Integrity, Sustainability of Pennsylvania OUD Centers of Excellence At Risk

In 2016, I had the great opportunity to watch and participate in the birth of Pennsylvania’s Opioid Use Disorder (OUD) Centers of Excellence (COEs). In fact, my role at the Department of Human Services (DHS) as special assistant to the secretary was exclusively to support the implementation and operation of the COEs. Today, with a changed vantage point but still close to the COEs, I am afraid I am watching the program’s demise as seven years of consistent requirements and expectations give way to a mishmash of wildly varying requirements across five behavioral health managed care organizations (BH-MCOs) that threaten the integrity and jeopardize the sustainability of the program… [click “continue” button to read more].

Like many new programs, the COE launch was not smooth. No one will say it was. But it was and still is an important initiative. It was, at the time, Pennsylvania’s single largest investment to address an opioid overdose death epidemic that was and still is raging out of control. It was a significant part of Pennsylvania’s answer to the epidemic, and, for Medicaid patients, it aimed to: 1) expand access to evidence-based treatment, especially medication to treat OUD; 2) create community-based care management teams that would help individuals access treatment faster and remain engaged in the continuum longer; and 3) create a hub-and-spoke model that enabled greater integration of physical and behavioral health care in an effort to treat the whole person.

Forty-five behavioral and physical health providers each initially received a $500,000 grant to carry out this work. The funding was to be used mostly to hire a community-based care management team, including certified recovery specialists and care managers, because there was little to no reimbursement available for behavioral or physical health providers to provide the care management support services envisioned for the COEs. The grant funding and, later, the DHS-directed per-member per-month payment, acknowledged that for COEs to provide the services necessary to retain clients in treatment and keep them on a path of sustained recovery, payment would have to be made to cover services that historically were not billable.

In the seven years the COEs have operated, the program has been successful. For the first quarter of 2023, according to data collected by the University of Pittsburgh’s Program Evaluation and Research Unit (PERU), 65 percent of new clients enrolled in COEs statewide returned within one calendar month after the last face‐to‐face care management service they received for ongoing recovery and care management support. Top-performing COEs have a return rate of over 80 percent. Why does retention matter? Because the longer someone stays engaged with the system, the greater the chance of long-term recovery.

Two years after the program launched, Pitt PERU published a paper on the COE program’s results. More than 70 percent of the Medicaid population diagnosed with an opioid disorder was receiving treatment, and of that group, 62 percent remained in treatment for more than 30 days. In the days before COEs, just 48 percent were receiving treatment and, of that group, only 33 percent remained engaged in treatment for more than 30 days. In addition, follow-up within seven days after an OUD-related emergency department visit increased 51 percent from 45 percent to 68 percent, and the number of primary care visits increased 46 percent.

In assessing COE effectiveness, one MCO correlated increased access to medication to treat opioid use disorder (MOUD) to increased retention in treatment, finding that some COEs, including those in rural areas, had retained nearly 50 percent of their patients one year later.

DHS found the program so worthwhile that in 2020 it expanded the program, resulting in an increase to more than 250 COEs across the state. And that number is likely higher today.

Then, in 2021, DHS began transitioning COEs from a directed payment model into the hands of managed care. Based on what we see thus far, many would say that was the beginning of the end of the COEs as they were intended.

Vastly different expectations among and directives from BH-MCOs of what the COEs are to do creates confusion and unnecessary administrative burden, especially for those who contract with multiple MCOs, and risks program integrity and sustainability. Some BH-MCOs are requiring services that weren’t required for seven years. Although we’re still in this transition process, the mood of the behavioral health COE operators is somber.

Some BH-MCOs are signaling a relegation of the hallmarks of care management and recovery support while emphasizing clinical focus. Yet amazingly, only a few weeks ago, DHS re-asserted that care management is, in fact, the foundational element of the COEs.

There’s been much talk about admission and discharge criteria, too, which never existed for someone with an OUD to receive services from a COE. In fact, last year, one of the Commonwealth’s five BH-MCOs had this to say:

“Retention in COEs is directly related to reduction in the cost of behavioral health services over time, due to significant reductions in crisis levels of care, such as psychiatric hospitalizations, residential treatment, and withdrawal management … Conversely, individuals with an OUD who disengage from treatment tend to cycle through crisis services … Because COEs have been effective at retaining individuals longer than non-COE programs, the overall cost of care decreases over time.”

How can one BH-MCO see such value in long-term retention and another move the COEs toward a short-term crisis management focus? How can one BH-MCO use a value-based payment arrangement that incentivizes for long-term retention, while another BH-MCO reverts to a fee-for-service model that undoubtedly will strip away many of the services the COEs have been providing? In that instance, we will have come full circle, and not in a good way.

The road to recovery is often years long. It is fraught with peril. Consider those COEs deemed “exemplary” — indicating the COE has met or exceeded all domain benchmarks (i.e., enrollment, engagement, retention, and assessment). For some of them, nearly 50 percent of their clients have experienced overdose, which indicates the severity of their addiction. Establishing discharge data, as DHS and the BH-MCOs are currently working toward, is akin to telling a patient they’ve been on MOUD long enough. That’s a dangerous message and directive that puts lives at risk.

How can one COE that has operated one way for seven years now suddenly become two very different programs while operating under the COE umbrella? And what about the provider that operates multiple COEs? There are provider organizations in Pennsylvania that operate as many as 15 COEs and contract with at least four BH-MCOs. How can that organization and its individual COEs serve multiple and varying COE overseers? They can’t.

As I listened to RCPA’s recent webinar, “PA Behavioral HealthChoices Integrated Care,” during which Community Behavioral Health, Montgomery County Office of Managed Care Solutions, and Community Care Behavioral Health presented on programs aimed at integrating behavioral and physical health, I couldn’t help but think the COE program is absolutely in the same class as the featured programs that were chosen to exemplify the Commonwealth’s efforts to integrate care.

Why then is DHS, which holds the contracts with the counties/primary contractors, who then subcontract to the MCOs, allowing the COEs to be dismantled?

We can debate the merits and components of the COEs. The same can be done for any program. There absolutely are areas for improvement and continued refinement. DHS has said it would expect the program to evolve over time. We agree — evolve. Not devolve.

Guide rails are one thing. Five varied sets of guidelines for one program is another.

DHS established very specific guide rails in July 2020 when it expanded the program to all Medicaid providers and announced the process for enrolling as a COE. That is and should remain the COE program. Whether through agreements with its primary contractors or another way, DHS must enforce consistency in the COE program from MCO to MCO.

A COE cannot be defined and reimbursed five different ways.