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Pennsylvania’s Novel Public-Private Approach to Combatting the Opioid Crisis

The Centers of Excellence model is designed to encourage innovation among its providers, while adhering to standards of care that encourage access to Medication-Assisted Treatment (MAT), integration of physical and behavioral health care, and continued engagement along the continuum of care, leading to improved outcomes. For patients diagnosed with opioid use disorder, the COE model has led to increased rates of access to and use of MAT, continued engagement in treatment beyond 30 days, and decreased rates of overdoses.
NEJM Catalyst
October 1, 2020

Summary

Pennsylvania’s initial grant funding support was designed to relieve start-up financial pressures. The commonwealth is increasingly focusing on outcome-based value-driven payments. The Centers of Excellence include a variety of provider types, including large hospital and health systems, federally qualified health centers, methadone clinics, mental health service providers, primary care practices, and case management agencies. The care model also emphasizes care management by certified recovery specialists, who are uniquely positioned to understand the language of addiction and relate to their clients, including an appreciation for patient needs related to recovery supports and social determinants of health.
The Commonwealth of Pennsylvania has been hard-hit by the opioid epidemic for several years. In 2015, Pennsylvania had the sixth-highest drug overdose death rate per 100,000 in the nation (26.3) and accounted for the third-largest number of drug overdose deaths of any state (3,264).1 That same year, Pennsylvania also experienced a statistically significant increase in the rate of non-fatal opioid-related overdoses.2 Such startling statistics mobilized Pennsylvania’s Medicaid program to look closely at the way that substance use disorder treatments are provided and to rapidly incentivize and encourage innovations in care delivery to get people into treatment faster and keep them in treatment longer.
One innovation, the Opioid Use Disorder Centers of Excellence (COE) program,3 has been leading this transformation and reconfiguration of the service delivery model for Opioid Use Disorder (OUD) treatment. Launched in 2016 and facilitated by state-funded grants to providers, its primary goal has been to increase access to addiction treatment and help ensure that people with Opioid-Related Substance Use Disorders stay in treatment to receive follow-up care and are supported within their communities.
The COEs deviate from traditional addiction treatment service delivery in a variety of ways. Primarily, not all COEs are licensed drug and alcohol treatment providers. They span a range from large hospital and health systems, to federally qualified health centers (FQHCs), methadone clinics, mental health service providers, and case management agencies. By allowing such a diverse group of providers to receive a COE designation, Pennsylvania Medicaid promoted innovation to develop models of care delivery closely tailored to the patients’ and communities’ needs. By alleviating financial pressures through initial grant funding and now a care coordination bundled payment structure, the program has enabled this group of providers to rethink the way they provide care and flip the service delivery model by focusing on ease and convenience for the patient, versus one of convenience and ease for the provider.
The hub-and-spoke model is designed with the patient at the middle of the hub, and a team with carefully tailored care management resources to meet the individual’s needs is built around the patient through the spokes. The COEs are responsible for addressing their patients’ full array of clinical and non-clinical needs by facilitating connections to other providers that are best suited to meet those needs. In addition, these centers coordinate care for people with Medicaid coverage, and treatment is team-based and whole person–focused, integrating behavioral health and primary care. They are not limited to providing services within the walls of their physical locations. Rather, COEs have been charged with providing community-based services, meeting patients where they present — whether that is in a hospital emergency department, a homeless shelter, a courtroom, a restaurant, or a home — and utilizing telehealth in hard to reach communities, such as in rural parts of the state. COEs are encouraged to take health care to where the patient is.
COEs have been charged with providing community-based services, meeting patients where they present — whether that is in a hospital emergency department, a homeless shelter, a courtroom, a restaurant, or a home — and utilizing telehealth in hard to reach communities, such as in rural parts of the state. COEs are encouraged to take health care to where the patient is.

