OIG Opinion Sees Favorable Outlook for Contingency Management Services

In the fight against substance use disorders (SUDs), a number of providers have been turning to contingency management (CM) services as a solution, and a new report from the government shows it is working.

The idea of providing certain incentives to individuals for hitting treatment benchmarks has been backed by various published studies. Additionally, the Biden administration – as part of its first year policy priorities – said that it was committed to policies advancing CM. Currently, CM is being reimbursed as part of a newly rolled-out demonstration program from the Centers for Medicare & Medicaid Services.

CM services took another big step recently in the form of a favorable report from the Office of Inspector General (OIG), which asserted that it is an effective treatment model.

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“We’ve heard consistently from our members that they are desperate to be able to implement solutions to support people with stimulant disorder addiction,” said Chuck Ingoglia, the President and CEO of the National Council for Mental Wellbeing, said during an interview with Behavioral Health Business. “Contingency management is one of the interventions that’s been shown to have the best effect for these folks.”

DynamiCare joins the fight for CM

OIG’s February 25 issuance looked at an app-based program developed by Boston-based DynamiCare Health Inc., which specializes in providing CM platform services to addiction treatment providers.

DynamiCare – which has raised over $6 million since it was launched in 2016 – works with providers that treat a range of SUDs including opioids, stimulants, alcohol and nicotine. DynamiCare’s platform includes such tools as appointment and medication reminders, saliva tests for drugs, breathalyzers for alcohol and recovery coaching support.

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“[Contingency management] is acceptable to the regulators when it’s practiced correctly — but that means it has to be clinically sound [and] an evidence-based protocol,” DynamiCare CEO Eric Gastfriend told BHB last year. “It can’t be used as a way to advertise the program or incentivize patients to pick one program over another.”

DynamiCare provides monetary incentives through the form of a smart debit card that prohibits its use at bars, liquor stores or other vice-like business establishments. Cash withdrawals are also prevented at ATMs.

Seventy percent of DynamiCare’s incentives are tied to patients providing negative test results. Twenty percent of the incentives are tied to attendance benchmarks, with the rest going towards users engaging in self-guided content.

“[DynamiCare] certified that substance use disorders are known to impair the brain reward mechanisms responsible for healthy motivational drive,” the OIG noted about the company in its opinion. “[DynamiCare] further certified that CM is a highly effective, cost-efficient treatment approach that uses incentives … to motivate and sustain behavioral health efforts in people who suffer from substance use disorders.”

Unlike some of the providers it contracts with, DynamiCare itself is not a federally-enrolled supplier and provider of health care. However, organizations like the National Council believe that federal laws in some ways inhibit the growth of CM services across the SUD treatment sector.

In particular, fears within behavioral health are rampant that providing CM incentives to individuals for meeting treatment goals might violate the federal Anti-Kickback Statute (AKS) and Beneficiary Inducement Prohibition (BIP). Whereas AKS applies to payments between providers and businesses, BIP applies to payments to patients.

Violations such as those against AKS and BIP can take effect when gifts in excess of $75 per year are given by providers to compel patients into treatment. DynamiCare’s protocol allows up to $599 per year for every patient.

“The concern that providers had is that if they provide this service, that they are opening themselves up to potential prosecution by the federal government for violating federal anti-kickback laws,” Ingogolia said. “That scares a lot of people, and having legal protection is really important.”

The future of CM after the OIG ruling

Because DynamiCare is not a federal provider of health care services, Ingoglia said that it made it easier for the National Council to approach them for assistance as they sought the OIG advisory opinion.

That process, Ingoglia said, began roughly late last year.

“We did contemplate whether or not it should be an actual provider of services who sought the approval from the OIG,” he stated. “I don’t know that we would have been successful. I think it helped a lot that DynamiCare does not bill federal health care programs directly.”

Even though DynamiCare might have an elevated profile among private providers of CM services, Ingoglia said name recognition was not a factor in the National Council teaming up with the company to seek the opinion.

“They’re so committed to this topic and trying to make this work,” he said. “They’re involved in multiple efforts, and it was more of having encountered them, being aware of their work and then their willingness also to partner with us.”

In the opinion, OIG said that DynamiCare’s protocols are in line with evidence-based research presented by the National Institutes of Health (NIH), as well as effective SUD treatment principles put forth by NIH’s National Institute on Drug Abuse.

OIG also asserted that DynamiCare’s CM incentives offer a low monetary value for users on a yearly basis, along with affirming the company’s status as a non-federal health care provider.

“Based on this assessment, … we conclude that the Arrangement presents a minimal risk of fraud and abuse under the Federal anti-kickback statute,” the OIG stated.

Ingoglia is hopeful the opinion can pave the way for more CM to be delivered by treatment providers, as well as more CM companies to emerge.

“You want to be very careful before you invest too much of your time or energy into something that could potentially not be allowed,” he said. “We’re hoping that this advisory opinion helps to pave the way for other companies to want to invest in this particular treatment area.”

He added that the National Council is seeking to get the ear of more policymakers who can add legislative support to the OIG ruling.

“I think that this advisory opinion gives us an opportunity to do that,” he said. “We do look forward to engaging other folks to continue this conversation.”

To view the OIG opinion in its entirety, click here.

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