The growing awareness of New Jersey’s opiate crisis has prompted a bevy of government responses, from expanding access to overdose-reversing medicine, to employing recovering addicts to help others in crisis, to increasing reimbursement rates for physicians who treat those with substance use disorders.
But a critical lack of space at inpatient treatment facilities in the Garden State, and the region, remains a gaping hole in the safety net of recovery strategies, experts have long agreed. Some 28,000 substance abusers sought treatment last year and many facilities have dozens if not hundreds of individuals on a waiting list.
To help address this need, U.S. Sens. Bob Menendez and Cory Booker, both D-NJ, have joined a bipartisan congressional group calling for additional freedom in the way Medicaid can be used to pay for drug addiction treatments at certain in-patient facilities. They said 12 percent of adults covered by the federal and state-funded insurance program, or more than 3.4 million individuals, now suffer from substance use disorders.
The lawmakers are urging the Centers for Medicare and Medicaid Services (CMS), which oversees the program, to further reform what is known as the Institutions for Mental Disease (IMD) exclusion. The six-decades-old provision banned states from using Medicaid dollars to cover behavioral health services for adults who are treated at residential facilities with more than 16 beds.
Long a target for reform, the IMD exclusion was designed to force states – not the federal government – to fund the bulk of inpatient psychiatric care, according to the Legal Advocacy Center. Created at a time when few options existed beyond massive, state-run psychiatric institutes, the exclusion applies to patients aged between 21 and 65 receiving care at an “institution for mental diseases,” which is defined as a hospital, nursing home, or other facility with more than 16 beds.
[related]As healthcare has evolved, with a greater focus on equal access to behavioral health, the IMD exclusion has become increasingly outdated, according to the advocacy center. Congress members have tried over the years to trigger reforms, but in April the Department of Health and Human Services issued new rules that amended the exclusion and, for the first time, enabled states to use Medicaid managed-care programs to pay for adults to spend up to 15 days in a residential treatment facility that cares for 16 or more patients.
But the bipartisan group of senators said these changes do not go far enough. In an August 2 letter to the CMS, a division of DHHS, Menendez and Booker joined more than two dozen colleagues, including Sens. Kirsten Gillibrand (D-NY) and Bob Casey (D-PA), calling on federal officials to “take additional steps, utilizing existing authorities, to provide greater flexibility in ensuring patient access to medically necessary evidence-based substance abuse treatment.”
The senators noted that many patients might need more than 15 days of residential care and said that limiting the time could result in a need for more costly and long-term treatments down the road. They urged the CMS to update the definition to clarify which type of treatment facilities are eligible for reimbursement. In addition, they questioned whether the exclusion contradicted a 2008 law that required parity in payments for mental health and addiction services. The change would not only help more people to afford access to recovery programs, but would also encourage providers to expand capacity at residential treatment facilities.
“Our nation is in the midst of a heroin and prescription opioid epidemic that has shined a spotlight on barriers to patient access to life-saving care,” the senators wrote in a letter to acting CMS Administrator Andy Slavitt. “There are numerous Congressional efforts underway seeking to address this issue, but we strongly urge CMS to use existing authorities to broaden treatment opportunities, such as by removing SUD treatment and facilities from the IMD Exclusion.” CMS declined to respond directly to the senators’ letter.
Federal data suggests some 2 million Americans are addicted to opiates. Nationwide, some 78 people die each day from opiate-based pharmaceuticals or heroin, which many eventually turn to as a cheap alternative; in New Jersey alone there were 1,200 overdoses last year, Menendez said.
In July DHHS nearly tripled the number of patients that a doctor can treat with buprenorphine, a highly effective replacement medication used alongside therapy to treat opioid addicts. Menendez had pushed the department to raise this patient “cap” – then set at 100 – during a hearing in February; after a four-month review, it changed the rules to allow physicians to prescribe buprenorphine to as many as 275 patients.
Expanding access to treatment is just one approach the department has undertaken to combat addiction. DHHS now requires physicians with the bureaus of Indian Affairs and Veterans Affairs to check the relevant state prescription drug-monitoring database when considering opiates for a patient; it is now reviewing Department of Defense protocols. DHHS has also launched more than a dozen scientific studies on opioid addiction and pain management to help fill knowledge gaps.
Booker and Menendez were also among the sponsors of the Comprehensive Addiction and Recover Act, which President Barack Obama signed into law earlier this summer. The measure – which would expand prevention efforts, create national treatment standards, and invest in ways to reduce the illegal diversion of prescription drugs – received bipartisan support in Congress. However, it was approved without any funding, which the senators have said makes for a hollow victory.