Opioid Legislation Takes Important Steps to Create Treatment Capacity and ID At-Risk Patients

Comprehensive screenings and instituting a "dose ceiling" are two ways to tackle care for at-risk patients.

Medicare's Impact on the Opioid Crisis

Stephanie Kennan

October 19, 2018 11:04 AM

When Congress passed H.R 6, the “Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act” (also known as “SUPPORT for Patients and Communities Act”) as its response to the opioid epidemic, it included provisions to expand capacity in Medicare and includes preventative measures for a population that is vulnerable to opioid use disorder.

An analysis of Medicare Part D data by the Health and Human Services (HHS) Office of the Inspector General revealed that more than 500,000 Medicare Part D beneficiaries received high amounts of opioids in 2016, with the dose far exceeding the manufacturer’s recommended amount. Beyond the treatment of addiction, opioid use can also pose health risks such as breathing complications, confusion, drug interaction problems, and increased falls, which can in itself pose significant health problems for elderly patients. In 2014, the Agency for Healthcare Research and Quality published a report demonstrating that elderly females had a higher rate of opioid-related inpatient stays than elderly males and the rate of opioid-related inpatient stays was highest among those aged 65 and older in 13 states. The report highlighted a need to expand capacity for treatment and increase ways to identify at-risk Medicare patients.

Inclusion of Opioid Treatment Programs

To expand capacity, the legislation expands Medicare coverage to include Opioid Treatment Programs (OTP) for the purposes of Medication Assisted Treatment. Opioid Treatment Programs were not previously recognized as Medicare providers, forcing beneficiaries to pay out-of-pocket for their services. This provision allows Medicare to pay the outpatient OTP through bundled payments made for holistic services including medications, counseling, and testing.

Elimination of Site Requirements for some Telehealth Services

Of significant importance to expand capacity, as well as advance the use of telehealth services, is a provision that expands Medicare’s coverage of telehealth services specifically for the treatment of opioid use disorder and other substance use disorders (SUD). This provision eliminates certain statutory originating site requirements for telehealth services provided to a Medicare beneficiary for the treatment of SUD and co-occurring mental health disorders. Beginning July 1, 2019, the provision allows for payment of those services provided at sites regardless of geographic location, including a beneficiary’s home. A separate facility fee would not be provided if the originating site is the beneficiary’s home. A stumbling block to the expanded use of telehealth in Medicare has been the statutory originating site requirements. While not eliminated for all telehealth services, this provision is notable for changing those requirements for SUD treatment.

Comprehensive Screenings

Another significant provision addresses opioid misuse in the elderly population by allowing for comprehensive screenings for Medicare beneficiaries for opioid use disorder and other substance disorders. The screenings will be included in the initial preventive physical examination (the “Welcome to Medicare” visit) and annual wellness visits thereafter. The physician may include a review of the beneficiary’s current opioid prescriptions and screen for potential substance abuse disorders. The comprehensive screening is an important tool to assess patients and allows the physician to create care plans to both address pain and ensure a patient receives appropriate treatment for substance use disorder. However, in order to receive the comprehensive screening patients must opt-in, which may result in patients who need help to not receive the screening.

Opioid Dose Ceiling

Other provisions addressing the Medicare program and the opioid epidemic build upon the Center for Medicare and Medicaid Services (CMS) efforts that began April 10, 2018, when CMS finalized the 2019 Medicare Part D prescription drug program requirements and included a ceiling for opioid doses. Any prescription at or above the 90mg morphine equivalent units would trigger a “hard safety edit” requiring the pharmacist to talk with the prescribing doctor about the dose. CMS also adopted a new policy that requires all new opioid prescriptions for short-term acute pain to be limited to no more than seven days’ supply. Several states have already adopted similar measures.

Drug Management Programs

H.R. 6 accelerates the development and use of drug management programs for at-risk beneficiaries by mandating that all prescription drug plans use such a program by 2022. The legislation also requires CMS to identify beneficiaries enrolled in Medicare Part D with a history of opioid-related overdose and include them in the definition of beneficiaries potentially at-risk for prescription drug abuse under the Part D drug management program.

Given the vulnerability of the elderly population, it was important to address both capacity for treatment and the identification of at-risk Medicare patients in the SUPPORT for Patients and Communities Act. The legislation takes important steps towards addressing opioid and other substance abuse disorders in the Medicare program. Implementation of these provisions will determine if they are effective and if additional measures will be needed in the future.


Stephanie Kennan is a senior vice president with McGuireWoods Consulting where she spearheads healthcare policy services for clients of McGuireWoods Consulting and McGuireWoods LLP.

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