MAT- Are you ready? · CONTACT JEAN GLOSSA, MD, MBA, FACP SCOTT HAGA PA-C 120 North Washington Square Suite 705 Lansing, MI 48933 517.482.9236 | [email protected]

MAT- Are you ready?Operational Considerations

Scott Haga PA-C, Senior Consultant

Jean Glossa MD, MBA, FACP, Managing Principal for Clinical Services

June 12, 2019

Today’s Speakers

Scott Haga, PA-CSenior ConsultantLansing, Michigan

Jean Glossa, MD, MBA, FACPManaging Principal for Clinical Services

Washington DC

Copyright © 2019 Health Management Associates, Inc. All rights reserved. PROPRIETARY and CONFIDENTIAL.

#HMAtalksopioids- available on the HMA website

Understanding the Impact: An Overview of the Opioid Epidemic from a Systems Perspective Corey Waller, MD

Public Health Response to the Opioid Epidemic: Prevention Opportunities in the Midst of a Crisis; Primary, Secondary and Tertiary Strategies to Prevent Opioid Misuse and Overdose

Shannon Breitzman and Lindsey Kato

The Role of Health Plans in Addressing the Opioid Crisis: Opportunities and Initiatives Craig Thiele, MD

Stigma Associated with Addiction Uche S. Uchendu, MD, and Barry Jacobs, PsyD.

The Role of Community in Addiction and Recovery: Strategies for Community Action and Addressing Health Risk Factors

Liddy Garcia-Bunuel and Marci Eads

Health & Public Safety: Partnerships to Address Substance Use and the Opioid Crisis John Volpe, Laquisha Grant

Correctional Health: Impact of the Opioid Crisis and Unique Opportunities Donna Strugar-Fritsch TBD

Medicare Payment and Delivery Models for Substance Abuse Treatment: New Directions in Traditional Medicare and Medicare Advantage

John Blum TBD


4

Team Based Care:

• Engagement

• Roles and

Responsibilities

• Team

communication

Building a Financially

Sustainable Model

Regulatory:

• Documentation

• Registry

• Workflows

Communications:

• Community

messaging

• Overcoming

stigma

• Transitions of Care

Readiness Assessment:

Leadership and Change Management


WHAT DO I NEED TO KNOW?

Todays webinar will cover some of the operational considerations

➢ What are the medications? Prescribing vs dispensing- what is given in the office?

➢ Who can prescribe?

➢ How will we engage the staff? Will they quit? Will the staff need more training?

➢ How to overcome the stigma? Will my practice become an SUD practice?

➢ How can we bill for this?

➢ Will the DEA inspect my practice?

➢ How will this impact scheduling?

And more….


REASONS TO DO MAT:

✓ Reduction in Overdose deaths

✓ Most effective treatment for OUD

✓ Reduction in infectious diseases – HIV, Hepatitis C, endocarditis

✓ Treating OUD like any other chronic condition, part of primary care

✓ Extremely rewarding

If done properly, adding MAT to your practice can be a financially sustainable business model


7

COUNTIES WITH BUPRENORPHINE WAIVERED PROVIDERS


Why Use MAT?

What is Addiction?

It is a chronic neurobiological disorder

centered around a dysregulation of the

natural reward system

8


ADDICTION 101


700

60

650

55

500

50

400

45

300

40

250

35

250

35

225

35

200

40

250

4030

20 20 20 22 24 22 25 24 26

0

100

200

300

400

500

600

700

800

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Relative Dopamine Levels in Brain

Normal Heroin


WHY DO WE USE MAT?

Medications for Addiction Treatment or Medication Assisted Treatment

Dopamine


Methadone

• Full Agonist

• Moderate

binding affinity

Buprenorphine

• Partial agonist

• Strong binding

affinity

Naltrexone

• Antagonist

• Very strong

binding affinity

12

MAT for Opioid Use Disorder


REQUIRED TRAINING TO PRESCRIBE BUPRENORPHINE FOR OUD

➢ MD or DO+ 8 hour course

+ 30 patients in first year then can apply to go to 100

+ Immediately to 100 patients if in a Qualified Practice Setting

+ If want up to 275 patients+ board certification in addiction medicine or addiction psychiatry by the American Board of

Addiction Medicine (ABAM) or the American Board of Medical Specialties (ABMS) or certification by the American Osteopathic Academy of Addiction Medicine, ABAM or ASAM

+ Or work in a qualified practice setting

➢ PA, NP, CNM+ 24 Hour Course

+ 30 patients in first year then can apply to go to 100

+ Practice dependent on state laws


MEDICATIONS FOR ADDICTION TREATMENT (MAT)

Methadone Buprenorphine Naltrexone

Who can prescribe Physician in NTP Waivered prescriber Any prescriber

Location NTP Any practice setting Any practice setting

Limits Based on state laws 30/100/275 No limits

Action Full agonist Partial agonist Antagonist

Formulation Oral • Sublingual• Implant• Monthly SQ injection

Monthly IM injection

Stocked in office • Witnessed dosing• Take home

• Generally Rx to pharmacy (SL)

• Injectable direct to prescriber

Stocked or ordered from pharmacy for office administration

Pregnancy Yes Yes Generally No


WORK FLOW IN PRIMARY CARE

Screening (MA, RN or

PT)

Intake 1 hour appointment

Decision made to place on

Buprenorphine

Pick Date

Pick Method

Write script and

have patient bring to

office

Induction


INDUCTION/STARTING BUPRENORPHINE

The science

and art of

avoiding

precipitated

withdrawal


INDUCTION/STARTING BUPRENORPHINE

+ Avoiding precipitated withdrawal

+ Stocking buprenorphine vs. writing for patient to bring back

+ When is the patient ready?

