The American Medical Association (AMA) and the American Society of Addition Medicine (ASAM) have a jointly proposed a new alternative payment model (APM) centered around patients with a physical dependence on opioids, with a one-time payment for initiating medication-assisted treatment (MAT) and monthly payments for continuing treatment.
The goals of the model, called the Patient-Centered Opioid Addiction Treatment (P-COAT), include encouraging more primary care physicians to offer MAT to treat opioid use disorder, increasing coordination of care for these patients and reducing hospitalizations and deaths due to opioid abuse.
“The current physician reimbursement structure does not account for all the services that patients with an opioid use disorder need to progress to successful treatment and recovery,” Shawn Ryan, MD, MBA, chair of the AMA-ASAM APM Working Group and ASAM’s Payer Relations Committee, said in a statement. “While we know that a combination of medication and psychosocial support systems is the evidence-based standard for treatment, we continue to find that patients are not able to access treatment due to limited or non-existent insurance coverage. We hope that today’s announcement will begin a national conversation with insurers and policymakers about what it takes for successful treatment and recovery.”
Under the model, physician practices which are a part of an “Opioid Addiction Treatment Team” will receive an initial payment for patients diagnosed as having opioid use disorder, recommended for MAT and who agree to receive those services under the practice’s supervision. Providers can decide to exclude certain populations with special needs from the model, such as pregnant women.
This initial payment wouldn’t cover all services related to opioid dependence. For example, emergency department visits and hospitalizations in the month the first payment is billed would be paid separately.
Performance could affect up to 4 percent of the payment based on measures like the percentage of patients who filled and used the medications beginning their treatment and a risk-adjusted average of emergency department visits per patient related to opioids.
Practices can then receive a monthly maintenance payment if patients complete a month of MAT or had moved from an inpatient to outpatient treatment facility.
Expanding availability of MAT has been a consistent piece of models and policy recommendations on addressing the opioid epidemic. Additional funding for MAT has been included in recent federal legislation on opioid abuse and has been approved in Medicaid waivers for opioid treatment.
“This new tool will remove a brick in the wall that prevents patients from accessing needed treatment,” said Patrice Harris, MD, MA, chair of the AMA’s Opioid Task Force. “Eventually, this wall will be torn down. Until then, we must continue fighting for our patients and remove arbitrary barriers to care.”
The AMA hasn’t been in total lockstep with congressional and regulatory suggestions on combating opioid abuse, however. The same federal legislation which would offer more funding for MAT also proposed limiting initial opioid prescriptions for acute pain to three days—which the AMA has criticized as arbitrary, according to The Hill.
“Pain is a complex, biopsychosocial phenomenon, and individuals experience pain in different ways,” Harris said. “The AMA believes that decisions around dosages needs to be left between the patient and the physician.”