The Senate Finance Committee is looking at how changes in Medicaid and Medicare policy could help in the treatment of opioid use disorder.
One of the most effective treatments, peer support services, has no government reimbursement, said Senator Ben Cardin of Maryland. Peer support programs have been successful in his state, he said.
"The problem is there is not a reimbursement structure," Cardin said. "A lot of this, you have to find either third party sources to fund it, or creative ways, or hospitals coming in to help us because they know it will reduce their emergency rooms."
"We agree peer support is part of the continuum to care," said Kimberly Brandt, principal deputy administrator for Operations, for the Centers for Medicare and Medicaid Services.
The challenge is that peer support is not considered a provider for purposes of Medicare reimbursement, she said. CMS would have to expand the definition of a provider to give that flexibility.
States are having success with peer support programs that are being done under their own authority, she said.
More than 60,000 Americans fatally overdosed on drugs in 2016 and many of those were opioid overdoses, said Senate Finance Chairman Orrin Hatch.
On Thursday, committee members met with Brandt and also with Admiral Brett Giroir, MD, assistant secretary for Health and senior advisor to the secretary for Mental Health and Opioid Policy for the Department of Health and Human Services.
After Giroir and Brandt answer questions by an April 26 deadline, the Senate Finance Committee will draft a bipartisan bill, according to Ranking Member Ron Wyden.
Giroir was asked about alternatives to care outside of using the emergency room, where there are security issues for people coming out of an overdose.
Giroir said the government supports community-based programs and care would be primarily on an outpatient basis.
In opening statements, Giroir said CMS is focused on three areas to prevent opioid use disorder: encouraging non-opioid pain treatments; increasing access to evidence-based treatment and leveraging data to target prevention and treatment efforts and to support fraud, waste, and abuse detection efforts.
CMS recently finalized a series of additional changes for 2019 to further those goals. Beginning in 2019, CMS expects all Part D sponsors to limit initial opioid prescription fills for the treatment of acute pain to no more than a seven days' supply.
Also, a new opioid care coordination safety-edit will be implemented to create an alert for pharmacists when a beneficiary's daily opioid usage reaches high levels.
In addition, President Trump's FY 2019 budget includes a proposal that would provide the HHS Secretary with the authority to require plan participation in a prescriber and/or pharmacy lock-in program to prevent prescription drug abuse in Medicare Part D. This proposal would save an estimated $100 million over ten years, according to Giroir.
As of FY 2016, 37 states have edits in place to limit the quantity of short-acting opioids that will be covered for a beneficiary and 39 states have similar edits in place to limit the quantity of long-acting opioids.
States are required to report on their providers' prescribing patterns. Establishing minimum standards would not only help increase oversight of opioid prescriptions and dispensing in Medicaid, but would save the program an estimated $245 million over 10 years, he said.
In the 2019 Final Call Letter, CMS finalized additional enhancements including revised metrics to track high opioid overuse and to provide additional information to sponsors about high risk beneficiaries.
Prescription drug monitorin programs are more effective as they become part of the physician workflow., Giroir said.
"We think there's great potential for prior-authorization, it is something we have been looking at," Brandt said.
Tools such as e-prescribing helps give them the ability see in real time what's happening, what's being requested and especially who is requesting services, she said.
The Senate Finance Committee is looking at CMS policy as the Senate Help Education Labor and Pensions Committee gets ready to markup the Opioid Crisis Response Act on Tuesday, April 24. The legislation is comprised of 40 different bipartisan proposals.