Politics taking hold as Congress eyes loosening opioid treatment limits

In Cincinnati, wait times for opioid addicts seeking residential treatment have dropped as the city’s providers are banding together to manage the barrage of cases across different settings.

In January, Mercy Health partnered with 10 outpatient treatment centers. The hospital offers short-term detox stays for patients, then the clinics take over and manage the long-term treatment, nearly on demand. After they have stabilized, patients can decide whether they want residential treatment or outpatient care.

This approach is key to managing the scope of opioid addiction cases, said Shawn Ryan, founder and chief medical officer of the outpatient treatment center BrightView, because it matches patient needs with what providers offer.

But there is a constraint on longterm treatment for mental illness and substance abuse that hinders creative use of hospitals, nursing homes and other facilities. That barrier is the socalled institutions for mental disease, or IMD, exclusion, which since the 1970s has largely banned Medicaid from paying for stays at IMDs with more than 16 beds.

“In the Medicaid field, with reimbursement not robust, no one could make it really well without cobbling together grants and other funding,” Ryan said. “The removal of IMD exclusion could really help.”

The IMD exclusion was at the center of congressional debate last week as House lawmakers eyed loosening the restrictions. The legislation would allow states to amend their Medicaid plans to cover up to 30 days of residential treatment for opioid addicts.

Many mental health ad- vocates and people on the ground trying to beat back opioid overdoses and addiction rates agree that the longtime Medicaid funding ban for institutions for mental disease is outdated. But Congress’ attempt to change it has drawn sharp criticism from some, who say lifting it for treating opioid addicts could skew states toward focusing on expensive residential treatment over less-intensive therapies on the continuum of care.

Congress has tried and failed in the past to open up the exclusion. The Obama administration took a regulatory step in 2016 to let Medicaid pay for stays of up to 15 days, provided they were coordinated through a managed-care plan.

The Trump administration has picked up where the Obama administration left off, expediting Medicaid 1115 waivers to fund IMD stays for opioid and substance abuse patients for 15 days each month.

With Congress poised to take another step on IMDs, reaction is mixed.

Some critics say the waivers are enough and congressional action could motivate states to focus on residential treatment at the expense of community behavioral health programs.

“People need an array of recovery options,” said Hannah Katch of the Center on Budget and Policy Priorities, a liberal think tank. Katch listed peer support services and other community options as equally key for treatment.

She said residential facilities are

costly and worries that states would be encouraged to invest money in IMDs over community-based services. Katch prefers the administration’s waivers, which require states to remain vested in community programs as well.

But even clarifying the actual cost is problematic.

Congress’ previous attempt to allow Medicaid to pay for stays of up to 30 days was deemed so expensive by the Congressional Budget Office that the effort fell apart. Apart from California, states didn’t have data on how many IMDs they have, where they are located or what they cost. The CMS also doesn’t have that data, so the CBO projected a $40 billion to $60 billion price tag for that bill.

Now the CBO is working on a new score; a GOP committee aide said the agency has indicated the proposed repeal is in the “low single-digit billions.”

But until the government has data on IMDs, the score doesn’t mean much, said Frankie Berger of the notfor-profit Treatment Advocacy Center. Another bill the House Energy and Commerce Committee is considering with its opioid package would order the Medicaid and CHIP Payment and Access Commission to run an exploratory IMD study.

Berger said this will open lawmakers’ eyes to just how states are navigating around current laws to manage treatment for the growing number of mentally ill and addicted patients.

“They will figure out this exclusion has left states stuck between a rock and hard place, and are skirting the exclusion all over the place,” Berger said. “They will find that it’s been to the benefit of their constituents.”

Meanwhile states that have obtained 1115 waivers are working to implement them.

West Virginia is launching its new benefits July 1. Allison Adler, communications director for the West Virginia Department of Health and Human Resources, said these will include a “continuum of care that ensures that members can enter (substance use disorder) treatment at a level appropriate to their needs and step up or down to a different intensity of treatment levels.”

Medicaid will pay for short-term residential treatment for all levels of treatment, Adler said.

As the debate simmers, Berger said stakeholders and lawmakers have gotten hung up on talking about facilities and how they should be used. But the bigger issue boils down to payment structure. “This is the only thing that isn’t paid for by Medicaid based on where a facility is and what care it offers,” Berger said. ●

“In the Medicaid field, with reimbursement not robust, no one could make it really well without cobbling together grants and other funding.”

Shawn Ryan

Founder and chief medical officer BrightView