Ophelia, CareSource, Gateway: Investing in Community Can ‘Start Moving the Needle’ on SUD Treatment

Community support often falls outside of the addiction treatment-managed care fee-for-service paradigm.

Payers and providers alike know the importance of fostering community in addiction treatment, and it’s a key to effective treatment and long-term recovery. However, developing communities fall far beyond their typical scope of services. Regardless, innovations around managed and value-based care seek to address just that.

“We’ve got to be able to take a long-term perspective and invest in people and families in the context of their communities and in the context of their circle of supports,” Joshua Boynton, senior vice president of complex health solutions for the nonprofit managed care organization CareSource, said at Behavioral Health Business’ event VALUE.


Building up “networks of people that aren’t paid to be in their lives” is vital in addiction treatment. This is as important to supporting plan members as developing provider networks, Boynton said.

“Once we do that, we start moving the needle,” Boynton said.

Managed care’s place in the value-based care movement is to be a community convener. Managed care innovation alone won’t address addiction treatment issues in the Medicaid population. Instead, stakeholders should look for solutions addressing non-clinical, community issues, Boynton said. This may include managing and preventing childhood trauma, and it may also include addressing social determinants of health, such as housing issues.


Still, treatment is necessary for those in addiction, even if facing non-clinical issues, especially for opioid use disorder (OUD). OUD presents a uniquely specific challenge in managed care and addiction treatment.

Opioid use disorder in managed care

About 28% of the American population is covered by Medicaid programs. A Kaiser Family Foundation analysis found about 3.3% of those on Medicaid have an OUD. The same report states its rate of use estimate is likely an undercount.

Across the U.S. population, only about 1% of all Americans aged 12 and older can be identified as having an OUD. Most people with an OUD do not have a formal diagnosis and are not seeking treatment, according to the 2020 National Survey on Drug Use and Health.

“Much of the cost that goes into providing care for these services happens outside of billable visits and most of that is not covered by our fee-for-service contracts,” Zack Gray, CEO of digital OUD medication-assisted treatment (MAT) provider Ophelia Health, said. “We have been founded on the hope that we can make a fee for service work at scale in Medicaid. As we’re learning, it’s a lot harder than it sounds.”

Joshua Boynton and Zack Gray discuss managed care and addiction treatment at VALUE 2023. Behavioral Health Business
Joshua Boynton, senior vice president of complex health solutions for the nonprofit managed care organization CareSource, left, and Zack Gray, CEO of Ophelia Health, right, discuss managed care and addiction treatment at VALUE 2023.

Bundled payment plans cover about 15% of Ophelia Health’s patient population, Gray said. Fee-for-service plans cover the remainder.

Many models and community services for OUD often don’t account for the harsh realities of the health care system today, Gray said. Wait times to get care can stretch into months. Even in primary care, wait times to see providers that see Medicaid patients can take weeks if they can get care at all, he said. 

About 70% of Ophelia Health patients are Medicaid enrolled. Nearly all haven’t seen a primary care provider in years.

“That means they care much more about their opioid addiction than they do any other health condition,” Gray said. “We are the only touchpoint to the health care system and virtually all of our patients come to us directly.”

Before securing payer contracts, Ophelia Health charged patients $195 a month. This is still the company’s cash-only price. Medicaid patients still joined Ophelia even though they could get treatment for free or near-free cost to them, Gray said.

Gray said this proves the accessibility problem in the addiction treatment system today.

Gray acknowledges that some patients require added community support. However, he sees greater benefits in getting OUD patients on and keeping them on MAT regimens.

“Obviously, having a network of support is vital,” Gray said. “But if you [mandate] community services and support groups on top of the bare minimum — which is just like the treatment for depression, anxiety — medication and counseling with a licensed provider — then you scare a lot of people away.”

The view from a legacy nonprofit

Chicago-based Gateway Foundation requires its mental health treatment locations to provide MAT. Gateway has 15 mental health and addiction treatment locations in Illinois and corrections-focused services in Delaware, Florida, Georgia, Michigan, Missouri, New Jersey, Texas and Wyoming.

It has also supplemented its clinical services with a continuum of support services such as alumni support, peer support and recovery coaches. All the while, it seeks to integrate its services better within its communities.

The Gateway Foundation’s Illinois-based locations provide telehealth, outpatient and residential services. The organization was founded in 1968

Screening bias in certain communities across the U.S. disrupts efforts to get patients to the right level of care and community support, Jeremy Klemanski, CEO of Gateway Foundation, said. 

Managed care and addiction treatment discussion at VALUE 2023 with Jeremy Klemanski, Joshua Boynton and Zack Gray Behavioral Health Business
Gateway Foundation CEO Jeremy Klemanski, left, discusses managed care in addiction treatment at VALUE 2023.

“I see it particularly, in the public systems where the screening tilts to what we can get somebody qualified for and get them into,” Klemanski said. “The more levels of care we have, the more appropriately we can place a person at the right level [of] what they need and the easier it is to move them from one level to the next because it’s available.”

Patients in sustained recovery and improvement often have a mix of supports — both supports that are tied to the patient like family and provided support services, such as peers or support groups.

Bringing support and clinical services will likely continue to get easier via technology, and using telehealth to do that is vital to value-based care and managed care populations, Klemanski said.

He added that regulations should place trust in providers to decide the level of care they need in response to a question about proposed regulatory changes to telehealth.

“The line that we use with government regulators is that it should be as easy to get help as it is to get a substance on the street,” Klemanski said. “If I can use my phone to get help for a lot of other things or simply to order or buy drugs, why can I use my phone to access a tele-appointment and get something from a controlled healthy environment where a clinician or practitioner is going to use their judgment to decide if I need to come in for some sort of an in-person visit?”

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