Jul 09, 2020

Continuing Progress in the Fight against the Opioid Crisis

Kim Brandt
Principal Deputy Administrator for Policy and Operations
Topic

The COVID-19 pandemic has taken a devastating toll on Americans across the country, whether in lives lost or economic impacts, and it has particularly affected our fellow citizens who have the most vulnerabilities, including the elderly and communities of color.  We’ve been forced to adjust and adapt our daily lives in innumerable ways, while significant public health resources have had to be redirected to help us meet and beat this unprecedented pandemic.

But even as we’ve battled COVID-19, federal, state, and private sector initiatives didn’t stop addressing other critical issues, including another one of the most pressing public health crises facing our country:  opioid misuse and overdose.  As the largest healthcare payer in the U.S., the Centers for Medicare & Medicaid Services (CMS) is actively using coverage and payment levers to advance evidence-based responses to the opioid epidemic.  To frame our strategy, we’ve created a three-part Roadmap to fight the epidemic:  preventing opioid misuse; expanding access to opioid use disorder (OUD) treatment; and using data to better target our efforts.

We recently announced a proposed rule for Medicaid (CMS-2482-P) that builds on current policies to help ensure that opioid prescribing is appropriate, medically necessary, and avoids adverse medical events.  The proposal would address a requirement in the SUPPORT for Patients and Communities Act (the SUPPORT Act) that states have systems in place to identify or limit inappropriate prescribing of opioids under certain conditions, such as if a beneficiary is already receiving medication assisted treatment for substance use disorder (SUD).  We’re also seeking input from Medicaid stakeholders on proposals for future rulemaking that would require additional review of opioid prescribing, medication assisted treatment, and naloxone prescribing.     

This proposed rule is part of a comprehensive effort in recent years to advance our overall Opioid Roadmap goals, through which we have fulfilled over 20 provisions of the SUPPORT Act.  Enacted in 2018, the SUPPORT Act aims to increase options to treat Medicare and Medicaid beneficiaries with substance use disorders including OUD; to ensure appropriate prescribing; to improve the treatment of acute and chronic pain; to heighten safety; and to illuminate prescribing data.  

Overall, CMS has made significant progress in fighting the opioid crisis including:

Prevention

CMS has taken a number of steps to identify and stop inappropriate prescribing to help prevent the development of new cases of OUD, while balancing the need for continued access to prescription opioids for appropriate, individualized pain management.  For example, the SUPPORT Act requires all Medicare Part D sponsors to have a Drug Management Program (DMP) for plan years beginning on or after January 1, 2022.  As of January 2020, 87% of Part D plans have already implemented a voluntary DMP.  Thanks to policies promoting safer opioid use, the percent of Medicare beneficiaries receiving higher than recommended doses of opioids declined by 45% between 2016 and 2019.  

We also introduced Medicare Part D opioid safety policies to reduce prescription opioid misuse, while preserving medically necessary access to these medications.  These policies include reviews of certain drug therapies at the point of sale to help ensure Part D beneficiaries do not overuse opioids or receive potentially harmful concurrent medications.  While it’s good news that fewer patients are receiving higher than recommended doses of opioid medication, our policies are structured to allow physicians to make the final determination about the best care plan for their patients, including in circumstances where higher doses may be necessary to treat debilitating pain that restricts an individual’s daily activities and reduces their quality of life.

Additionally, to respond to patient demand for more coverage of non-opioid pain treatments, we finalized a decision to cover acupuncture for Medicare patients with chronic lower back pain starting January 21, 2020.  Before this final National Coverage Determination (NCD) reconsideration, acupuncture was nationally non-covered by Medicare.

We’ve also issued guidance to states on strategies for expanding Medicaid coverage of non-opioid pain management therapies to increase treatment options for chronic pain.

Treatment

As we’ve enhanced our prevention activities, we’ve also made great strides in expanding access to evidenced-based OUD treatment.  As of January 2020, for the very first time, Medicare covers methadone furnished by opioid treatment programs (OTPs) for beneficiaries suffering from OUD.  This new benefit will also cover other OUD treatment services as part of a bundled payment. These services include: dispensing and administration of medications used in medication-assisted treatment (MAT); substance use counseling; toxicology testing; as well as intake activities and periodic assessments.  Additionally, the coverage includes substance use counseling and individual and group therapy services furnished by OTPs either in-person or via two-way interactive audio-video technology, which broadens access to these critical services particularly for those living in rural areas that have been among the hardest hit by the opioid crisis.  

