On July 25, Sylvia Burwell, secretary of the Department of Health and Human Services (HHS), announced at the National Governors Association (NGA) annual meeting that there would be $100 million in grants to Federally Qualified Health Centers (FQHCs) through the Health Resources and Services Administration (HRSA) for treatment for substance use disorders (SUDs). On July 27, Vikki Wachino, director of the Center for Medicaid and CHIP Services, part of the Centers for Medicare & Medicaid Services (CMS), sent out a Dear Medicaid Directors letter that relaxes the IMD exclusion for people with SUDs, allowing Medicaid reimbursement for residential and inpatient treatment via waivers. These are two huge steps; the fact that both initiatives were unexpected created much excitement for the field last week.

Burwell also announced at the NGA meeting the awarding of $11 million for medications and treatment for opioid use disorders, jumping the gun, as the agency awarding the grants, the Substance Abuse and Mental Health Services Administration (SAMHSA), hadn’t even sent the notices to the awardees yet.

In our many phone calls reporting these events last week, we picked up on a feeling in Washington that Secretary Burwell wanted to have something done — not just said — about the opioid problem.

IMD exclusion

“This is a very big step,” said Mark J. Covall, president and CEO of the National Association of Psychiatric Health Systems, of the IMD exclusion letter. “This really would allow for states to waive the IMD exclusion for inpatient as well as residential treatment for addiction services,” he said. “Prior to this CMS has said they would not be granting this kind of waiver.” Covall noted that the 15-page Medicaid letter includes many conditions for the waiver, which would really be part of “SUD system reform.” 

Although the IMD waivers would only apply to SUDs, Covall sees the move as a “good development.” He noted that the letter goes beyond reforming the delivery of care for SUDs. “They lay out details about having evidence-based care,” he said.

Although Dear Medicaid Director letters become effective the date they are sent out, it takes time to complete the cumbersome 1115 waiver process, said Covall. But the letter does give direction to the state on what CMS wants to see in the proposals. In the letter it’s clear that CMS is not saying one service is more important than another, but rather that there are barriers to access to treatment across the board, and that the IMD issue is one of those barriers.

The National Association of Medicaid Directors was still studying the letter, and spokeswoman Kathleen Nolan said the group was not ready to comment yet.

Andrew Kessler, principal with Slingshot Solutions, would rather see the IMD exclusion problem fixed at the federal, not the state, level, noting that many states refused to expand Medicaid under the Affordable Care Act (ACA). “While I’m thrilled to see CMS take an approach that encourages innovation and gives states an opportunity to request waivers, we still have work to do,” he told ADAW. “A state with a governor that is resistant to increasing the role of Medicaid — and we’ve seen from the ACA how politics can impact a governor’s decision to accept increases in the program — simply will not go through the process of applying for a waiver from CMS.” As a result, “the 1115 waiver process can only alleviate problems such as the IMD exclusion when a state chooses to ask for help,” he said. “In the end, the IMD rule is a federal problem that requires a federal fix.”

The TCE grants

The $11 million going to medications and accompanying treatment for opioid use disorders falls under the Targeted Capacity Expansion (TCE) grant program administered by SAMHSA, which put out the Request for Applications to states last spring (see ADAW, March 16). The announcement should have come from SAMHSA and not HHS. In fact, the single state agencies (SSAs) who were awarded those TCE grants had not even received their notices yet, and learned of it the way everyone else did — a press release put out by HHS that contained a link to the SAMHSA awards.

Although Secretary Burwell suggested that the money was coming from HHS and SAMHSA, the funding for the $11 million in TCE grants actually came from Congress, which added it into the spending bill last year (see ADAW, Dec. 15, 2014). “It’s hard to articulate how difficult it was for the champions in Congress to get that money as an isolated set of dollars for MAT,” one insider told us. After the fact, however, the administration and others tried to claim credit for their behind-the-scenes work in getting the money through.

Congress allocated $12 million for the TCE grants; the other $1 million is being used for technical assistance, to be managed by SAMHSA’s Division of Service Improvement (a contract proposal is currently out).

