TennCare to Cover Longer-Term Opioid Addiction Treatment

Knoxville News Sentinel USA TODAY NETWORK - TENNESSEE

To Ed Ohlinger, Suboxone, methadone and other medications are important for treating addiction — but they’re only the first step.

“The medication quiets the brain,” Ohlinger said — which then allows therapy and other methods to start to work.

Ohlinger is chief operating officer for ReVIDA Recovery Centers, a Nashvillebased company that in October 2018 bought seven outpatient Wautaga Recovery Centers in Tennessee and Virginia with an eye toward implementing its own brand of treating substance abuse disorder: looking at the whole person and measuring “recovery” through goals like attaining permanent housing, a job, a car, a bank account, custody of one’s children.

But the biggest immediate difference: ReVIDA takes TennCare/Medicaid.

Three or four years ago, that would have been a concern for ReVIDA CEO Lee Dilworth, a Nashville health care executive who co-founded the recovery chain.

“But now, Medicaid is embracing medication-assisted therapy more,” Dilworth said. “They see it saves a lot of money. ... That’s a change, a shift.”

New focus on MAT

Over the past year, TennCare and its managed care organizations have put more focus on the use of medication in addiction treatment, “strengthening and broadening its Medication Assisted Treatment provider network,” said Sarah Tanksley, TennCare’s deputy director of communications.

In addition, it’s given those in the network “enhanced resources and clinical support,” Tanksley said, “including a more streamlined prior authorization process” and access to more types of medication.

But it also requires mental health services — therapy and counseling — are available and provided to patients getting the medication-assisted therapy. That’s something that clinics providing buprenorphine and other such treatments in the past often did halfheartedly, if at all.

With medication alone, Ohlinger said, the risk of relapse is much higher. But in the past, getting payors to cover long-term therapy services could be a challenge.

“This is a chronic disease, just like diabetes,” he said. “If you have opioid use disorder, or any substance use disorder, you have it forever, so you’ve got to maintain it forever. ... Everybody involved in this for a long time now understands that the longer people are treated, the better the outcome.”

Just a couple of years ago, treatment wasn’t as available to people with more limited resources: TennCare or no insurance, low income. That situation is common to people in the throes of addiction, who often have lost jobs and family support by the time they’re ready to seek help.

That was the population Dilworth aimed to serve when he and others raised capital for ReVIDA through a network of friends, family and others with an interest in substance abuse disorder.

“Two or three years ago, I got sick of going to funerals of young men in their 20s that either I knew or my children did,” Dilworth said. “I didn’t think we were doing enough (in health care) to attack this epidemic.”

ReVIDA accepts TennCare and charges the uninsured on an incomebased sliding scale, though the plan is to soon add commercial insurance as well, he said. It also accepts pregnant women as patients.

“There are a lot of patients who suffer from opioid use disorder who can’t afford to pay,” Dilworth said. “We want to help them.”

Metrics for success

ReVIDA has a system, with metrics measured every three months, to track patients’ success not only at abstaining from drug use, but at regaining their lives, Ohlinger said. That’s intended not only to help ReVIDA see what methods are working best, but also to show “payors and other stakeholders the benefits” of long-term, holistic therapy.

Part of that is assessing what the patient is ready for, he said, and helping them move up a scale: from thinking about recovery, to abstaining from drugs, then maintaining a drug-free lifestyle in a drug-free environment, then other specific goals such as completing probation, regaining child custody, opening a bank account, finding stable housing and employment, reconciling with family.

“They don’t necessarily have the skills to navigate society” without a treatment plan, Ohlinger said.

That plan includes outpatient care weekly in the beginning, tapering to biweekly or monthly, after which ReVIDA individualizes a “recovery plan” that can include years of follow-up.

“They will always have the opportunity to come here for follow-up for continuing care, ‘aftercare,’ “ Ohlinger said. “We have groups where alumni come and continue to participate as long as that’s a part of their recovery process.”

MAT not for everyone

That’s a model that Blount Countybased Cornerstone of Recovery has long used successfully — long-term followup and peer support.