Additionally, during this COVID-19 public health emergency, CMS has greatly expanded telehealth flexibilities, allowing Medicare beneficiaries to obtain counseling, therapy, and in some cases, periodic assessments over the telephone, without leaving home and risking unnecessary exposure to the virus. 

For Medicaid beneficiaries, we also issued guidance to states that outlines their options for using telehealth to expand access to beneficiaries living in rural areas—and to provide SUD treatment to Medicaid beneficiaries more broadly.  Especially during the COVID-19 pandemic, we encourage all states to make full use of these tools to help their populations overcome the challenges of accessing SUD care, including workforce shortages, social distance guidelines, lack of transportation, privacy issues, or the risk of contracting COVID-19.

To further improve access to OUD treatment for Medicaid beneficiaries, we’ve approved 28 state Medicaid demonstrations that focus on beneficiaries with SUD, including providing coverage of inpatient and residential treatment for certain eligible beneficiaries in “Institutions for Mental Diseases” (IMDs).  These Section 1115 demonstrations include an expectation that participating states provide access to the continuum of care for beneficiaries with OUD, and take action to improve access to naloxone, an opioid reversal agent, used in the case of opioid overdose. 

We’re also expanding access to naloxone in Medicare by strongly encouraging Part D plans to provide an opioid reversal agent (i.e. naloxone) on a generic tier, making it easier for beneficiaries who are at risk of opioid overuse or misuse to access an overdose reversal product.  In 2020, for the first time, all plans have at least one naloxone product on a generic tier.  Also this year, all Medicare Advantage prescription drug plans and Medicare Part D plans have at least one MAT product on a non-branded tier.  The percentage of on-formulary MAT products that require prior authorization has significantly declined from 41.6% in CY 2018 to 0.25% in CY 2020.

Additionally, through the Integrated Care for Kids (InCK) and the Maternal Opioids Misuse (MOM) models, which are temporary arrangements between payers and provider, we’re testing new coverage and payment approaches for CMS to coordinate care and increase access to SUD treatment for two vulnerable populations: children and pregnant women.

We also awarded $48.4 million for planning grants to 15 state Medicaid agencies to enhance the capacity of their SUD treatment workforces.  Grantees have been actively pursuing value-based payment models, improving SUD data quality, expanding use of medication-assisted treatment, and addressing gaps in the availability of Medicaid SUD providers especially for those serving adolescents, perinatal women, substance-exposed infants, American Indians, and beneficiaries living in rural areas.

Data

We know that using data is critical in CMS’ efforts to better identify patients at risk of OUD and to target areas most in need of prevention and treatment efforts.

Last year, we published the first Transformed-Medicaid Statistical Information System SUD Data Book using new, nationwide Medicaid data on SUD prevalence and treatment, helping researchers and policymakers better understand where attention is needed.  We also refreshed the Opioid Prescribing Mapping Tool for Medicare and Medicaid to highlight our commitment to using data to better inform local prevention and treatment efforts, particularly in rural communities hard hit by the opioid crisis.  The tool allows users to make geographic comparisons of Medicare Part D opioid prescribing rates in urban and rural areas at the state, county, and ZIP code levels.  For the first time, the tool also includes data for opioid prescribing rates at the state level in the Medicaid program.  This mapping tool gives our state and local partners the data they need to create their own targeted solutions and to observe the progress of those efforts.

Finally, we’re also working regularly to share Medicare data (taking appropriate precautions) with prescription drug plans and prescribers to identify patterns of potential misuse as early as possible.  For example, from 2017 to 2019, we sent over 25,000 letters to clinicians whose opioid prescribing was in the highest percentile compared to their peers, detailing their prescribing practices and emphasizing patient-centered care and safety. In May 2019, CMS observed that, on average, clinicians that received the comparative letters reduced the number of opioid prescriptions per patient by 1.1% and decreased the number of days of opioid supply by 1.9%. The number of unique opioid prescribers declined by 3.3%.

Going forward, we’re committed to continuing our work to successfully implement our opioid Roadmap—even as we continue to battle the COVID-19 pandemic—and we’re planning a number of creative initiatives to continue the fight against the opioid epidemic.  Through all of our efforts, our goal is to remove this deadly shadow that has fallen across too many lives and too many communities.  Stay tuned for more information on what’s coming up this year!

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