The ongoing news about the opioid crisis has led to both the federal and state governments seeking ways to break what has become a national epidemic. Despite various programs to tackle the issue, deaths from opioids continue to rise, with more than 33,000 deaths in 2016, according to the National Institutes of Health (NIH).
The purpose of opening waiver programs, such as the 1115A and 1332 programs, was to encourage states to develop innovative ways to address substance abuse without exceeding budget neutrality requirements. The waiver programs also allow states to be creative and better coordinate the loose patchwork of resources — grants, programs, centers, trained healthcare professionals — to address opioid use disorder (OUD).
With regard to the 1115A waiver program, as of December 2017, there were 15 approved 1115 behavioral health waivers, including mental health and substance use disorders and 12 pending applications across 22 states. The first two states to receive approval for using waivers for opioid treatment were Utah — expanding access for treatment — and New Jersey — for more comprehensive medication-assisted treatment initiatives.
States could also potentially draw on state innovation waivers under section 1332 of the Affordable Care Act to modify coverage provisions. This would allow the states to adjust individual waivers and employer mandates, as well as change cost-sharing reductions, among other things, to ensure that their modifications would stay budget-neutral while they attempted to offer access to care and affordable plans.
Understanding the rules
While these waiver initiatives open new doors to states, the challenge states face is understanding how they can flex the rules surrounding the waiver programs to meet their individual needs.
For example, the 1115A waiver initiative is relatively new in this context, so states will also have to consider how the programs might change over time to meet community needs, outcomes, costs and access to care. The Centers for Medicare & Medicaid Services (CMS) listed comprehensive instructions in a letter to all Medicaid directors, including how such a 1115A OUD program should ideally be constructed. Given that the needs and gaps of states vary considerably, states will need to determine individually how they go about prioritizing their needs and then meeting those objectives. Again, states must proceed with caution, as failure to report and meet objectives in a timely fashion will be met with expensive consequences: $5 million deferral per missing, late or incomplete item.
Careful consideration also needs to be given to how the states will monitor progress and strategies for reporting. For example, how will they assess and analyze performance measures and ensure that their programs are aligned with the needs defined by American Society of Addiction Medicine (ASAM) criteria? To meet their objectives and adhere to the waiver requirements, states will need to become better at sharing information and coordinating efforts by those on the front lines — doctors, nurses, emergency medical technicians (EMTs), pharmacists and coroners — which will require uniform deployment of analytics across each state and between states. It will also be necessary to ensure that all trained professionals are able to practice to the top of their licensure to address treatment gaps.
States should also consider the evaluation of new treatment regimens, including U.S. Food and Drug Administration-approved digital health innovations for OUD treatment as well as new non-opioid medications that are being developed to treat pain. If utilized properly within state-sponsored programs, these new interventions may help stem the crisis, save lives and keep costs down.
States will need to assess all options available to them through the waivers and how these programs could help them tackle the onerous issue of OUD.
Find out more about the use of data and analytics from various programs and initiatives in the battle against substance abuse disorder in our recent white paper, Fighting the opioid crisis with data, analytics and waivers — a coordinated approach.