Substance Abuse Treatment System of Care Use of Medicaid Funding for Opiate Treatment Expansion in Vermont Barbara Cimaglio – Deputy Commissioner June 15, 2016

Origin and Development of Successful Reform Developing the model Number of people seeking treatment for opiate addiction was rising: From 1199 in 2004 to 2944 in 2011 Existing treatment network had limited capacity to treat opiate addiction Limited number of treatment slots/areas with no OTP/long wait lists Not enough physicians who could treat this population Medical expenditures were rising for this population – 3x the average per capita costs of other Medicaid beneficiaries Health outcomes were poor for this population Current services were siloed – lack of access to full health care for people with addictions Vermont Agency of Human Services

Origin and Development of Successful Reform Vermont Department of Health Source: Alcohol and Drug Abuse Treatment Programs Vermont Agency of Human Services

Origin and Development of Successful Reform Opportunity: Affordable Care Act Section 2703 – opportunity to create a specialty health home 90/10 match for 8 quarters Requirement to include 6 health home services Comprehensive care management Care coordination Health promotion Comprehensive transitional care/follow-up Patient and family support Referral to community and social support Detail: Actual people 228,021 in SFY13, expenditures: $2,116,773 Includes: SPF SIG, OJJDP, Prevention activities, SAP actual expenditures Vermont Agency of Human Services

Origin and Development of Successful Reform The Care Alliance for Opioid Treatment, also known as the Hub and Spoke initiative is designed to expand access to treatment by creating a coordinated, systemic response to the complex issues of opiate and other addictions in Vermont. Key goals: Improve access to addictions treatment Integrate addictions treatment with health care Improve outcomes for addictions patients Key elements: Enhanced health homes for addiction treatment – Hub & Spoke Bundled payment/capacity payment for spokes High level results/outcomes: Improved access to care Lower health costs Improved patient outcomes Vermont Agency of Human Services

+ + Vermont Payment Reforms for Primary Care Insurers Fee for Service Department of Vermont Health Access Vermont Payment Reforms for Primary Care Medicaid Commercial Insurers Medicare Insurers Fee for Service Unchanged Allows competition Promotes volume Payment for Quality Payment to practices Consistent across insurers Capacity Payment Community Health Teams Shared costs as core resource Consistent across insurers Minimizes barriers + + NCQA PPC-PCMH Score $1.20 - $2.49 PPPM Based on active case load $350,00/ 20,000 people Scaled based on population Vermont Agency of Human Services

Origin and Development of Successful Reform A Hub is a regional opioid treatment center responsible for coordinating the care and support services for patients who have complex addictions and co-occurring substance abuse and mental health conditions. Patients who need methadone must be treated here. Patients who need buprenorphine may be treated here. A Spoke is a “medical home” – such as a primary care practice or health center – responsible for coordinating the care and support services for patients with opioid addictions who have less complex medical needs. Only patients who are treated with buprenorphine receive treatment in the spokes. Depending on the patient’s needs, support services may include mental health and substance abuse treatment, pain management, family supports, life skills, job development, and recovery supports. Vermont Agency of Human Services 7

Origin and Development of Successful Reform Hubs Rate/based Basic OTP Rate Enhanced rate to include health home services Spokes FTEs added/100 patients Nurse case manager Masters-prepared clinician Vermont Agency of Human Services 9

Origin and Development of Successful Reform Vermont Agency of Human Services 10

Vermont Agency of Human Services VT Department of Health Department of VT Health Access http://oas.samhsa.gov/NSDUH/2k9NSDUH/MH/2K9MHResults.pdf http://mentalhealth.vermont.gov/sites/dmh/files/pip/DMH-PIP_April_13_2012.pdf http://www.samhsa.gov/data/NSDUH/2k11MH_FindingsandDetTables/2K11MHFR/NSDUHmhfr2011.htm#4.7 Vermont Agency of Human Services 11

Outcomes Data collection: Medical & Social Health care expenditures Access to treatment Engagement in treatment Drug use Emergency department utilization Hospitalizations Rates of continuous health insurance Incarceration rates Unemployment rates Children in DCF custody Housing stability The number of people being treated for residential services has remained stagnant over time; the number receiving hub/methadone services has increased, and the number receiving outpatient care are relatively flat. Vermont Agency of Human Services

Outcomes Using 2007-2013 Vermont Medicaid data, analysis shows: Individuals with an opioid dependent diagnosis receiving MAT have lower medical care costs than those who have an opioid dependent diagnosis and are receiving non-MAT substance abuse treatment or no treatment at all Longer MAT engagement corresponds to lower non-treatment related medical care costs . Vermont Agency of Human Services 13

State Contacts / More Information Department of Vermont Health Access Aaron French, Deputy Commissioner – aaron.french@vermont.gov Beth Tanzman, Blueprint Deputy Director – beth.tanzman@vermont.gov Vermont Department of Health Harry Chen, MD, Commissioner – harry.chen@vermont.gov Barbara Cimaglio, Deputy Commissioner – barbara.cimaglio@vermont.gov Additional resources: Vermont Department of Health Website/Care Alliance for Opiate Addiction: http://healthvermont.gov/adap/adap.aspx Vermont Blueprint for Health: http://hcr.vermont.gov/blueprint Hub and Spoke Briefing: http://www.healthvermont.gov/adap/documents/HUBSPOKEBriefingDocV122112.pdf Hub and Spoke State Plan Amendment: http://www.medicaid.gov/state-resource-center/medicaid-state-plan- amendments/downloads/vt/vt-13-0071.pdf Gov. Shumlin’s 2014 State of the State Address: http://www.c-span.org/video/?317076-1/vermont-state-state- address Vermont Agency of Human Services 14