The grant program is called Targeted Capacity Expansion: Medication Assisted Treatment — Prescription Drug and Opioid Addiction (MAT-PDOA).

The TCE grants are going to the SSAs with authority over the Substance Abuse Prevention and Treatment (SAPT) block grant in the following states: Indiana, Iowa, Kentucky, Maryland, Massachusetts, Missouri, New Jersey, Vermont, Washington, Wisconsin and Wyoming.

FQHCs

There was some mystery surrounding the $100 million going from HRSA to FQHCs; nobody is sure where the money is coming from. Even the HHS press release didn't specifically mention FQHCs, instead referring to "community health centers" (HRSA confirmed that the money is going to FQHCs). But the SSAs who administer the SAPT block grant, which has been proposed for a $50 million cut by Senate appropriators (see ADAW, July 13), hope that the FQHCs getting the money work with them. Mark Stringer, director of the Missouri Department of Mental Health and the state’s SSA, told ADAW that he hopes he can work with FQHCs so that state-contracted providers who are already treating SUDs can be a part of the program.

“It’s an age-old issue — do you give money directly to providers, or to the state?” said Rob Morrison, executive director of the National Association of State Alcohol and Drug Abuse Directors. “Either way, if it’s going to addiction services, that’s a good thing,” he said. “Hopefully, the dollars will come out with a requirement that there’s collaboration with the SSA.”

In some states, FQHCs are already providing treatment for SUDs. “Several of our FQHCs are very strong addiction providers, so if there is something available, we would welcome additional support,” said Barbara Cimaglio, deputy commissioner for the Vermont Department of Alcohol and Drug Abuse Programs and the state’s SSA.

Specialty providers also hope that the FQHCs will work with them. Mark Parrino, president of the American Association for the Treatment of Opioid Dependence, which represents opioid treatment programs (OTPs), said that if FQHCs utilize more medications as a result of the money, that’s a good thing, but he hopes they can work with OTPs so that patients can receive comprehensive treatment, not just medications.

Indeed, there have always been concerns about whether the FQHC workforce can deliver SUD treatment services. Sara Moscato Howe, chief executive officer of the Illinois Alcoholism and Drug Dependence Association, said “there needs to be a competent workforce utilizing clinicians trained to deliver SUD treatment.”

She also supported any efforts to enhance resources for people with SUDs. “Clearly, the opioid epidemic has brought attention to the significant treatment gap in this country,” she said. “We hope the additional funds are utilized to increase access to treatment for the millions of Americans in need of services and that this is just the start of a serious investment to address our nation’s number-one public health problem.”

And Jeffrey Quamme, executive director of the Connecticut Certification Board, said he hopes the FQHCs that receive the funding “have an appropriately trained workforce with evidence of competency in working with clients with SUDs, and not just seek professionals with any behavioral health license regardless of SUD competency.”

Details from HRSA

The $100 million going to FQHCs is “new money,” said Martin A. Kramer, spokesman for HRSA. But he doesn’t know where the money is coming from — whether it was appropriated or funding left over from another program. “We knew that the secretary would make this announcement,” he said. The secretary wanted to present it to the governors first, he said.

All 1,300 FQHCs who are supported by HRSA are eligible for the 300 grants that will be made with the $100 million, said Kramer. The Funding Opportunity Announcement, which was just posted July 30, contains more details. It is clear that all recipients must increase the number of patients on MAT.

The funding can be used for screening with SBIRT, adding MAT patients, reducing opioid overprescribing by training, enhancing or establishing integrated primary care and behavioral health, or various other services.

For the press release from HHS about the three initiatives, go to www.hhs.gov/news/press/2015pres/07/20150725a.html.

For the link from SAMHSA on the TCE awards, go to www.samhsa.gov/grants/awards/mat-pdoa.

For the Dear Medicaid Director letter, go to http://medicaid.gov/federal-policy-guidance/downloads/smd15003.pdf.

For the link to the Funding Opportunity Announcement for FQHCs, go to http://bphc.hrsa.gov/programopportunities/fundingopportunities/substanceabuse/index.html.

Bottom Line…

Major funding and policy changes are being made in Washington toward the treatment of opioid use disorders.