Inside the Rollout of CMS’ Value-Based Opioid Treatment Pilot Program

As if anyone needed a reminder about the severity of substance use disorder (SUD), the number of deaths from drug overdoses continues to provide a sobering snapshot.

As 2021 wound down, the Centers for Disease Control & Prevention (CDC) reported that overdose deaths reached yet another record level on a 12-month basis. More recently, the CDC released provisional data indicating no let up in the epidemic, as year-over-year deaths are on track to exceed 101,000. And many of the deaths are opioid-related, responsible for 70% of all SUD fatalities since 2019.

More SUD treatment providers have been busy dispensing services in a market estimated to be worth anywhere between $4.5 billion and $42 billion. Now, the Centers for Medicare & Medicaid Services (CMS) is trying its hand at stemming the SUD tide with a value-based treatment pilot program.

Beginning last April, CMS – which is the nation’s largest payor of behavioral health services – began the Value in Opioid Use Disorder Treatment Demonstration (ViT) initiative. The program gives regular payments and incentives to providers for helping patients achieve value-based treatment goals such as a reduction in hospitalizations and an improvement in health outcomes.

CMS initially allocated $10 million for ViT, which was open to up to 20,000 applicants. Ultimately, 61 providers from 36 states and Washington, D.C. were selected to participate.

For their participation, each provider is paid a monthly stipend of $125 to dispense enhanced, value-based services through such avenues as expanding care modalities, hiring new workers or adding social support services. Additionally, performance-based incentives are available for providers who are able to effectively deliver on resources such as medication-assisted treatment (MAT).

The ViT program is scheduled to run through December 2024. While time will tell as to whether the demonstration project is a success, two different providers are welcoming the opportunity to receive federal help with a novel approach for fighting against SUDs.

A regional health care system takes on the opioid epidemic

The SUD epidemic may not be as dire in Iowa as in many other states, as the rise in drug overdose deaths has lagged behind the national average. That still does not mean that SUDs are not a major issue in the Hawkeye State, as opioid-related deaths increased by 35% in 2020.

“We’ve certainly identified more and more people that have opioid use disorder,” Alison Lynch, a clinical professor and a director of the addiction and recovery collaborative at the University of Iowa (UI) Health Care System, told Behavioral Health Business.

A major health care provider for the state, UI Health Care has been ramping up its addiction care treatment services in and around its Iowa City campus. The increase in services is happening as Iowa suffers from a lack of prescribers for MAT drugs like buprenorphine, according to Lynch.

“People in Iowa are dispersed, and end up driving longer distances to get to a provider,” she said.”

Along with access, Lynch stated that many Iowans struggling with SUDs are grappling with issues such as stigma.

“There is a lot of stigma around substance use disorders,” Lynch said. “And we believe that’s why many people don’t access treatment.”

Having long been interested in issues surrounding health care reimbursement, Lynch believes the process of paying for services can be confusing for some to maneuver, even potentially acting as a deterrent in a state where opioid use is problematic.

“I’ve worked in health care for about 20 years, and sometimes the payment system is very complicated,” Lynch said. “Things that are incentivized sometimes just add complexity and don’t necessarily promote health.”

It was that complexity, Lynch said, that drove the interest of her and her colleagues in ViT.

“The whole idea of participating in an alternative payment model and innovative payment model is very appealing,” she said. “It gave us an opportunity to access some additional resources to reinforce and grow some of our programming.”

As part of ViT, UI Health Care – who had already been seeing heightened demand and increased services for SUD assistance – has been using its allotted CMS funding to help individuals at its clinics get more access to MAT drugs like buprenorphine, in addition to expanding care modalities like telehealth.

UI Health Care had specifically outlined in its application that it wanted to use the demonstration funding to bring on more case managers that could provide lower level services to patients – such as follow-ups on appointments and help with troubleshooting on insurance and prescription matters.

