, like, ‘There’s no way we’re going to reward people for doing what they should be doing in the first place,’” Ryan said, noting that line of thinking is “not appropriate at all.”

Payer, regulatory progress

While contingency management isn’t yet widely reimbursed by payers, it does seem to be gaining some ground.

Under the Biden administration, the Office of National Drug Control Policy (ONDCP) included promoting reimbursement for contingency management in its list of year one drug policy priorities. Plus, there’s currently a bill in the California state legislature that would require the state’s Medicaid program to cover contingency management for stimulant use disorder.

Gastfriend said those developments are exciting — but there’s still a lot of confusion around contingency management. Regulations require programs to use clear, documented evidence-based protocols, and they prohibit contingency management from being used as a marketing tactic.

“You can do contingency management under the current regulations if you do it correctly and follow the proper safeguards — and that’s been recognized by HHS OIG — but it would be really nice to have some clarification from HHS and [for it to] create kind of a safe harbor around contingency management,” Gastfriend said.

Getting payer support for contingency management is also a problem — and one that stakeholders are working on.

For example, Affect Therapeutics — a year-old company aiming to make contingency management affordable, scalable and auditable — is currently working to score a number of contracts with payers. Results from a contingency management field study in California help make its case.

Since January, Affect has treated about 55 patients with severe meth use disorder in 16-week episodes of care, with retention rates of about 50%.

“We have been in discussions with a number of payers at both the commercial and Medicaid level,” Affect CEO Kristin Muhlner told BHB. “We are in contracting with a couple of those … and I anticipate that we will be in market with a set of beachhead states — initially Arizona, Nevada, Kentucky — in Q4 of this year.”

Once Affect goes to market, it will provide patients with a six-month intensive episode of care with an open-ended maintenance period. Patients will receive the digital therapeutic app, as well as an assignment to a dedicated care advocate, addiction counselor and psychiatrist.

Each day, the app gives patients a behavioral health curriculum filled with lessons and tasks to complete, while also allowing Affect to collect a variety of data points. Patients also have twice-per-week group therapy, once-per-week addiction counseling and twice-per-week drug screens, as well as regular touch points with care advocates, who keep them on track and offer support.

“Every single aspect of that is incentivized with contingency management incentive,” Muhlner said. “Those can be fixed payments for specific task completion or meeting attendance, … or they can be variable payments. For example, for streaks of abstinence, … your incentive for getting those goes even higher.”

Meanwhile, DynamiCare is also working with health plans to get its services covered.

In 2020, the company launched a pilot with Horizon Blue Cross Blue Shield of New Jersey to see if contingency management can make a positive impact on the plan’s members with SUD. It’s currently available to fully insured commercial members, as well as some self-insured groups and Horizon employees who fit the criteria for having an SUD. The pilot will run until at least 2022, and if it’s successful, the plan hopes to add contingency management as a formally covered benefit, according to Rachel Goldberg, the director of behavioral health client partnerships and product innovation at Horizon.

“We want to be able to think outside of the box and offer as many different types of innovative solutions as we possibly can, but I think that the rest of the payer community hasn’t yet gotten to that point,” Goldberg said.

Additionally, DynamiCare has partnered with Vermont Medicaid, who has agreed to help them find organizations and health care providers to recruit Medicaid members to participate in a $1.6 million study to test whether contingency management can help Vermonters with alcohol use disorder to stop drinking.

“At the end of the day, a health plan should be most concerned about getting the results, and if this gets results, then it would be malfeasance not to pursue it,” Vermont Medicaid Chief Medical Officer Strenio said.