COVID-19 Compounds Opioid Crisis And Treatment Gaps For Vulnerable Americans: Will A Biden Administration And New Congress Expand Medicare Coverage? – Food, Drugs, Healthcare, Life Sciences

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Abstract Takeaways:

  • Fee misalignment in Medicare FFS for Substance Use Dysfunction
    (SUD) therapy as the topic of potential legislative and/or
    regulatory reforms

  • New alternatives for investor-backed behavioral well being
    platforms in Medicare Benefit and different value-based

  • New attainable focus areas for well being plans with experience in
    Medicaid managed care to develop into Medicare managed care fashions
    for SUD therapy

The opioid epidemic has been additional fueled by the COVID-19
pandemic and a lately revealed report by the Authorized Motion Heart
(entitled Medicare Coverage of Substance Use Disorder Care:
A Landscape Review of Benefit Coverage, Service Gaps, and a Path to
) (the Report) shines a lightweight on the shortcomings of
Medicare to supply critically wanted entry and protection for SUD
therapy.  Based on its mission assertion, the non-profit
Authorized Motion Heart makes use of authorized and coverage methods to struggle
discrimination, construct well being fairness, and restore alternative for
individuals with prison data, substance use problems, and HIV or

Whereas sadly most of us know somebody impacted by opioid
habit, there may be little public consideration on this important
well being concern for older adults. The very fact is that continual ache, a
extremely prevalent affliction for the growing old and disabled inhabitants,
has been accompanied by a major improve in opioid use.
In the meantime, knowledge exhibits that solely roughly 23% of
opioid-addicted Medicare beneficiaries obtain any SUD therapy.
The Report reveals that this therapy hole is probably going attributable
to the truth that Medicare’s protection for SUD therapies is
far much less (by way of scope, providers, reimbursement charges, and
in any other case) than that offered by employer well being plans, different
business payers, and even Medicaid.

The Report examines the present state of Medicare protection for
SUD therapies and advocates for reforms to ship providers
advisable below evidence-based requirements of care. Although Medicare
Half A (institutional care), Half B (non-institutional medical
gadgets and providers), and Half D (pharmaceuticals) cowl sure
elements of SUD therapies on the care continuum, reimbursable
providers are usually grouped on the two excessive ends of the
spectrum (i.e., probably the most intensive ranges of care and least
restrictive ranges of intervention/screening) with little assist
in between. Particularly, Medicare Half A covers inpatient hospital
therapy and sure prolonged care providers; Medicare Half B
covers doctor providers and sure outpatient providers, as effectively
as early intervention and screening providers; and Medicare Half D
covers pharmaceuticals which embody drugs for the
therapy of SUDs (methadone, buprenorphine, and naltrexone, however
usually provided that offered in a doctor workplace or different coated
therapy setting).  Medicare doesn’t reimburse most
intermediate ranges of care – these sometimes furnished in
the group by freestanding SUD therapy amenities.

Furthermore, Medicare guidelines restrict protection for SUDs such that
therapies are usually not coated to the identical extent as for different medical
situations. For instance, inpatient psychiatric hospital providers
are topic to a 190-day lifetime restrict, whereas different inpatient
medical providers are usually reimbursable for a course of
therapy for a spell of sickness (usually outlined because the interval
of consecutive days starting with the primary day on which a
beneficiary is furnished inpatient hospital or prolonged care
providers are offered, and ending on the finish of the primary interval of
60 consecutive days by which the beneficiary is in neither a
hospital nor a talented nursing facility). Additional, many supplier
sorts broadly accepted as efficient in managing SUDs, together with
licensed counselors, licensed habit counselors, and peer
counselors, are usually not licensed Medicare suppliers. This results in a
scarcity of obtainable Medicare suppliers, which drives up
health-care prices for seniors, the Report stated.

The restrictions and restrictions on SUD therapy protection below
Medicare, if proposed or maintained by Medicaid or business
insurers, would seemingly be invalidated by the federal 2008 Psychological
Well being Parity Act (the Parity Regulation), a non-discrimination regulation which
requires protection of SUD and psychological well being advantages to be
akin to medical and surgical advantages. Nonetheless, Medicare is
the one largest payer exempt from the Parity Regulation.

Concluding that “sufferers who don’t meet medical
necessity standards for acute hospital care, however are too ailing to
obtain acceptable care in an office-based setting can not entry
acceptable SUD providers by means of Medicare,” the Report presents
steps that Congress and CMS may take to enhance SUD therapy for
Medicare beneficiaries. These embody extending protection to
intermediate SUD therapy settings; overlaying all practitioners
licensed by state regulation to supply SUD therapies; and altering
reimbursement requirements. Although the Report makes clear that
significant Medicare protection reforms could be achieved wanting
amending the Parity Regulation, the Report advocates that extension of the
Parity Regulation to Medicare would guarantee complete protection for
evidence-based SUD therapies and continuity and entry to wanted
therapy for older and disabled Individuals.

The query stays whether or not Congress and CMS will undertake any of
the Report’s suggestions. Although the brand new Congress and
presidential administration have many urgent coverage issues on
the agenda, it’s maybe revealing that President Biden campaigned
on numerous priorities for tackling the opioid disaster and referred to as on
Congress final month to put aside $4 billion for HHS to develop drug
therapy entry in the course of the pandemic. We’ll proceed to observe
legislative and regulatory developments within the space of Medicare
protection of SUD therapies and implications for suppliers and

The content material of this text is meant to supply a basic
information to the subject material. Specialist recommendation must be sought
about your particular circumstances.

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