Implementing the Model

After applications from potential providers were reviewed, the COE designation was awarded to 45 providers based on standards of excellence laid out in the funding announcement as guiding principles. The overall goal was to modernize their clinical pathways to allow for rapid progression through the cycle of referral, assessment, induction, engagement, treatment retention, and full recovery. Specifically, applicants for the COE program had to indicate that they were enrolled Medicaid providers, attest that they would not charge cash to any Medicaid-enrolled client, agree to use an electronic health record within their practice, and demonstrate that they could evaluate the majority of referrals for MAT within one business day for a new client and facilitate admission into treatment for new clients within 14 days of their first encounter. COEs were also required to have face-to-face contact every 30 days and update individualized care plans for each client to address both the medical treatment and non-medical treatment (i.e., social determinants of health) needs integrating total health care for the patient. A patient-centered medical home designation was recommended but not required.
Applicants had to agree to provide MAT services on-site, commit to providing access to MAT for 300 new individuals within the first grant year, describe how they would employ a community-based care management team with licensed and unlicensed professionals, and accept warm handoffs. Once applicants were evaluated and selected, grantees were required to execute an agreement that delineated these specific requirements. Upon beginning operations, progress was tracked based on reporting of quality measures, care management activities, and outcomes data, while enabling a culture of learning and innovation.
The key was for COEs to take a leadership role in their communities using a multidisciplinary approach by convening stakeholders that included non-traditional partners such as transportation providers, criminal justice agencies, housing, employment service agencies, and the courts. COEs would further solidify their places as leaders in the recovery community by contributing in a learning network, which was developed by University of Pittsburgh’s School of Pharmacy Program Evaluation & Research Unit (PERU). The learning network would allow for sharing of information related to organizational health, data-driven decision making, community-based case management, case-based learning, best practices, and cross-pollination of novel approaches from one center to another.
In 2019, as the two-year grant program matured and the foundational components of the COE program strengthened, the payment model needed to evolve to ensure sustainability. The state submitted a directed payment arrangement application to the Centers for Medicare & Medicaid Services. CMS approved that arrangement, which established a set per member per month payment (PMPM) rate for the full array of care management services provided by COEs. This PMPM rate was incorporated into the capitated rates paid by the Medicaid program to its behavioral health primary contractors and contracted Managed Care Organizations (MCOs). The COEs now started to bill the MCOs directly for the programmatic component of the COE via the care coordination fee rather than draw on the grant funding.

Supporting Recovery

As is demonstrated by these standards and requirements, Pennsylvania’s COE program was designed to put the patient experience at the forefront by increasing access to MAT, integrating physical and behavioral health care, and providing a full range of recovery support services through community-based care management teams. This involved adding non-clinical staff and either co-locating them with the clinical team or deploying them into the communities they serve to bring health care (and in many cases, social services) directly to their patients. The linchpin of these care management teams has been the certified recovery specialists (CRSs).
Through their lived experience in recovery, CRSs are uniquely positioned to understand the language of addiction and relate to their clients. Because they are not medical providers, CRSs are often best situated to address a client’s needs with respect to social determinants of health. Many newly engaged COE patients report difficulties with housing, transportation, childcare, employment and/or education as barriers to achieving and maintaining recovery. While the physicians and nurses on the care management team focus on the patient’s clinical needs, the CRSs or social workers are able to develop treatment plans that are designed to address these barriers. Helping with creating opportunities for the clients is one of the goals and after a full year of recovery, clients are eligible to work toward credentialing as a CRS and can apply to be a CRS as an employee of the COE.

Confronting Challenges

Despite the attention to the design of the COE model, implementation has not been without its challenges for the state Medicaid agency, the MCOs and behavioral health primary contractors, or its providers. Some of the key lessons include:
Developing, implementing, and monitoring a program such as the COE program requires a significant commitment by the state to assist with initial funding to enable innovation. To sustain change, the payment model needed to evolve; Pennsylvania’s PMPM framework required departure from a focus on the volume and duration of patient visits, to the value the care was providing. This new PMPM framework allows providers to tailor the intensity of engagement to each individual and manage each patient’s care without concern for whether a particular intervention is billable or the amount of time it will take, with the only priority being improving total patient outcome.
In a hub-and-spoke model such as this, cooperation among stakeholders is critical to ensure each patient receives the necessary care. Each stakeholder must understand the others’ roles and have confidence in the ability of each of the other spokes to fulfill and synergize their roles to maximize the impact. When implementing the program, states would be well-advised to incorporate that feedback into the process early and often. With a system transformation such as this, it is critical for MCOs and behavioral health primary contractors, providers, and other stakeholders to clearly understand the desired state as well as what is expected of them as they work toward that end state. Without an opportunity to provide input in the development phase, stakeholders may not be fully committed to operationalizing program requirements. This ongoing deliberation may extend the implementation phase and lead to delayed service delivery transformation, but the final model is what the entire stakeholder community builds together. We purposefully focused on having a robust dialogue with ongoing bidirectional communication and sharing of best practices via formalized sessions that included the learning network and regularly scheduled multi-stakeholder meetings.
There needs to be thoughtful planning, communication, and coordination with the MCOs or behavioral health primary contractors, COEs, other stakeholders, and cooperation between and among state and federal entities involved in the administration of the Medicaid program. Growing pains associated with these kinds of technical and operational changes can be alleviated by decisive action and improved communication that is clear and consistent. In Pennsylvania, physical health and behavioral health benefits are managed through two separate program offices. Providers in each system are not necessarily familiar with the processes of the other, and it is necessary to bridge the gap between those systems to facilitate effective care coordination. This is a consistent challenge that was exacerbated by a desire to implement the COE model as quickly as possible in the face of climbing overdose death statistics. In states with similar landscapes, all stakeholders should participate in the planning and development of the framework to the extent possible. Staff from Pennsylvania’s Medicaid program also consulted with CMS to develop an approved directed payment model to facilitate the transition from grant funding to billing.
When developing any new service delivery model, ensuring a plan to provide targeted and intensive technical assistance can be the difference between success and failure of that transformation. PERU, on behalf of the Commonwealth, uses a standardized framework (called the Systems Transformation Framework) to support its technical assistance efforts with the COEs. This framework proposes the collection of real-time data that are then used to inform and improve the care management processes provided by the COEs.4
Through the provision of care management, it is important to create a program model that accommodates a diverse array of provider types and unique community needs. A one-size-fits-all approach would stifle provider innovation and would steer providers away from developing models that address the needs of their individual patients. Equally important is a concerted effort to balance clear standards, which, when taken too far can become overly prescriptive and rigid, and which, if left unchecked and unstructured can result in non-standardization and varying outcomes.
Prior to the Centers of Excellence in 2016, of Medicaid patients diagnosed with opioid use disorder, only 48% were receiving treatment, and of that group, only 33% remained engaged in treatment for more than 30 days. By December 2018, those numbers had increased to where more than 70% of the Medicaid population diagnosed with an opioid disorder was receiving treatment, and of that group, 62% were remaining in treatment for more than 30 days.

