Presentation is loading. Please wait.

Presentation is loading. Please wait.

 Stuart Gitlow, MD, MBA, MPH, FAPA  President, American Society of Addiction Medicine  Follow us on Twitter and online #addictionmeds.

Similar presentations


Presentation on theme: " Stuart Gitlow, MD, MBA, MPH, FAPA  President, American Society of Addiction Medicine  Follow us on Twitter and online #addictionmeds."— Presentation transcript:

1

2  Stuart Gitlow, MD, MBA, MPH, FAPA  President, American Society of Addiction Medicine  Follow us on Twitter and online #addictionmeds 

3 Federal Partners  Office of the Assistant Secretary for Health  Center for Substance Abuse Treatment, SAMHSA  National Institute on Drug Abuse  Executive Office of the President, Office of National Drug Control Policy Sponsors  Alkermes  Behavioral Health Group (BHG)  Cigna  Covidien  Millennium Laboratories  Orexo  Pfizer Inc.  Reckitt Benckiser Pharmaceuticals Inc.  Titan Pharmaceuticals, Inc.

4

5  Mark Kraus, MD, FASAM (Co-Chair)  Richard Soper, MD, JD, FASAM, DABAM (Co- Chair)  Kelly Clark, MD, MBA, FASAM  Mark Publicker, MD, FASAM  Ken Roy, MD, FASAM

6

7  Every state Medicaid program covers at least one of the four FDA-approved medications for the treatment of opioid dependence  Many state Medicaid programs have implemented a variety of authorization requirements which must be met in order for payment for these medications to be approved.  Requirements for approval can range from limited to severe, and may include “fail first” policies or a history of frequent service utilization 7

8  Written Medicaid criteria for authorization of a medication may actually be implemented either with flexibility or rigidity by different state Medicaid agencies. The survey on which this report is based could only review the written criteria. Actual implementation of written criteria may vary.  Accuracy of the survey results was degraded by an unknown amount by the lack of knowledge of state Medicaid respondents about policies in areas outside of their immediate sphere of understanding. Review of survey responses indicated that many Medicaid agencies contain separate medical, pharmacy and Opioid Treatment Program (OTP) “silos”. 8

9 9 * See Appendix to Report for complete data including Alaska and Hawaii

10 10

11 11

12 12

13 13

14 14

15 15

16 16

17  One Western state Medicaid FFS program offers both Suboxone ® and Subutex ® (film and tablets) as on its Preferred Drug List, and also offers Vivitrol ® on that same drug list, although in a non-preferred status  One Mid Western state Medicaid FFS program allows providers to offer all of the medications in its OTP's, many of its criminal justice facilities and is planning to expand availability that to Community Mental Health Centers next year.  A New England Medicaid FFS program has a unique, Medicaid-supported MAT hub (OTP) and spoke ( 200 office based physicians) regional specialty system that provides methadone and buprenorphine statewide 17

18  Payment for FDA-approved addiction medications by state Medicaid programs hinges on compliance with often complicated authorization requirements.  Medicaid agencies reported widely varying authorization requirements for each FDA-approved medication for the treatment of opioid dependence.  There is little agreement among state Medicaid agencies regarding this life-saving, evidence-based set of interventions.  CMS and/or other federal authorities interested in addressing the spread of addiction to prescription narcotics and other opioids may need to consider intervening to limit such disparities and inequities in the accessibility of these medications to patients covered by Medicaid. 18

19

20  Most plans cover pharmacotherapies for opiate dependence  Coverage is complex  Significant regulation of methadone and buprenorphine

21  Inclusion in a plan’s formulary does not equate to easy access  Utilization management (UM) can reduce access  Most common UM requirements are:  Prior authorization  Quantity and dosage limits  Step therapy or “fail first” requirements

22  Most widely available is Suboxone  New formulations may make Suboxone even more available  Generic formulation approved by the FDA in March, 2013 is already available in about 50% of plans studied  While methadone is available in Opioid Treatment Programs (OTPs) study found no commercial coverage

23  Although clinical services are covered as a benefit, few plans required clinical services in parallel with medications  Clinical services in conjunction with medications is an evidence-based practice that should be required by commercial health plans

24  Recession decreased spending on behavioral health treatment significantly from 7.2 % of total health spending to 2.7% largely due to unemployment (Levit, I. et al. 2013).  Between share of spending by commercial insurers increased to 16% from about 12% and spending on medications was about 4% from an undetectable amount in 2001.