+ Home inductions

+ Team members helping with induction

+ Billing for additional time


BEHAVIORAL HEALTH

+ All patients on MAT are required to receive counseling. This takes many forms.

• Individual therapy• SUD counselor• Peer recovery• Group

+ Counseling can be external referral- Know the resources in your community for referral

+ What if your patient doesn’t agree to or go the BH visit?


Syndrome

of

AddictionSocial

Determinants

& Prevention

Data

collection &

evaluationScreening

& referral

Medically

Managed

Detox (4)

Payment

Models

Treatment

EducationOutpatient

treatment (1)

IOP (2)

Residential

Detox (3)

Criminal

Justice

Where Do We Fit In?


WHAT IF OUR OFFICE DOESN’T PROVIDE BEHAVIORAL HEALTH SERVICES

Reduce Stigma

Train all office staff on appropriate language

Educate on biological basis of Opioid Use Disorder

#HMAtalksopioids webinar “Stigma Associated with Addiction”


WHAT IF OUR OFFICE DOESN’T PROVIDE MAT?

+ Implement evidence based practices in your current work flow+ Screening for SUD- NIDA quick screen


WHAT IF OUR OFFICE DOESN’T PROVIDE MAT?

+ Implement evidence based practices in your current work flow+ Distribute/Prescribe Naloxone


QUESTIONS?

PREPARING FOR A POSSIBLE DEA VISIT

Inspection Audit

State Medical/Nursing license of all waivered providers State Medical/Nursing license of all waivered providers

State CS license of all waivered prescribers (if required) State CS license of all waivered prescribers (if required)

DEA registration certificate of all waivered prescribers DEA registration certificate of all waivered prescribers

Verification of number of patients on buprenorphine for OUD for each prescriber

Verification of number of patients on buprenorphine for OUD for each prescriber

Inventory of controlled substances on hand

Reconciliation of received/dispensed/remaining

Inspection of secure storage


TRACKING PATIENTS ON BUPRENORPHINE


BILLING FOR MAT SERVICES

+ Billing and coding▪ Coding for SUD screening▪ Standard E&M codes, often based on time (>50% in counseling and

coordination)▪ Billing for behavioral health services

+ Prior authorizations- Most states are moving towards streamlining authorizations for MAT

+ OUD is a chronic disease and can use chronic disease and collaborative care codes if appropriate


DOCUMENTATION

What do I need to document?

❑Diagnosis of OUD

❑SUD history

❑Effect of medication

❑Toxicology results

❑Check of PDMP database

❑Counseling

❑Dose adjustment?


VERY BRIEF OVERVIEW OF TOXICOLOGY

+ Recommend doing a point of care UDS in office to have clinical information available

+ Types of testing• ELISA vs. GC/MS• Urine, Blood, Oral Swab, Meconium

+ ALWAYS send for confirmation of unexpected results before changing therapy

• Test positive for substance not prescribed• Test negative for substance that is prescribed

+ Know what your UDS tests for (and what it does not!)

+ Tampering with sample

+ Frequency of testing

+ Billing


DIVERSION

Studies have shown majority of buprenorphine that is purchased from diverted supplies is used to treat opioid

withdrawal by individuals who can’t get legal MAT treatment

Clues to diversion• Early refills• Lost/stolen prescriptions• Multiple prescribers/pharmacies• Paying cash when they have

insurance• Lack of buprenorphine

metabolites

Addressing suspected diversion• Talk to your patient!• More frequent visits• Random pill counts• Return empty foil pouches at each visit• Witnessed UDS


#HMATALKSOPIOIDS- AVAILABLE ON THE HMA WEBSITE

Understanding the Impact: An Overview of the Opioid Epidemic from a Systems Perspective Corey Waller, MD

Public Health Response to the Opioid Epidemic: Prevention Opportunities in the Midst of a Crisis; Primary, Secondary and Tertiary Strategies to Prevent Opioid Misuse and Overdose

Shannon Breitzman and Lindsey Kato

The Role of Health Plans in Addressing the Opioid Crisis: Opportunities and Initiatives Craig Thiele, MD

Stigma Associated with Addiction Uche S. Uchendu, MD, and Barry Jacobs, PsyD.

The Role of Community in Addiction and Recovery: Strategies for Community Action and Addressing Health Risk Factors

Liddy Garcia-Bunuel and Marci Eads

Health & Public Safety: Partnerships to Address Substance Use and the Opioid Crisis John Volpe, Laquisha Grant

Correctional Health: Impact of the Opioid Crisis and Unique Opportunities Donna Strugar-Fritsch TBD

Medicare Payment and Delivery Models for Substance Abuse Treatment: New Directions in Traditional Medicare and Medicare Advantage

John Blum TBD


CONTACT

JEAN GLOSSA, MD, MBA, FACP

SCOTT HAGA PA-C

120 North Washington Square

Suite 705

Lansing, MI 48933

517.482.9236 | [email protected]

www.healthmanagement.com

Documents

MAT- Are you ready? · CONTACT JEAN GLOSSA, MD, MBA, FACP SCOTT HAGA PA-C 120 North Washington Square Suite 705 Lansing, MI 48933 517.482.9236 | [email protected]