Measuring Progress

The outcomes of the program have been encouraging. Prior to the Centers of Excellence in 2016, of Medicaid patients diagnosed with opioid use disorder, only 48% were receiving treatment, and of that group, only 33% remained engaged in treatment for more than 30 days. By December 2018, those numbers had increased to where more than 70% of the Medicaid population diagnosed with an opioid disorder was receiving treatment, and of that group, 62% were remaining in treatment for more than 30 days. In addition, a preliminary report analyzing the Medicaid-enrolled individuals in 2017 and 2018 indicated that COE engagement corresponded to an increase in use of MAT from 46% prior to engagement with the COE to 72% after. Also, in that two-year span, COE-engaged individuals showed decreased inpatient and emergency department utilization related to opioid overdose by 29%, from 11.1 to 7.9 emergency department visits per 1,000 member months. Hospitalizations related to opioid overdose also decreased, by 33%, from 1.8 to 1.2 hospitalizations per 1,000 member months.
In addition to the overall Medicaid statistics above, the table below indicates the positive outcomes observed over two years comparing 2016 to 2018 data for the population that were in the COEs (Table 1).
Table 1
MeasureImpact
Engagement in OUD treatment after receipt of OUD diagnosis29% increase (increased from 28% to 36%)
Follow-up within 7 days after OUD-related Emergency Department visit51% increase (increased from 45% to 68%)
Number of Primary Care Visits46% increase (increased from 2.4 visits to 3.5 visits)
Positive Outcomes in First Two Years; Comparing 2016 and 2018
Positive Outcomes in First Two Years; Comparing 2016 and 2018

Source: The authors

On deeper analysis, when comparing COE care process and client outcome data for the time periods of September 2017 to August 2018 and September 2018 to August 2019, the measures continued to improve (Table 2).
Table 2
MeasureImpact
Percent of engaged clientsa20% increase (increased from 55% to 66%)
Percent of retained clientsb20% increase (increased from 74% to 89%)
Wait time from referral to initial contactc68% decrease (decreased from 8 days to 2.53 days)
Year-Over-Year Improvements of Care Improvement; Comparing 9/17–8/18 to 9/18–8/19
Year-Over-Year Improvements of Care Improvement; Comparing 9/17–8/18 to 9/18–8/19

a Percentage of engaged clients: the percentage of COE clients who have a face-to-face meeting in a given month. b Retention: Of the clients who have been involved with the COE for six or more months, the percentage who have had six or more treatments. c Wait time from referral to initial contact: The average time (in days) between the client being referred to COE services and initial contact with the COE. Source: The authors

From a provider experiential perspective, the use of the CRS staff has been well-received. At Tadiso Inc., a Pittsburgh-based facility that provides all three FDA-approved forms of medication used in MAT and is now designated as a COE, Katie Glover MSW, LSW, a COE Care Manager, specifically notes the benefits of employing CRS staff. The CRS and care management team members have been successful in referring and connecting patients to support services and community resources based on the patient’s recovery support interest and readiness to change. Glover says, “The COE has allowed patients to have access to CRS staff to guide them through recovery. CRS staff are able to refer patients to agencies for resources and complete the warm handoff process by providing transportation and support through each step of the process. CRS staff model recovery and inspire hope for patients who are struggling by sharing their recovery journey, in a way traditional clinical service cannot.”
In monitoring a program such as this, careful selection of measures needs to be tracked, as well as developing a plan for a streamlined and reliable method for collecting, reporting, and tracking this data. States should focus on a select set of measures that demonstrate quality of care as well as fidelity to their chosen model. Examples include retention in treatment, utilization patterns away from emergency care and toward preventive care, increased screening and referral rates for specific conditions or services, and improved scores on evidence-based surveys that assess progress toward recovery. Moving forward, and as a result of this initial experience, Pennsylvania will be including the following measures into the next evolution of paying for outcomes in its proposed Value-Based Payment Model:
Retention at intervals of 180, 270, and 365 days
MAT engagement
Receipt of outpatient physical and behavioral health services
Screenings for social determinants of health needs

