Twenty-Seven Percent of MassHealth Members Who Were Treated for Opioid Use Disorders Did Not Receive, and/or May Not Have Had Access to, Recommended Counseling.

Bump encourages MassHealth to take additional measures to ensure those who need OUD counseling have full access to care and treatment.

Overview

Although it is widely recognized that effective treatment for opioid use disorders using medication-assisted treatment (MAT) includes both medication and counseling, we found that for various reasons, MassHealth and its prescribers did not effectively facilitate member participation in, and access to, necessary counseling. As a result, these members may not have received the most effective treatment to combat their opioid use disorders.

Using data analytics, we found that approximately 7,000, or 27%, of the MassHealth members treated with buprenorphine from January 1, 2011 through December 31, 2015 did not receive any type of opioid use disorder counseling. We found several issues with the administration of counseling related to the members in our sample:

Type of Problem	Number of Sampled Members
Prescribers did not know whether the members they were treating for opioid use disorders actually received their prescribed counseling.	11
Prescribers did not enforce consequences (e.g., directing members to other types of treatment) for members who did not attend their prescribed counseling, even though their treatment policies required members to participate in counseling.	33
Prescribers stated that members experienced wait times to obtain counseling. Wait times ranged from a few days to 12 months.	23

 

Although it was not possible to determine from the data exactly why this occurred for all 7,000 members, our interviews with prescribers for 83 of 103 sampled members revealed a number of possible reasons, described in the “Reasons for Issues” section below.

Authoritative Guidance and Best Practices

Section 823(2)(B)(ii) of Title 21 of the US Code imposes the following requirements as a condition of dispensing controlled substances, such as buprenorphine:

With respect to patients to whom the practitioner will provide such drugs [as buprenorphine] or combinations of drugs [i.e., any controlled substances listed by the Drug Enforcement Administration as schedule III, IV, or V controlled substances], the practitioner has the capacity to refer the patients for appropriate counseling and other appropriate ancillary services.

Providing opioid use disorder counseling as part of MAT for people who have opioid use disorders is widely accepted as a best practice, as evidenced by the following examples:

• The federal Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction: Treatment Improvement Protocol (TIP) Series 40 states that opioid use disorder treatment with buprenorphine is most effective in combination with opioid use disorder counseling.
• The American Society of Addiction Medicine’s (ASAM’s) Opioid Addiction Treatment Guide states that opioid use disorder counseling is essential in conjunction with any pharmacological treatment, including buprenorphine.
• Several MassHealth opioid use disorder treatment professionals and personnel at opioid use disorder treatment programs we interviewed indicated that counseling is highly recommended to all patients. In fact, personnel at one large Boston-based opioid use disorder program told us they required all opioid use disorder patients to participate in counseling as a condition of treatment.
• The chief executive officer of the Association for Behavioral Healthcare⁶ told us in interviews that the association’s members who are also behavioral healthcare providers believe strongly in opioid use disorder counseling for patients who are treated with medication. The association is currently working with Congress and state officials to enhance health systems to enable high-quality opioid use disorder counseling.

Reasons for Issues

Interviews with prescribers, and reviews of their medical records, indicated that some MassHealth members encountered three main types of obstacle in obtaining opioid use disorder counseling—programmatic limitations, limited counseling options, and lack of understanding of available services and/or treatment protocols—as detailed below.

Reported programmatic limitations include the following:

• Many prescribers stated that there were not enough counselors available for patients with opioid use disorders.

• Prescribers reported a lack of consistency regarding MAT covered by MassHealth’s managed-care organizations (MCOs):⁷ some MCOs require prior authorization for services, and others do not. In addition, some MCOs limit how many counselors can cover a specific geographic area, causing shortages of counseling in some areas.
• Some prescribers indicated that there is not enough support (for example, case managers) to, among other things, manage members’ transition from inpatient detoxification programs to outpatient programs or connect them with MAT prescribers and opioid use disorder counselors.
  Reported issues with limited counseling options include the following:

• Many counseling providers do not take walk-in appointments, nor do they provide services on evenings and weekends.
• MassHealth reimbursement rates for opioid use disorder counselors are too low, and there are no additional financial incentives.
• There are few bilingual or multilingual counselors.
  Reported issues with a lack of understanding of available services and/or treatment protocols (on the part of both prescribers and members) include the following:

• MassHealth does not have a specific policy requiring prescribers to ensure that members have access to, and receive, opioid use disorder counseling.
• There is limited formal advanced addiction medicine education at medical schools, in residency training, and in continuing education; therefore, many prescribers have not had the opportunity to learn about the importance of counseling in conjunction with MAT.
• MassHealth’s website does not provide links (like those it provides for dental services, for instance) that members and their families can use to educate themselves and advocate for counseling during opioid use disorder treatment.