25  Commercial health plans were reluctant to respond to the survey  CEOs who were contacted by their Medical Directors about the survey directed them not to respond  In the “health marketplace” transparency will be critical so individuals can compare plans

26  Em0ployers may be key to assuring coverage and benefits for medications and clinical services  Limitations on behavioral health benefits may increase employers non-behavioral direct and indirect healthcare costs (Nat’l Bus. Grp. On Health, 2005)  Education of employer groups is needed

27  Under-utilization has been driven by:  State licensing requirements that restrict hiring of physicians  Restrictions on use of some medications in specific settings  Cultural and attitudinal issues in the workforce

28  Plans are working to engage treatment providers to improve use of medications in treatment Plans view this as cost-saving and evidence- based  Plans are creating internal programs to assist patients and providers with access problems

29 ASAM-TRI Review of Medications for Treatment of Opioid Addiction Effectiveness and Cost-Effectiveness

30 1.All databases searched – Emphasis on post Cochrane methods – 2 independent reviewers 3.Results 1.Effectiveness a)642 candidate articles = 75 analyzed 2.Cost-Effectiveness a)362 candidate articles = 20 analyzed

31 1.Patient engagement & retention 2.Reduction of opioid use 3.Reduction of non-opioid drug use 4.Reduction of opioid-related health and social problems a)HIV and other infections b)Crime c)Unemployment

32 Benefits/Effectiveness Shown: Engaging and retaining patients Reducing opioid use Reducing opioid related health/social problems Side Effects: Abuse cases increase with increased availability Overdose incidents and deaths with methadone

33 Benefits/Effectiveness Reducing and even eliminating opioid use Reducing opioid related health/social problems Side Effects Oral naltrexone has significant withdrawal effects if administered <72 hours following detoxification

34 Benefits/Effectiveness Shown: Engaging and retaining patients Reducing opioid use Reducing opioid related health/social problems Side Effects: Abuse cases increase with increased availability Overdose incidents and deaths with methadone

35 1.Meds have little effect on non-opioid substance use a.Naltrexone-alcohol an exception 2.Medication effects enhanced with good health/social supports a)Patients rarely get these services b)Thus medications are consonant with recovery-oriented care.

36 3.Medication benefits only shown for maintenance – NOT for detoxification a)This has been a source of public disappointment b)BUT – medications are both effective and cost-effective when used for long-term maintenance

37 1.Cost-Effectiveness = Cost per unit of effectiveness on a single outcome measure. – e.g. cost per drug-free day 2.Cost-Benefit = Total dollar costs to deliver an intervention divided by the total benefits realized expressed in dollars 3.Cost-Offset = Savings from an intervention – Costs of that intervention

38 1.Methadone = economic evaluations since 2006 continue to show cost-effectiveness – and also showing cost-effectiveness for HIV-prevention 2.Buprenorphine = far fewer economic evaluations than for Methadone – but results are very encouraging as cost-effective treatment 3.Naltrexone = no meaningful economic evaluations since 2006 supporting cost-effectiveness – but cost-analysis studies are encouraging

39 1.Less than 30% of treatment programs offer medications for opioid dependence 2.And less than half of patients in these programs receive them 3.The numbers are far lower in non-specialty treatment (i.e. primary care)

40 1.Maybe they aren’t attractive to Patients? a)Methadone and Buprenorphine – definitely no – waiting lists in many cities b)Naltrexone – Yes – particularly oral naltrexone 2.Maybe they aren’t effective? a)Definitely No

41 1.Maybe they cost too much? a)Methadone cost/ month = ~$40 b)Buprenorphine cost/month = ~ $140 c)Oral Naltrexone cost/month = ~$60 d)XR Naltrexone cost/month = ~$700 e)Insulin cost/month = ~$200

42 1.It appears that the underutilization is attributable to Other Reasons: a)Physician Availability and Training b)Official and de-facto Regulations c)Specialty Care Limitations - ideology d)Patient/Employer Demand

43 Treatment Research Institute

44

45  Zenger Room, with live feed to Holeman Lounge  Speakers  Stuart Gitlow, MD, President of ASAM  Tom McLellan, PhD, Executive Director of Treatment Research Institute, former Deputy Director of the White House Office of National Drug Control Policy  Michael Botticelli, Deputy Director of the White House Office of National Drug Control Policy  John O’Brien, Senior Policy Advisor, Center for Medicare & Medicaid Services (invited)  Whitney, patient taking buprenorphine

46

47  Michael Botticelli, Deputy Director, Office of National Drug Control Policy  Barbara A. Cimaglio, Deputy Commissioner, Alcohol and Drug Programs, Vermont Department of Health  H. Westley Clark, MD, JD, MPH, CAS, FASAM, Director, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration  Andrea Kopstein, PhD, MPH, Director, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration  Douglas Nemecek, MD, MBA, Board Member, Association for Behavioral Health and Wellness and Chief Medical Officer, Cigna  Jack Stein, PhD, Director, Office of Science Policy and Communications, National Institute on Drug Abuse  Mark Stringer, MA, Director, Missouri Division of Behavioral Health

48

49  Capitol Hill Briefing: September 30  ASAM Speakers’ Bureau  Clinical Guideline

50  All reports are available online at s-for-Opioid-Addiction-Treatment s-for-Opioid-Addiction-Treatment


Download ppt " Stuart Gitlow, MD, MBA, MPH, FAPA  President, American Society of Addiction Medicine  Follow us on Twitter and online #addictionmeds."

Similar presentations


Ads by Google