Looking Ahead

The goal for 2022 is now to align payment for COE care management services to overall health outcomes. As we change the way services are delivered, the way services are paid for must also change. Historically, Medicaid programs have struggled with designing payment mechanisms for non-traditional providers that render services in non-traditional settings. This has been especially true for the OUD providers that include CRSs and case managers who see patients in the community. Pennsylvania has addressed this challenge by initial grant funding that then expanded to using a PMPM bundled care management payment to pay for COE services in its Medicaid program. As this payment structure moves along the continuum of value-based payment strategies, Pennsylvania is looking to incentivize quality of COE services by providing payments for achievement of certain key outcomes, including long-term engagement in treatment, adherence to MAT medications as prescribed, screenings for social determinants of health needs, and ensuring that patients receive primary care and ambulatory behavioral health services.
Pennsylvania is looking to incentivize quality of COE services by providing payments for achievement of certain key outcomes, including long-term engagement in treatment, adherence to MAT medications as prescribed, screenings for social determinants of health needs, and ensuring that patients receive primary care and ambulatory behavioral health services.
This proposed pay-for-performance schema has been developed collectively by Medicaid MCOs, behavioral health primary contractors, and a diverse array of providers. These stakeholders, some of whom are competitors with one another, came together in a cooperative manner to advance a common vision and goal: modernizing the way that treatment is delivered and paid for in order to produce the best possible outcomes. This work group has been facilitated by the state’s Medicaid agency and technical assistance providers from the University of Pittsburgh, but the model of the proposed pay-for-performance program is the result of design work and collaboration among the providers who serve individuals seeking recovery and the entities responsible for paying for their services. When implemented, it will represent the first step toward modernizing payment for the care management services necessary to keep patients engaged in treatment and recovery. As service delivery continues to evolve, Pennsylvania will continue to push further along the continuum toward more mature and progressive payment models, never losing sight of the patient at the center of it all. Only then can innovation be sustainable and systemic.

Notes

The authors acknowledge the contributions of Erh-Hsuan Wang, PhD, Scientific Data Director, Program Evaluation and Research Unit (PERU), University of Pittsburgh, School of Pharmacy.
Poonam Alaigh and Gwendolyn Zander have nothing to disclose. Janice L. Pringle has a consulting relationship with C4 Recovery Management LLC, which advocates for the improvement of the health care system, provides education, and works with interested organizations to increase efficiency and use accountability-based management practices.

References

1.
CDC. Drug Overdose Mortality by State, 2018. Page last reviewed: April 29, 2020. Accessed July 22, 2020. https://www.cdc.gov/nchs/pressroom/sosmap/drug_poisoning_mortality/drug_poisoning.htm
2.
CDC. Nonfatal Overdoses: All Opioids. Page last reviewed: April 21, 2020. Accessed July 22, 2020. https://www.cdc.gov/drugoverdose/data/nonfatal/nonfatal-opioids.html
3.
Pennsylvania Department of Human Services. Centers of Excellence. Accessed July 22, 2020. https://www.dhs.pa.gov/Services/Assistance/Pages/Centers-of-Excellence.aspx
4.
Scott KA and Pringle J. The Power of the Frame: Systems Transformation Framework for Health Care Leaders. Nurs Adm Q 2018;42:4-14 https://journals.lww.com/naqjournal/Abstract/2018/01000/The_Power_of_the_Frame__Systems_Transformation.3.aspx.

Information & Authors

Information

Published In

NEJM Catalyst Innovations in Care Delivery
October 1, 2020

History

Published in issue: September 1, 2020
Published online: October 1, 2020

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Authors

Affiliations

Poonam Alaigh, MD, MSHCPM, FACP
Research Professor and Director of Innovation of Program Evaluation and Research Unit (PERU), University of Pittsburgh School of Pharmacy
Gwendolyn Zander, JD
Chief of Staff, Office of Medical Assistance Programs, Pennsylvania Department of Human Services
Janice L. Pringle, PhD
Professor and Director of Program Evaluation Research Unit (PERU), University of Pittsburgh School of Pharmacy

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