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

2. 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

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

4. 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

5. 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

6. + + 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
$ $2.49 PPPM
Based on active case load
$350,00/ 20,000 people
Scaled based on population
Vermont Agency of Human Services

7. 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

8. 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

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

10. Vermont Agency of Human Services
VT Department of Health
Department of VT Health Access
Vermont Agency of Human Services 11

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

12. 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

13. State Contacts / More Information
Department of Vermont Health Access Aaron French, Deputy Commissioner – Beth Tanzman, Blueprint Deputy Director – Vermont Department of Health Harry Chen, MD, Commissioner – Barbara Cimaglio, Deputy Commissioner – Additional resources: Vermont Department of Health Website/Care Alliance for Opiate Addiction: Vermont Blueprint for Health: Hub and Spoke Briefing: Hub and Spoke State Plan Amendment: amendments/downloads/vt/vt pdf Gov. Shumlin’s 2014 State of the State Address: address
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