Opportunities to Improve Opioid Use Disorder and Infectious Disease Services Integrating Responses to a Dual Epidemic (2020) / Chapter Skim
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3 Barriers to Integration
3 Barriers to Integration
Pages 47-110
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From page 47... ...
PRIOR AUTHORIZATION POLICIES Medicaid funds a significant proportion of buprenorphine prescriptions for treating OUD (Ducharme and Abraham, 2008; Stein et al., 2012)
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Prior authorization represents a significant barrier to creating integration between OUD and infectious disease care, as continued injection of opioids -- as well as co-occurring risky sexual behaviors -- maintains a high risk of infectious diseases (MHAF, 2018)
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In a 2019 study, Andrews and colleagues (2019) found that only 17 percent of drug treatment programs in states with prior authorization requirements were prescribing buprenorphine for OUD.
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. These examples provide precedence for how these medications, paid for by either state Medicaid programs or private insurers, can be made more widely available by removing prior authorization restrictions.
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In a 2015 study, Johnson and Richert conducted interviews with more than 400 patients in opioid treatment programs. More than 80 percent of patients perceived that diversion was mostly positive, and more than 75 percent considered it morally right to do so (Johnson and Richert, 2015)
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From page 52... ...
. If prior authorization policies increase administrative burden on health professionals -- as demonstrated in the case studies -- it is plausible that a smaller number of patients will receive cost-effective, beneficial, and safe treatments for OUD (Andrews et al., 2019; CMS, 2019c; NASEM, 2019)
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From page 53... ...
Conclusion • Prior authorization policies represent a barrier to prescribing efficiently that reduces the number of patients offered medications for opioid use disorder, is inconsistent with the urgency of the epidemic, and increases the risk of infectious diseases. Recommendation 3-1: The Centers for Medicare & Medicaid Services (CMS)
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From page 54... ...
They almost always get that prior authorization the same day for patients. They work really well." (Christopher Bositis, M.D., Clinical Director, HIV and Viral Hepatitis Programs, personal communication)
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That was huge for us as a barrier to providing buprenor phine." (Nick Van Sickels, M.D., Chief Medical Officer; and Jason Halperin, M.D., Infectious Disease Physician, personal communication) renewal fee of $551 to become eligible to prescribe controlled substances (including buprenorphine)
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From page 56... ...
Recognizing that intravenous drug use is a major risk factor for contracting an infectious disease, many of the programs acknowledged that treating OUD effectively and taking a harm-reduction approach is the most effective way to provide integrated care between OUD and infectious diseases. Programs often cited the time-consuming nature of the waiver training.
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. There is evidence that effective education about MOUD and mentorship would increase the number of providers comfortable treating OUD (and infectious diseases)
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. Just as with other areas of medicine, training to treat OUD (and concurrent infectious diseases)
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Recommendation 3-2: Congress should amend Section 303 of the Controlled Substances Act to allow buprenorphine and other medications for opioid use disorder to be prescribed by physi cians, physician assistants, nurse practitioners, clinical nurse spe cialists, certified registered nurse anesthetists, or certified nurse midwives without undergoing the mandatory training currently required by law, requiring a Drug Addiction Treatment Act waiver, or limiting the number of patients that can be treated.4 4 The committee notes that clinically relevant training should nonetheless be widely avail able to trainees and providers, as outlined in the remaining recommendations of this report.
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. Regulatory challenges are especially relevant in the context of integrating OUD and infectious disease services, and interviewed programs mentioned them as barriers.
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Greater Lawrence Family Health Centers (GLFHC) Providers have become more aware, however, that they must treat infectious diseases and OUD simultaneously for maximum efficacy.
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. I tried to write SAMHSA and get my waiver extended early, but I have to wait until October to treat 100 patients." (Nick Van Sickels, M.D., Chief Medical Officer; and Jason Halperin, M.D., Infectious Disease Physician, personal communication)
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From page 63... ...
