Medicaid’s health homes program: A powerful way for states to address the opioid crisis
Opioid-related deaths are still on the rise, and evidence is mounting of the adverse social, health, and economic impacts of opioid use disorder for individuals, families, and communities. Accordingly, policymakers are seeking ways to promote evidence-based treatments for this national problem. Our new study draws attention to opioid-focused Medicaid health home programs, a promising Medicaid initiative that has been implemented in Maryland, Rhode Island, and Vermont.
These programs are based on the Medicaid Health Home State Plan Option authorized under the Affordable Care Act. This option provides states with eight quarters of 90 percent enhanced federal matching funds for services that both integrate primary and mental or behavioral health care and improve care coordination for patients with chronic conditions. Twenty-one states and the District of Columbia have implemented Medicaid health home programs for various patient groups.
Our study examined the three states that adapted the health home model for individuals with opioid use disorder. These states based the model on providers that deliver the most effective drug therapies for opioid use disorder (opioid agonist therapy involving buprenorphine or methadone). The designated health home providers, opioid treatment programs and office-based opioid treatment programs, specialize in coordinating opioid agonist treatment via methadone or buprenorphine with primary, specialty, and behavioral health care and social services to provide “whole-person” care.
Combined, these health homes enrolled about 10,000 patients with opioid use disorder in 2016. Our study identified facilitators and barriers to the program's implementation from the perspectives of 70 policymakers, practitioners, payers, and advocates across the three states.
We found that implementation was facilitated by state efforts to collect and act on stakeholder input and to provide technical assistance and support to practices. Stakeholders reported that the program’s success depended on opioid treatment program providers’ deep experience providing opioid agonist therapy to patients with severe opioid use disorder as well as staff members’ skills at building strong, trusting relationships with patients.
Six services are required under the health home program, and those services closely aligned with providers’ opioid treatment program objectives. Providers reported that they had already been offering some of these services, their capabilities had been stifled because of inadequate staffing and infrastructure. While each provider and state varies in approach, opioid health home reimbursement allows participating providers to expand and supplement the following services and supports to enhance effective treatment for opioid use disorder, address patients’ health and psychosocial needs, and promote recovery:
- Comprehensive care management, including assessing patient’s needs by screening for social determinants of health, developing care plans, monitoring progress toward patients’ goals, and collecting data to strengthen comprehensive care management.
- Care coordination that provides referrals to and coordination with needed medical care, such as primary and behavioral health care with opioid use disorder treatment.
- Health promotion, such as nutrition education, which is key for recovery for those with substance use disorders, and education about common co-occurring conditions such as diabetes.
- Comprehensive transitional care services, such as follow-up treatment after a hospital stay, detox, or emergency department visit.
- Individual and family services, such as integrating peer supports and training families to buttress an individual’s treatment goals.
- Referral to community and social support services and programs, such as health insurance (e.g., reenrollment in Medicaid), disability benefits, subsidized or supportive housing, legal services, nutrition assistance, and employment services.
Across the study sites, providers offered examples of health home enrollees whose lives and care were dramatically improved because health home reimbursement allowed providers to deliver a higher level of care management and other health home services.
For example, providers reported that several patients got necessary care for their psychiatric comorbidities because trusted Medicaid health home case managers accompanied patients on their first psychiatric visits. This helped the patients keep the appointments and develop trust with the new providers. In other cases, Medicaid health home staff members connected patients with stable housing, enabling patients to reconnect with their children.
The experiences of Maryland, Rhode Island, and Vermont in implementing the Medicaid health home program for those with opioid use disorder can guide development and implementation of similar Medicaid initiatives in other states. For states that haven’t implemented an opioid-focused Medicaid health home program, the enhanced federal match for health home services is still available.
In addition, states can apply for financial assistance to plan an opioid health home program. States could also apply to use Substance Abuse and Mental Health Services Administration’s State Targeted Response to the Opioid Crisis grant funds authorized under the 21st Century Cures Act to help cover start-up costs that are not covered by the enhanced federal match (i.e., staff training, staff meetings, and infrastructure development to support coordination services and data requirements).
All three states in our study have continued to fund the opioid-focused Medicaid health home programs and sustain practice changes after the end of the enhanced federal matching period. But uncertainty about Medicaid financing; the possibility of Congress repealing the Affordable Care Act; and the adequacy of health home reimbursement to hire, train, and retain competent staff (even with the 90 percent enhanced match) were reported as concerns for the future of the programs.
Yet these states are committed to continuing or expanding the programs, which providers said were responsible for substantial improvements in care for challenging and complex patients. Policymakers seeking to address the opioid crisis should consider the opioid-focused Medicaid health home program, which has strong potential to dramatically improve lives, particularly in states that expanded Medicaid under the Affordable Care Act, since those programs can reach low-income adults who are hardest hit by the opioid crisis.
In this March 8, 2017 photo, Ashley Gardner, 34, takes a dose of methadone at Counseling Solutions of Chatsworth, Ga. Gardner, 34-year-old woman said her addiction started in the seventh grade when she wanted to numb the pain after she was sexually assaulted. She was assaulted another time, and saw both fathers of her two of her children die from an opioid overdose. Photo by Kevin D. Liles/AP.