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Two of the most significant public health crises of our lifetime – the Covid pandemic and the opioid overdose death epidemic – have hit the addiction treatment system and the patients it serves especially hard. Add to a chronically underfunded system struggling with an alarming workforce shortage the Pennsylvania Department of Drug and Alcohol Programs’ (DDAP) ill-timed transition to the American Society of Addiction Medicine (ASAM) Criteria that includes unfunded mandate add-ons, and the very integrity of the system is at risk. Fortunately, the federal government has stepped in with resources to combat the epidemic and the pandemic. In fact, by this fall, DDAP will have received just this year more than $100 million in special grant money, including $55 million in Covid supplemental funds and $48 million in American Rescue Plan (ARP) dollars. Now, perhaps more than ever, addiction treatment providers desperately need this money. Unfortunately, none of it has made its way to providers yet.

Despite urgent pleas for help – by way of either rate increases, regulatory relief, or other one-time funding infusions to address multiple short-term crises within the system – the Wolf administration has not operated with urgency. Consider that in early June, the Substance Abuse and Mental Health Services Administration (SAMHSA) approved DDAP’s plan to spend the $55 million in Covid supplemental money. Nearly two months later, the most-needed chunks of those dollars — $10 million in provider stabilization payments and $15 million in workforce development funding – have not made their way to providers. The $10 million in provider stabilization funds is expected to be available to providers in October, more than four months after their approval. There is no estimate on when the $15 million in workforce development dollars will be available.

Providers recognize that this $25 million across a system comprised of approximately 800 licensed facilities is no panacea. But what message is being sent when providers continually stress to DDAP the real possibility of program closures because of burdensome mandates, no counselors, and insufficient reimbursement rates while money sits unused? There is a disconnect between the front lines and the regulators.

Then there is the $48 million in ARP money. It is supposed to be available to DDAP by the fall, at which point it’s entirely possible that the department will be sitting on more than $100 million (not to mention the $5 million annually for the next five years from the McKinsey opioid settlement) with none or very little having reached the providers.

Although the governor had sought to extend his latest opioid disaster declaration beyond August 26, now that his ability to do so unilaterally has been limited to 21 days, the legislature said “no.” While on the surface this would seem problematic for the D&A treatment community, this may not be the case. When RCPA informally polled its provider members on what the end of the opioid disaster declaration would mean, none who responded could identify any practical or operational benefit of the declaration. Those things they did mention – broader access to naloxone, for example – are not tied to the declaration.  Thus, while well intended, from a day-to-day standpoint for D&A treatment and access to services, there are many other ways that the administration and the legislature could greatly assist without necessitating a further extended emergency declaration.

The provider system needs meaningful help, including a more transparent, effective reimbursement rate-setting process and relief from burdensome mandates that create barriers to effective treatment. We have demonstrated repeatedly that the very thing DDAP purports to seek through its mandates – improved quality – will actually be negatively affected, because providers cannot find staff to meet these new mandates or afford to pay them, in part, as a result of a vastly changed pandemic job market. Ultimately, access to treatment will be limited, and Pennsylvania’s most vulnerable citizens will continue to be the collateral. The fact that funding meant to ease these real burdens has not reached the providers yet is salt in the wound. RCPA will continue its work educating the legislature on the tenuous situation in an effort to get the help that we need.

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In early 2017, the Pennsylvania Department of Drug and Alcohol Programs (DDAP) announced the beginning of a major transition to the ASAM Criteria, a comprehensive set of guidelines governing the level of care most appropriate for patients and the services provided at those levels. Improved quality of care through outcome-oriented and results-based treatment was among the many changes this transition promised.

DDAP cited several reasons for the change, from ensuring the necessary federal Medicaid funding through an 1115 waiver to support the continuation of residential services, to the consistency that the most widely used system would bring to the Pennsylvania provider and payer world.

Today, the commonwealth’s addiction treatment system is little more than four months away from DDAP’s July 1 deadline for implementation, yet providers still have questions about the specifics of many of the changes taking place. Some of these changes go beyond ASAM Criteria, creating additional questions and confusion.

And as providers analyze the cost implications of the change, driven by increases in required treatment services, decreases in counselor-to-patient ratios, and requirements for more highly trained counselors, therapists, and doctors, it is becoming clear to them how significant those costs will be. With no plan from the commonwealth to increase reimbursement rates to cover these mandates and a funding environment in which reimbursement is already often inadequate in comparison to costs, providers are frustrated. Some have lamented the possible closure of facilities because of the exorbitant cost increases. Yet perhaps most troubling, at a time when the Covid pandemic is helping to drive overdose deaths to a level not seen since the peak of the opioid overdose death epidemic in 2017, these costs could limit patient access to care.

Despite these issues, RCPA drug and alcohol treatment provider members support efforts to increase quality in Pennsylvania’s addiction treatment system. They recognize the strength of the ASAM Criteria. But to put their full support behind ASAM, they need reimbursement increases to cover the costs and favorable resolution of the mandates that go beyond the ASAM Criteria in a way that seriously considers provider input.

RCPA enjoys and appreciates strong working relationships with DDAP, the Department of Human Services and its Office of Mental Health and Substance Abuse Services, county drug and alcohol administrators, and the commonwealth’s Medicaid managed care organizations. In the spirit of avoiding any unintended consequences and ensuring a quality system is available to continue to treat all Pennsylvanians in need of addiction treatment services at all levels of care, RCPA will continue to collaborate with these groups to highlight the issues and identify and work toward solutions, all the while bringing to bear its resources to effect these changes on behalf of its members.

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The Intensive Behavioral Health Services (IBHS) regulations went into effect on January 17, 2021 after a one-year implementation period. Recently, the regulations have gone through some adaptations to address the clinical needs of children and families. One such change was the release of a bulletin outlining the approval to deliver 1:1 services for both ABA and Individual IBHS Services in a community or site-based setting, as well as the compatible billing codes.

These bulletins are both retroactive to January 17, 2021; the full bulletins can be found below.

As part of the ongoing IBHS implementation, the Office of Mental Health and Substance Abuse Services (OMHSAS) also released an updated IBHS Frequently Asked Questions (FAQ) Guide. This guide represents a composite of updated inquiries regarding the standards and will be updated as a companion piece to the implementation.

RCPA continues its efforts to support our members in the IBHS implementation through its IBHS Work Group, including work to create an equal billing platform for the delivery of individual services like its ABA counterpart. For more information on IBHS, please contact RCPA Children’s Policy Director Jim Sharp.