. As a result, any entity providing integrated care for SUD and infectious diseases -- wherein generalist health care providers may offer both types of care -- is very likely to be subject to 42 CFR Part 2 (Antonini et al., 2012; Ghitza et al., 2011)
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From page 64... ...
documenting and tracking both behavioral and physical health information, (2) coordinating between different care teams on the EMRs, and (3)
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For instance, privacy regulations may prohibit coordinated, integrated care because health professionals will be unaware of a patient's SUD. Additionally, a mere lack of shared information and coordination between SUD providers and PCPs may prohibit the exchange of information necessary for a holistic treatment plan (Schaper et al., 2016)
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, and the material consequences of information being shared, it is important to respect patients' desire to maintain confidentiality of SUD information. • Part 2 inhibits integration of primary care services (including infectious disease prevention)
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(Emma Fabian, M.S.W., Senior Director of Harm Reduction, personal communication) Greater Lawrence Family Health Centers "They [medical records and behavioral health records]
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From page 68... ...
related to our IT infrastructure and how our electronic medical record is set up and the different firewalls that we have to have between FQHC patients and non-FQHC patients." (Brad Finegood, M.C.P., Strategic Advi sor at Public Health; Hilary Armstrong, M.P.H., Project/Program Manager III; Julia Hood, Ph.D., M.P.H., Epidemiologist II; Julie Dombrowski, M.D., M.P.H., Deputy Director of the HIV/STD Program; and Joe Tinsley, Needle Exchange Coordinator/ PPM II, personal communication) ARCare Integrating medical records for infectious diseases and OUD patients has been difficult (from both technological and patient privacy standpoints)
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From page 69... ...
, and the segregation of SUD treatment from primary care. This hinders the medical workforce's ability to provide integrated care for OUD and infectious diseases.
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. Nevertheless, government-sponsored training specific to the integration of OUD and infectious disease services for a wide constellation of providers is not readily available.
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The clinics are often small, with little space for examination rooms and storage of medical supplies, and providing such care would require more staffing.6 In addition, as opioid treatment programs have been historically divorced from medical care, a shift to including it would likely require a cultural change.7 Because opioid treatment programs have a large number of patients with OUD in both urban and rural settings, they represent an opportunity to provide greater integration of infectious disease and OUD care, if a professional workforce were trained and able to offer such services. In at least one way, this integration of OUD care and medical care has begun already: in a majority of states, Medicaid funding can be used for OUD treatment in opioid treatment programs (Vestal, 2018)
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From page 72... ...
This included, most commonly, an issue with education. Several program informants believed there were simply not enough high-quality mechanisms for providers to be trained on integrated OUD and infectious disease care to meet the needs of patient populations.
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support these kinds of licensure requirements as a arrier to integrated care. b Regarding training, some have argued for additional OUD education in medical schools or residency programs, which could be coupled with infectious disease training that already exists (Dwarakanath, 2019; Haffajee et al., 2018; Ram and Chisolm, 2016; Ratycz et al., 2018; Wakeman and Barnett, 2018)
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. HRSA has the Substance Abuse Treatment Telehealth Network Grant Program, but it does not include a specific focus on integrating OUD and infectious disease care (HRSA, 2019d)
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• Despite treating thousands of patients with opioid use disorder and concurrent infectious diseases, opioid treatment programs (where methadone is dispensed) do not frequently provide infec tious disease care in this setting.
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Recommendation 3-8: The Department of Health and Human Services should explore policy incentives for providers and clinics to provide a wider array of evidence-based medications for opioid use disorder and to institute universal, opt-out testing and connection to treatment for infectious diseases, especially at methadone-based opioid treatment programs. Recommendation 3-9: Congress should amend Section 303 of the Controlled Substances Act to permit providers to deliver methadone treatment for opioid use disorder in primary care settings.
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. • The Accreditation Council for Graduate Medical Education should, among its common program requirements, require that residents and fellows receive practical, clinically rel evant, harm-reduction-focused, case-management-based training on OUD and infectious diseases.
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Plumas County Public Health Agency Agency staff are encouraged to take advantage of trainings offered by the state, and they have hosted local harm reduction and medications for opioid use disorder (4) organizational/institutional, and (5)
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(Nick Van Sickels, M.D., Chief Medical Officer; and Jason Halperin, M.D., Infectious Disease Physician, personal communication) Seven informants from the 11 programs interviewed commented on the role that stigma plays as a barrier for individuals seeking care and in shaping care delivery.
