Improving access to buprenorphine

Studies have shown that the prevalence of prescription opioid abuse has risen dramatically in the past several years. In 2004, the number of Americans reporting abuse of prescription medications was higher than the combined total of those reporting abuse of cocaine, hallucinogens, inhalants, and heroin, and direct healthcare costs for opioid abusers are approximately eight times higher than those of nonabusers, according to the National Survey on Drug Use and Health.

Congress intended to increase the number of people willing to seek and adhere to treatment by integrating opioid treatment into the mainstream medical setting by passing the Drug Addiction Treatment Act of 2000. The law provides a way for physicians to integrate treatment of opioid dependence into general outpatient medicine. Buprenorphine, an orally administered medication marketed by Reckitt Benckiser Pharmaceuticals, Inc., under the brand names Suboxone and Subutex, was approved by the FDA in 2002 for opioid dependence treatment, and it can be prescribed and monitored on an outpatient basis with the medication taken in the privacy of a patient's home.

Yet following completion of a 2006 review, CIGNA Behavioral Health (CBH) found very little utilization of buprenorphine for long-term maintenance treatment, and CBH struggled with finding available providers to manage this treatment when a member required or requested it. Thus, CBH set out to understand the barriers and to find solutions that would improve access to and availability of outpatient buprenorphine treatment for opioid dependence.

In 2003, CBH changed from being a traditional behavioral utilization management company to an operational foundation grounded with a philosophy of care advocacy. CBH's care advocacy philosophy means it supports evidence-based treatments, as well as working to eliminate barriers to access and improving outreach, education, and support to help engage members in effective treatments.

Buprenorphine tablets. Photo courtesy of www.NAABT.org

Members with a diagnosis of opioid dependence have provided a great opportunity to demonstrate this philosophy. This philosophy has helped initiate the process of working collaboratively with buprenorphine's manufacturer, our provider network, and our members to improve patient satisfaction and optimize clinical outcomes. CBH ended up becoming the first managed behavioral health organization to provide coverage for office-based buprenorphine induction.

The Gap in Treatment

When CBH first applied the care advocacy philosophy to how we manage opioid dependence, we revealed a gap in medical systems. When we examined the percentage of our inpatient admissions due to a diagnosis of nonalcohol drug dependence, the number increased from a little more than 6% in 2004 to more than 9% in 2006. Buprenorphine provides an opportunity to draw more opioid-dependent patients into outpatient treatment, without the stigma of receiving treatment at an opioid treatment program (usually a methadone clinic). So following buprenorphine's introduction, one would expect the number of people who require inpatient treatment for opioid dependence to decrease, as more people could obtain appropriate, effective treatment on an outpatient basis.

In 2006, when CBH reviewed the demographic and diagnostic data from 2002 to 2005, we found that the percentage of our membership receiving treatment for a diagnosis of opioid dependence had remained constant. The data also showed the percentage of members with a diagnosis of opioid dependence requiring inpatient treatment remained constant as well. Our care managers reported that facilities were using buprenorphine as part of an inpatient detoxification protocol, but rarely were these facilities and patients considering buprenorphine maintenance treatment. When we did receive a request for outpatient maintenance treatment, we frequently had a difficult time locating a provider in our network who would accept the referral.

Working to Improve Access

In 2006, CBH convened a workgroup to develop a plan to increase access to and availability of outpatient buprenorphine treatment for our members. CBH also sought to integrate this treatment and process for access into our clinical and operational practices.

CBH's pharmacy utilization department reviewed the number of our members receiving buprenorphine treatment for opioid dependence. As we expected, only a few outpatient prescriptions for buprenorphine were being filled for our membership. As a first step in determining how to improve access and availability for our members, we reached out to our provider network to learn what the current practices were with the use of buprenorphine.

"Comparing our contracted network of psychiatrists against the Drug Enforcement Administration's [DEA] list of buprenorphine-waivered physicians [i.e., those allowed to prescribe the drug], we found that only 9% of our physician network had obtained the waiver," says Network Development Specialist Sue Knutson. "To develop a better understanding of this issue, we sent each of these waivered physicians a survey to determine their current clinical practice, their billing practice, and their interactions with managed care organizations around buprenorphine treatment. This included specific questions about the various phases of outpatient treatment, including the initial assessment, induction, and maintenance visits. We had a very enthusiastic response, with 25% of our buprenorphine-waivered physicians returning the survey."

The survey responses were clear and consistent. Many providers stated that they were not billing managed care companies for the buprenorphine treatment-related office visits, but were charging patients cash to receive care. Providers said managed care companies did not effectively reimburse them for the amount of time necessary to provide the treatment.