Lynch further noted that the CMS funding has been used to bring on peer support workers in paid positions. She also credited the funding with buttressing UI Health Care’s contingency management program, which provides incentives to patients for meeting treatment goals.

“Our case managers and our peer recovery support specialists help people monitor their goals, and then can help connect them with the incentive payment when they are successful in meeting those goals,” Lynch said.

Currently, UI Health Care’s own ViT program has around six participants by Lynch’s estimate, with 18 more who have been screened and are eligible to participate.

Even if that seems like a small number, Lynch believes the program can be a bridge for the provider to do more work in the future treating Iowans with opioid addictions.

“We are totally thinking about the future,” Lynch said. “This is just part of launching more of a proactive, compassionate, evidence-based approach to providing care to anyone who has substance use disorder.”

A SUD treatment provider looks to hit on treatment goals via ViT

When it comes to SUDs in America, there are fewer states that have been hit as hard as Tennessee.

The CDC’s most recent provisional data has the Volunteer State having registered a 34% increase year-over-year from June 2020 to June 2021 in overdose deaths. The number exceeds the national average by more than 10 percentage points.

One Tennessee provider that is trying to meet that need is Cedar Recovery, which operates four opioid treatment locations in the state in addition to its flagship Mt. Juliet center in suburban Nashville. 

Like UI Health Care, Cedar Recovery offers MAT drugs like buprenorphine. The provider also offers services such as behavioral therapy.

TennCare, which is Tennessee’s state Medicaid program, expanded its coverage in 2018 to provide reimbursement for office-based opioid treatment. Two years later, Medicare came out with a bundled rate program for covering treatment in-office.

Even still, Cedar Recovery chief strategy officer Paul Trivette believed more needed to be done for Medicare recipients, along with opening more pathways for non-MAT drug assistance.

“Over 80% of our patients are Medicare or Medicaid beneficiaries,” Trivette told BHB. “But Medicare doesn’t cover all services necessarily needed for office-based opioid treatment. Nor do they do that even outside of [office-based treatment], such as for peer support, utilizing licensed professional counselors, licensed marriage and family therapists, or doing contingency management for achieving desired goals and outcomes.”

Cedar Recovery subsequently jumped at the opportunity to apply to ViT and currently serves 62 patients in the program. The provider is looking to increase that number to at least 100 people served by the end of 2022.

So far, the demonstration has allowed Cedar Recovery to see more Medicare patients (ViT does not extend to covering Medicare Advantage enrollees) and be reimbursed for using workers like peer support specialists, who are made available through a contract it has with health care management company Mindoula. ViT has also allowed Cedar Recovery to enlarge its reach by partnering with Nashville-area health system Maury Regional Medical Center to provide addiction counseling services.

Trivette said that he is particularly excited that ViT is enabling Cedar Recovery to be compensated for contingency management services, which he believes – like Lynch – is an effective, evidence-based form of treatment.  

Those services allow the provider to administer non-cash prizes to patients who accomplish certain treatment goals, which is done through a contest reminiscent of the game shows Wheel of Fortune and The Price Is Right.

“We can give them a treatment goal, and then say, ‘Hey, if you achieve this goal, you get to spin the wheel, and you’re going to get a prize,’” he said. “We do have a funding source so that we can buy soaps, shampoos, toilet paper [or] candy bars. They achieve a treatment goal, and that just keeps them motivated.”

Among its outcome goals, Cedar Recovery aims for patients to achieve six months of meaningful therapy sessions along with maintaining a high retention treatment rate – the latter of which currently stands at over 80%, according to Trivette.

While Trivette acknowledged that it is still very early to judge overall success for Cedar Recovery’s participation in ViT, he is encouraged by what he sees so far.

“We are not seeing anything on the prescription monitoring database or the control substance database to suggest that they’ve left our care to relapse,” he said about patients being served through ViT. “Our members would say that our retention is good, our engagement is good. And we know that as long as we’re doing that, and that these people’s lives are getting better … they’re staying alive to fight another day.”