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, infectious diseases (Alonzo and Reynolds, 1995) , and SUD more generally (Link et al., 1997)
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Primary care clinics, in particular, reported that integrating OUD treatment within primary care services resulted in less stigmatization. One reason is that, in an integrated clinic, patients may be visiting for any number of reasons, including SUD or infectious diseases or simply a primary care checkup.
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From page 82... ...
Findings • Stigma surrounding opioid use disorder, substance use disorder, and infectious diseases is pervasive in many corners of society, including in medical care and behavioral health systems. • Stigma and the lack of culturally competent care are likely key reasons that patients do not seek treatment, do not remain in treatment, or do not maintain strong social support systems (such as family or community ties)
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From page 83... ...
There is a robust literature describing effectiveness and costeffectiveness of syringe service programs in preventing new cases of infectious diseases among people who inject drugs. A systematic review found consistent effects across 15 studies, with decreases in HIV and HCV incidence and prevalence (Abdul-Quader et al., 2013)
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. If the ban on federal funding remains, on the other hand, it is expected that syringe service programs will not be able to offer additional services (e.g., testing for infectious diseases)
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It should also be mentioned that states can independently fund syringe service programs (including the provision of injection equipment) , and that state funding has been shown to increase the number of services that syringe service programs can offer (e.g., testing for infectious diseases onsite)
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Hence, other funding mechanisms are required. More generally, programs mentioned that they frequently had to create a patchwork of funding and build the financial case for integration to provide integrated OUD and infectious disease services.
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Findings • Syringe service programs are effective in reducing the transmis sion of infectious diseases and engaging patients in care, yet there are federal restrictions on funding for injection equipment. • Funding to pay for integrated services is insufficient or difficult for some programs to find and obtain.
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Conclusions • Syringe service programs are a crucial element in reducing the spread of infectious diseases and increasing connection to care for opioid use disorder. • Stable, easily accessible sources of funding are needed to ensure fully integrated services for opioid use disorder and infectious diseases (and primary care and substance use disorder more generally)
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From page 89... ...
Recommendation 3-16: The Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration and other government funders should require that organizations receiving funding for opioid use disorder (OUD) and infectious disease services submit information on a regular basis with data related to the opioid care cascade model and their plans for using the care cascade model to prevent, identify, treat, and promote recovery for patients with OUD.
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(Nick Van Sickels, M.D., Chief Medical Officer; and Jason Halperin, M.D., Infec tious Disease Physician, personal communication) Greater Lawrence Family Health Centers (GLFHC)
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Plumas County Public Health Agency To remain sustainable over time, the agency has tried to leverage federal grants toward instituting permanent services. One goal of the agency is to prevent and treat infectious diseases and opioid use disorder, since these diseases are so closely linked.
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They are only like 0.1 FTE Ryan White case management because that's what happens in rural populations is you do everything yourself. Everybody takes on multiple roles and with different grant requirements again, it adds to the complexity." (James Wilson, Health Education Coordinator; and Barbara Schott, M.S.W., Health Education and HIV/AIDS Program Manager, per sonal communication)
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From page 93... ...
In response to the interrelatedness of the opioid and infectious disease epidemics, CMS could encourage states to remove same-day billing restrictions. It could accomplish this through informational bulletins, as bulletins do not "establish new policy or issue new guidance" but rather "share information, address operational and technical issues, and highlight initiatives or related efforts" (CMS, 2019a)
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. The committee asked each of the programs about their practices and experiences with harm reduction, which revealed several themes related to harm reduction and integrated OUD and infectious disease services.
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From page 95... ...
. so people can see the behavioral health provider, and they can see me, or they can see a primary care provider and have a dedicated buprenorphine visit or HIV visit or whatever on the same day." (Nick Van Sickels, M.D., Chief Medical Officer; and Jason Halperin, M.D., Infectious Disease Physician, personal communication)
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From page 96... ...
This point was especially important in light of how syringe service programs can lead to treatment: several programs stated that local syringe services were frequently the entry point for patients to get tested for infectious diseases or to start MOUD. Insofar as syringe service programs can be the avenue for reduced use of injectable drugs and for safer sexual behaviors, they may reduce the risk of contracting infectious diseases.
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From page 97... ...