Finally, according to our discussions with some of the prescribers, there are few training opportunities sponsored by the Massachusetts Department of Public Health (DPH), or in the United States as a whole, for addiction medicine.

Recommendations

1. MassHealth should take additional measures to better ensure that prescribers effectively facilitate member participation in opioid use disorder counseling.
2. MassHealth should further investigate the reasons that were provided to the Office of the State Auditor (OSA) during this audit for members’ not having access to counseling and take whatever measures it can to minimize these barriers to access.

Auditee’s Response

MassHealth agrees with OSA about the importance of best practices and the need to ensure that members with [opioid use disorder, or OUD] receive quality, comprehensive care. However, MassHealth does not agree with OSA’s interpretation of the national guidelines or its resulting conclusions. Specifically, OSA’s analysis focused exclusively on only certain billed counseling services but did not account for other relevant treatment and services, including, for example, other outpatient behavioral health services, and nurse care management provided through the office based opioid treatment (OBOT) program. In addition, both the American Society for Addiction Medicine (ASAM) and the Substance Abuse and Mental Health Services Administration (SAMHSA) highlight the need for shared decision-making and patient choice in determining appropriate treatments; SAMHSA guidelines explicitly discuss instances in which individuals choose to not engage in counseling services.

To advance best practices and ensure members with OUD receive quality care, MassHealth, in partnership with the Department of Public Health (DPH), secured [federal approval] for expanding Substance Use Disorder services to combat the opioid epidemic. Over the five year period of the [federal approval] commencing in 2017, MassHealth will increase expenditures on [substance use disorder] and co-occurring disorder treatment services by more than $200 million, including expansion of co-occurring enhanced Residential Rehabilitation Services; supporting expansion of MAT; adding Recovery Coaches and Recovery Support Navigators services as a benefit; and implementing a standardized assessment tool based on the ASAM criteria.

MassHealth has also undertaken an analysis of claims data, the findings of which demonstrate the positive effects of MAT. MassHealth’s analysis reviewed FY17 claims for approximately 68,000 members, comprising the entire population of MassHealth managed care enrolled . . . individuals with at least one claim for any service where an opioid use disorder diagnosis was included on the claim. Of these approximately 68,000 MassHealth members, 67% (approx. 46,000) received MAT at some point during the year and of those members, 54% (approx. 25,000) were adherent to MAT, meaning that they received MAT for at least 80% of the year. The data showed that individuals on MAT, regardless of utilization of any other service, cost approximately $4,000 (15%) less per year than the cohort of members with OUD who did not receive MAT. This cost reduction was driven by declines in 24-hour and acute levels of care. Members who were adherent to MAT experienced the greatest reductions in 24-hour levels of care. Finally, members who were on MAT had fewer fatal and/or non-fatal overdoses (7% v. 13%).

Based on the demonstrated efficacy of MAT alone, MassHealth disagrees that the OSA finding of [27%] of sampled MassHealth members on buprenorphine not receiving counseling is necessarily demonstrative of negative care outcomes or a lack of adherence to best practices. OSA’s audit does not include an analysis of outcomes for members who did not receive counseling. Furthermore, the OSA analyzed the incidence of certain types of counseling services among the members who received a buprenorphine prescription, but the analysis of MassHealth’s claims data described above shows that 95% of MassHealth managed care members with OUD who utilized buprenorphine in FY17 also received at least one outpatient behavioral health service. Additionally, services funded by other state agencies, such as the OBOT nurse care management services would not be identifiable in an analysis of medical claims. The OSA audit does not account for these services in their analysis of the counseling and behavioral health supports provided to individuals receiving buprenorphine. . . .

The Baker Administration has made an unprecedented commitment to improving behavioral health services—the total investment to date and through FY22 (as a result of the Medicaid waiver) is $1.96 billion. These investments include $68 million in outpatient rate increases; $18 million in inpatient rate increases; an additional $14 million specifically with regard to child specific codes (bringing that investment since FY16 to over $42m); $83 million at [the Department of Mental Health] for adult services, with a very clear expectation that they have the capability to serve individuals with dual disorders; and a $50 million commitment to Community Health Centers (including to raise the rates for adult and child psychiatry) over the next five years. These investments are critical elements in supporting individuals with opioid use disorder with the full continuum of care and supports—not only enhanced MAT, but also strengthened outpatient behavioral health services and recovery coach supports. . . .

MassHealth will continue to invest in behavioral health services, including support for best practices for individuals with OUD and efforts to ensure access to all medically necessary behavioral health services. Furthermore, MassHealth agrees prescribers should offer referrals and follow-up to appropriate behavioral health outpatient counseling services for members who receive MAT services. However, MassHealth disagrees that members should be required to obtain counseling as a condition of obtaining MAT. MassHealth disagrees that specific measures to address rates of engagement in counseling, as defined by OSA, for members with OUD who are prescribed buprenorphine are necessary for the reasons state above.