In August, after nearly a year of negotiations with the state, Cornerstone also opened a program that accepts Tenn-Care/Medicaid: Stepping Stone to Recovery.

The difference: Cornerstone opted not to use the Medication Assisted Therapy protocol now favored by the state, although the facility does use buprenorphine for detox and offers clients the injectable, extended-release form of the non-narcotic naltrexone — Vivitrol — to block opioid receptor sites in the brain, easing drug cravings.

“It fits our philosophy better,” Cornerstone CEO Steve McGrew said. “We believe that with the changes drugs make in the brain, it can take months, and in some cases years, for the brain to repair itself, and it takes even longer if you have another drug, even one that’s less harmful, in your system.”

ReVIDA Recovery Chief Operating Officer Ed Ohlinger sits in one of the group therapy rooms at ReVIDA’s Knoxville location on Feb. 21. BRIANNA PACIORKA/NEWS SENTINEL

That said, Cornerstone doesn’t dispute that medication-assisted therapies like Suboxone and methadone also could provide harm reduction benefits. Cornerstone is piloting a program at its intensive outpatient program in Columbus, Ohio, in which “local, reputable” medication-assisted therapy providers use Suboxone on a “more extended tapering program,” monitoring the outcomes, he said. “There probably are people that would benefit from a MAT regimen, but what we’ve found is that the ‘M’ part is being emphasized more than the ‘A’ part,” McGrew said.

“We believe in the bio-psycho-socialspiritual nature of treating the whole person, and some of these programs do a good job on treating the biological component, but not so much on the other three. And that’s what we offer.”

And not all of Stepping Stone’s clients are addicted to opioids, he added — alcohol is still a big factor.

But McGrew wondered if Cornerstone’s resistance to making Stepping Stone a medication-assisted therapy program delayed its ability to get signed contracts with TennCare’s managed care organizations. Cornerstone hoped to open the program at the beginning of 2018 but was in network with only one MCO at the time.

It opened “when it appeared we were getting close to having signed contracts with the other two MCOs, since we had reached verbal agreements on the rates,” McGrew said, but didn’t have a signed contract until December 2018.

“It did drag out longer than it should have, and we’re still not in network with all three MCOs — and it very well seems to be related to our hesitancy to use buprenorphine as a long-term maintenancemedication,” he said.

“That being said, we have an excellent working relationship with the two MCOs we’re now in network with, and I’d like to think our combined efforts are making a difference in substance abuse treatment for East Tennessee’s underserved population.”

Counseling mandatory for provider, not patient

Tanksley said outpatient mental health therapy/counseling “is a Tenn-Care-covered benefit, and there are no limits on this service,” although it is based on “medical necessity.”

But while psychosocial services and counseling — minimum 30-minute sessions, at least twice a month when patients enter treatment and at least once a month in the first year of recovery — are among the “best practices” in the TennCare MAT network, “a member may continue to receive prescribed buprenorphine even if not participating in the counseling,” Tanksley said. “This decision should be based on the provider’s clinical judgment and the member’s overall involvement in their treatment and recovery.”

However, to stay in the network, a provider is required to “ensure that mental health therapy/counseling is available and provided for the patients,” she said, and that counseling must be provided by someone with a minimum master’s degree in mental health, supervised by a licensed mental health provider “practicing within the scope of their licensure.”

That’s intended to cut down on clinics that provide medication without offering adequate counseling, which became common — and were not as closely regulated — when opioid addiction escalated and buprenorphine showed up as a less-stigmatized option to methadone clinics, which “have gotten a bad rap,” Ohlinger of ReVIDA said.

TennCare is now “pushing people in the medication-assisted therapy space to provide the full array of services,” he said.

Dilworth said that has the potential to keep people clean longer.

“Suboxone’s not going to change anybody’s life; it’s going to change their body chemistry,” he said. “The behavioral health program is going to change their lives — if they want to change their lives.”

The 24-hour, toll-free Tennessee Redline, 1-800-889-9789, provides referrals to recovery services, including those that accept TennCare.

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