The Trends Defining the ‘New World Order’ of Addiction Treatment in 2022 and Beyond

Higher acuity patients, behavioral health parity and prescribing uncertainty will continue to define addiction treatment in 2022 and beyond.

That’s according to several operators queried by Behavioral Health Business.

As the country begins to unwind from the several temporary measures prompted by the public health emergency (PHE), the addiction treatment space will see a new phase of disruption as American life and business begins to settle into a “new world order,” Marc Turner, interim CEO of the Chicago-based Gateway Foundation, told BHB.

“The pandemic caused a lot of people who have used substances as part of their coping practices to increase the use of those substances,” Turner said. “As a result, a lot of people have moved beyond what may be [considered] use or misused into addiction.”

Here are the key trends defining 2022 and beyond.

Patients volumes could increase 

The pandemic has and will drive major changes in the volume and acuity of patients, Bob Poznanovich, vice president of business development for Center City, Minnesota-based The Hazelden Betty Ford Foundation, told BHB.

Fears of the pandemic or pandemic social distancing measures forced a major nationwide pause on high-acuity addiction treatment. Patients that did engage in treatment were much sicker than was typical because of not accessing care earlier.

“By the time we saw them at Hazelden Betty Ford, they were struggling mightily,” Poznanovich said.

As the pandemic dragged on and some restriction measures lifted, patient volumes began to get back to normal levels but with much greater acuity.

Turner, who independently echoed many of Poznanovich’s statements on patient acuity, said Gateway Foundation has become more proactive in its outreach and marketing. The move also helps get Gateway facilities back up to capacity which today are, on average, operating at between 70% and 80% capacity.

As mental health care needs increase across the U.S. during the pandemic, more patients that have co-occurring mental health conditions and substance-use disorders are seeking treatment at The Hazelden Betty Ford Foundation.

While operators are seeing sicker patients overall, Poznanovich added that there has been a recent influx of “people who are earlier in the progression of their substance use disorder.”

“Our responsibility as caregivers is to widen the door and meet people where they are, and to, in fact, offer many doors so that behavioral health care is as accessible as possible,” Poznanovich said.

Poznanovich and Turner said that increases in patient volumes are expected to continue for some time.

Parity could come into focus

Reimbursement parity remains a vital unresolved issue of federal advocacy. Thus far it has failed to materialize in light of several other legislative fights. The inaction comes in spite of tough talk from a key senate committee leader earlier in the year who vowed that time had run out for insurers on the issue.

Federal legislation is in the works that would impact parity. The Restoring Hope for Mental Health and Well-Being Act of 2022, sponsored by Rep. Cathy McMorris Rodgers of Washington’s 5th district, passed the U.S. House of Representatives on June 22. Among several addiction treatment and mental health reforms, it would strengthen the nation’s parity laws. 

On Aug. 25, the health insurance industry group AHIP said that it is on the side of parity after coming out in opposition to congressional efforts to reform parity laws earlier this year.

“Health insurance providers are committed to achieving mental health parity and will continue to collaborate with federal and state policymakers as they conduct the required reviews under the Consolidated Appropriations Act and advocate for process improvements,” a statement reads.

The 9th U.S. Circuit Court of Appeals could also soon decide whether or not it will rehear its overturning of a favorable district court ruling in Wit v. United Behavioral Health.

The 2019 ruling in the case “rippled throughout every single state, throughout every single payer” as a win for parity and for requiring health plans to make medical necessity determinations in line with generally accepted medical standards rather than internal standards.

Now, the industry awaits to see if the appeals court will revive the effort or if the plaintiffs will need to seek redress before the Supreme Court.

Telehealth is here to stay; reform is still needed

The Hazelden Betty Ford Foundation has invested and continues to invest in facility-based and digital care, Poznanovich said.

The Hazelden Betty Ford Foundation is embracing the “hybridized world” of addiction treatment. This will be key to initially engaging with and maintaining engagement with a potential influx in patients seeking treatment, Poznanovich said.

Nate Purpura, vice president of marketing for Boston-based digital opioid-use disorder (OUD) Bicycle Health said in a statement that telehealth became the “preferred” mode of accessing addiction treatment in 2022 so far.

While many addiction treatment providers have benefited from increased telehealth flexibility due to pandemic-era emergency waivers, this is particularly true for digital-only operators such as Bicycle Health. Bicycle Health and several others saw major investment rounds during this time frame.

There could be a potential regression in state-level regulations for telehealth in addiction treatment, Courtney Bearden, a psychiatric mental health nurse practitioner with Austin, Texas-based Iris Telehealth, in a statement.

“To return to pre-pandemic restrictions would be removing care access for many patients who rely on telehealth due to lack of transportation, lack of providers in their area, or privacy concerns,” Bearden said. “States with restricted practice environments have increased barriers to care, especially for patients in underserved or rural areas.”

She also called for states to allow more addiction care to be provided during the present dearth of mental health practitioners by “eliminating unnecessary regulations and caseload restrictions as well as allowing Advanced Practice Registered Nurse and physician assistants to practice independently.”

Payers are elevating digital addiction treatment 

Leading payers are increasingly working with digital behavioral health operators. 

Dr. Doug Nemecek, Evernorth’s chief medical officer for behavioral health, told Behavioral Health Business in a recent interview that Cigna’s health services entity was interested in finding “innovative partners that are starting to develop new, innovative ways of delivering care.”

“The pandemic has really accelerated this,” he said. “We now have partners that are delivering substance use disorder care virtually and able to do that at scale.”

Evernorth put this on display with its recent deal with Bicycle Health.

In a similar but larger deal, New York City-based Empire BlueCross BlueShield announced it added digital providers Alma, Headway, NOCD and Ophelia Health to its network. Ophelia Health is also a digital OUD provider.

But without major federal reforms, digital addiction treatment and other telehealth-based services could face the challenge of the return of pre-COVID regulations. These regulatory uncertainties are also at play at the intersection of virtual addiction treatment and retail pharmacies.

Retail pharmacies a new horizon and challenge for digital operators

Digital addiction treatment providers face a new dual hurdle and opportunity in addiction treatment: retail pharmacies.

Bicycle Health is looking at partnerships with retail pharmacies that are expanding their health care services beyond prescribing medication, Purpura said. While the Bicycle statement didn’t name them, pharmacy chains such as CVS have made several moves to add in-store mental health and tele-mental health services.

On the same hand, some of the nation’s largest retail pharmacy operators — including Walmart, Walgreens, Costco and CVS — have denied MAT prescriptions, according to reporting by Fierce Healthcare. 

At one level, pharmacies appear to be responding to the uncertainty that revolves around how the U.S. Drug Enforcement Administration will oversee telehealth and MAT.

In 2020, the DEA waived enforcing parts of the Ryan Haight Act. This regulation dictates how controlled substances may be prescribed via telehealth. Many addiction providers — facility-based and digital operators alike — use controlled substances such as buprenorphine to treat OUD.

The DEA is expected to clarify how it will approach telehealth and controlled substances in 2022. In March, Administrator Anne Milgram said in a statement that the agency was committed to ensuring MAT access.

However, in the absence of that clarification, Walmart and other retail pharmacies apparently are exercising caution in the administration of controlled substances following an Aug. 17 court ruling in Ohio that requires Walmart, CVS, and Walgreens to shell out $650.6 million for mishandling opioids. 

“The trend in pharmacies generally has been to limit access to medications for OUD, creating more difficulty filling prescriptions at a time when the medical community and public health officials are working to dramatically expand the quantity of those prescriptions being written,” Purpura said. “Mail-order buprenorphine essentially no longer exists.”