Auditor’s Reply

MassHealth asserts that OSA did not consider other relevant treatment and services, such as other behavioral health services administered by the Massachusetts Behavioral Health Partnership (a MassHealth contractor) and office-based opioid treatment, when conducting our analysis; however, this is not the case. In determining which procedure codes to include in our analysis, OSA conducted interviews with MassHealth, the Massachusetts Behavioral Health Partnership, and various medical professionals who administered office-based opioid use disorder treatment to obtain an understanding of all relevant procedure codes for opioid use disorder counseling. OSA ultimately included, among others, all procedure codes that are billed for behavioral health outpatient treatment paid for by the Massachusetts Behavioral Health Partnership and all outpatient office-based opioid treatment. It was during these interviews that some prescribers called our attention to the fact that not all members had access to appropriate counseling and others had to wait to obtain their counseling, which is why these issues are presented in our report.

Although we do not dispute that it is sometimes appropriate to let members with opioid use disorders choose not to engage in counseling, MAT by definition includes a combination of medication and other behavioral treatment, which studies have shown is the most effective treatment model. Federal regulations recognize the importance of providing counseling to treat opioid use disorders by requiring doctors to acknowledge, as a condition of dispensing controlled substances such as buprenorphine, that they have the capacity to refer patients to appropriate counseling and other ancillary services. Further, our report does not conclude that members’ being on buprenorphine and not receiving counseling always indicates negative care outcomes or a lack of adherence to best practices. Rather, our report presents our concern that MassHealth members who want, and might benefit from, counseling appear not to be receiving it for a variety of reasons and therefore may not have received the most effective treatment to combat their disorders. A number of authoritative sources, including SAMHSA and ASAM, state that the most effective treatment for patients recovering from opioid use disorders is to engage them in counseling while they undergo MAT. This type of treatment protocol is important because, according to the healthcare professionals with whom we spoke, many people with opioid use disorders have additional behavioral health issues (referred to as co-occurring disorders) that may have led to the opioid use. For this reason, many addiction treatment professionals we spoke with during this audit stated that it is important to provide patients with counseling, as it not only helps them recover from opioid use disorders but also helps treat co-occurring disorders.

In its response, MassHealth states that it performed its own analysis of fiscal year 2017 claim data and found many positive results from its administration of MAT to its members during this period. Because OSA was not given any information about this analysis during our audit and therefore did not have the opportunity to review it, and because MassHealth’s analysis covered a different time period from ours, we cannot comment on MassHealth’s analysis. It should be noted that MassHealth’s analysis was based on a different approach; it looked at members with diagnoses of opioid use disorders, whereas OSA’s analysis was based on members who were prescribed buprenorphine. 

MassHealth is correct in stating that our report does not analyze the outcomes of members who did receive counseling versus those who did not. This is because, given that providing opioid use disorder counseling in conjunction with MAT is widely accepted as a best practice, OSA decided to focus the audit work on determining the extent to which members who had opioid use disorders received and/or had access to appropriate counseling and, if not, why.

MassHealth states that our data analysis of medical claims would not have identified office-based opioid treatment nurse care management services. However, this is not the case. While interviewing prescribers, some of whom participate in the Boston Medical Center’s Office-Based Opioid Treatment Program, we asked what procedure codes were used to bill MassHealth for services rendered. We did include these codes (99201–99205 and 99211–99215) in our analysis. We found that during our audit period, approximately 7,000, or 27%, of the MassHealth members treated with buprenorphine did not receive any type of opioid use disorder counseling and therefore may not have received the most effective MAT treatment to combat such disorders. As stated in our report, providing opioid use disorder counseling as a part of MAT for people who have opioid use disorders is widely accepted as a best practice by organizations like SAMHSA and ASAM.

Contrary to MassHealth’s statements, OSA did not recommend that MassHealth require all members receiving buprenorphine to obtain counseling. Rather, OSA recommended that MassHealth work with its prescribers to ensure that to the extent practical, they facilitate member engagement in counseling, since it is recognized that counseling in conjunction with medication is the most effective treatment for people with opioid use disorders. To this end, we again recommend that MassHealth further investigate the reasons we were given during this audit for members’ not having access to counseling and take whatever measures it can to minimize these barriers to access.

6.   According to its website, the Association for Behavioral Healthcare “represents the community-based mental health and addiction treatment organizations of Massachusetts.”

7.    Effective March 2018, MassHealth started delivering health services through 17 accountable care organizations instead of through MCOs.

Date published:	March 21, 2019