Recommendation 3-20: Individual clinics, health care programs, and providers should incorporate harm-reduction strategies into both infectious diseases and opioid use disorder care, such as by linking patients to syringe service programs, distribut ing naloxone, adopting a harm-reduction philosophy focused on patient-centered care, prescribing pre-exposure prophylaxis, and providing safe drug use and safe-sex education. Recommendation 3-21: States should lift the remaining bans on evidence-based syringe services, offering syringe services at publicly funded health departments and allowing for indepen dently operated syringe service programs.
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From page 98... ...
In the State of Indiana, only health departments are legally allowed to have syringe service programs." (Beth Keeney, M.B.A., Senior Vice President for Community Health and Primary Care Services, personal communication) Plumas County Public Health Agency In many cases, patients will visit the agency for the syringe service program or other basic services but also be offered MOUD, naloxone, overdose prevention education, rapid testing for HIV/hepatitis C virus (HCV)
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From page 99... ...
That is the goal, and I think it is being realized finally." (Nick Van Sickels, M.D., Chief Medical Officer; and Jason Halperin, M.D., Infectious Disease Physician, personal communication) Greater Lawrence Family Health Centers "We got a grant to have syringe disposal bins placed strategically in public places.
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. This evidence suggests that the need to integrate OUD and infectious disease care is especially high in the criminal justice system and that there is a great opportunity to reach a large number of patients with comorbid illness through such integration.
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From page 101... ...
The syringe services are a primary referral source for other services -- it gets patients in the door to more intensive treatment for OUD and infectious diseases. In general, the syringe service program provides a use ful entry point for other services (including testing for infectious diseases, and MOUD services)
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From page 102... ...
. Eight programs mentioned various aspects of the criminal justice system as barriers to providing high-quality, integrated care for OUD and infectious diseases.
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From page 103... ...
. Because persons in jails or prisons are not eligible for coverage by Medicaid, many correctional facilities fund treatments for individuals in criminal justice settings through state block grants or direct appropriations at the state level (SAMHSA, 2019i)
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From page 104... ...
. Eligible grantees could consider using these funds for improved treatment access in correctional facilities, linkage to care follow ing the transition out of correctional facilities, or better integration of care for OUD and infectious diseases.
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From page 105... ...
One additional barrier to preventing a seamless transition out of correctional settings -- and maintaining suppressed viral load for infectious diseases -- is continuity of insurance coverage. State policies on the continuation of Medicaid in and out of correctional settings vary, as shown in Figure 3-1.
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• Rates of infectious diseases (including human immunodeficiency virus and viral hepatitis) are higher in correctional facilities than in the general public and higher still for incarcerated individuals with opioid use disorder.
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From page 107... ...
Recommendation 3-24: Clinics and organizations that treat opi oid use disorder and infectious diseases should coordinate with law enforcement and correctional facilities to better track and maintain records of patients entering and exiting the criminal justice system. Recommendation 3-25: Through federal grant funding, state block grants or direct appropriations, states should fund high quality, evidence-based reentry services for prisons and jails, including medications for opioid use disorder and infectious diseases, as well as linkage to care in the community and harm reduction services following release (e.g., naloxone to reduce the risk of fatal overdose)
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From page 108... ...
They have moved houses four times by the time they get to us a few days later." (Beth Keeney, M.B.A., Senior Vice President for Community Health and Primary Care Services, personal communication) Plumas County Public Health Agency The greatest step toward integration was forming a county-level coalition of stakeholders from hospitals, law enforcement, the district attorney's office, the behavioral health system, and public health departments from neighboring coun ties.
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From page 109... ...
It is a very delicate bal ance." (Nick Van Sickels, M.D., Chief Medical Officer; and Jason Halperin, M.D., Infectious Disease Physician, personal communication) Greater Lawrence Family Health Centers (GLFHC)
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From page 110... ...
We have done data linkages in real time between the Harborview Emergency Department and then the King County Jail to identify persons with an unsuppressed viral load who we want to get re-engaged in services." (Brad Finegood, M.C.P., Strategic Advisor at Public Health; Hilary Armstrong, M.P.H., Project/Program Manager III; Julia Hood, Ph.D., M.P.H., Epidemiologist II; Julie Dombrowski, M.D., M.P.H., Deputy Director of the HIV/STD Program; and Joe Tinsley, Needle Exchange Coordinator/PPM II, personal communication)
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