In drilling this down, we determined the biggest barrier to the provider-managed care relationship was the reimbursement for induction phase office visits. Unless providers had reached their 30-patient maximum, they were very interested in providing this service for CBH members, and were interested in being part of a specially credentialed network to be identified for referrals. (In 2006, the Drug Addiction Treatment Act of 2000 allowed only 30 patients to be treated per physician; this was increased to 100 patients by Congress effective January 1, 2007.) We determined that if we could find a system to reimburse providers equitably for induction phase visits, then we could establish referral patterns, allow members to utilize their substance abuse benefits, and improve the access to and availability of buprenorphine treatment for opioid dependence among our membership.

Establishing a Reimbursement System

The biggest hurdle in creating an appropriate reimbursement system for the induction phase office visits was that there is no specific CPT coding to differentiate these intensive outpatient office visits from any others. We were unable to find any work in progress with the American Medical Association and the Centers for Medicare and Medicaid Services to develop specific codes for induction visits. So we determined we needed to find a "unique" code for recognizing these induction visits.

We identified a code within the Healthcare Common Procedure Coding System (HCPCS) National Level II codes that supported the services provided during buprenorphine induction visits. Because this code was not commonly used by providers, it allowed for CBH to easily provide authorization, identify the claims, and track the specific utilization of this service for quality improvement initiatives. We then used information we had about the intensity of the office visits, as well as other relative reimbursement rates for office visits associated with substance abuse treatment, and determined an equitable reimbursement rate for an office visit for buprenorphine induction.

With the identification of a code for buprenorphine induction, and a fee schedule for the code, we began collaborating with our providers to improve access to and knowledge of this treatment. CBH reapproached the provider network of qualified physicians and invited them to participate in our program to provide outpatient buprenorphine treatment for opioid dependence. After a physician's DEA waiver is verified by CBH, the HCPCS induction code is added to his/her contract, allowing him/her to be reimbursed for treatment with buprenorphine.

While we were inviting our network providers to participate, we also updated our claims and customer service processes to integrate this additional service. All CBH care management and advocate staff received additional training both on buprenorphine treatment of opioid dependence and a new process to quickly allow increased member access to providers offering this service. With all this in place, CBH went live with this reimbursement on January 2, 2007.

Response

The response to adding reimbursement for the induction phase office visits has been tremendous. Providers repeatedly informed us that this was the first such reimbursement strategy they had seen for buprenorphine induction, and that they were glad to see us working to improve access to and referrals for the service. Providers have been excited about opportunities to receive additional referrals for this service, especially as the mandated patient limit increased this year to 100 patients per provider.

"Office-based treatment with buprenorphine has shown itself able to help thousands of opioid-dependent patients move into and remain in long-term recovery, when combined with appropriate psychosocial support," says Shaun Thaxter, president of Reckitt Benckiser Pharmaceuticals. "The challenge has been to establish a network of doctors who are readily available to provide treatment. CIGNA Behavioral Health's strategy is a great access model for the millions of Americans who need medical treatment for the brain disease of opioid dependence."

"We've received many calls from providers inquiring as to how they can join the CBH network for this treatment," says Knutson. "We are now looking at our membership to identify those areas of the country where we need to more quickly establish a network if one is not already available. It's really a team effort to collaborate with our providers to more readily identify those able and willing to provide immediate outpatient induction with buprenorphine."

CBH is able to reimburse psychiatrists, addictionologists, and medical specialists ASAM certified for this service, and now has more than 150 providers contracted in the network to provide this service.

"I have worked with opioid-dependent patients for over 20 years, and this [buprenorphine] is the only medication that I've heard patients call a miracle," says Joel Holiner, MD, executive medical director of Green Oaks Behavioral Healthcare Service in Dallas and chief of psychiatry at Medical City Dallas Hospital. "I think the program that CIGNA is offering to make this available to healthcare professionals is going to take away one of the biggest barriers to treatment."

What's Next

In just four months, we've authorized outpatient buprenorphine induction for more than 70 members. The process of allowing appropriate reimbursement for buprenorphine treatment for opioid dependence has improved network access, allowed us to more readily identify available providers, and provided immediate outpatient induction when a provider is available. We have benefited from improved relationships with our outpatient provider network, and will continue to collaborate with providers to allow our members to access this service while utilizing their substance abuse benefits.

CBH will be evaluating this service to better determine the effect this approach has on our members and treatment costs over time. We expect that with increased access to and utilization of outpatient treatment with buprenorphine, we will find increased presentation rates of opioid dependence, and that a decreasing percentage of these members will require inpatient treatment. We will continue to monitor engagement with this service compared to engagement with treatment after an inpatient detoxification for opioid dependence.

We plan to evaluate the impact that this treatment has on overall medical costs, both in the direct treatment of the acute phase, as well as the overall medical costs driven by the member having an opioid dependence diagnosis. CBH also will continue to use its care advocacy approach to ensure access continues to improve, and that members are receiving the support they require to fully engage in treatment and pursue a healthier life.

For more information about CBH, visit https://www.cignabehavioral.com.