The Centers for Medicare & Medicaid Services (CMS) announced on May 29 a new, voluntary Alternative Payment Model (APM) called the Value in Opioid Use Disorder Treatment Demonstration. This demonstration is designed to increase access to OUD treatment and services, improve physical and mental health outcomes for Medicare beneficiaries with OUD, and decrease Medicare expenditure where possible.
In 2017, over 47,000 Americans died from opioid-related drug overdoses, with Medicare paying for roughly one-third of all opioid use disorder-related (OUD) hospital stays.
The Value in Opioid Use Disorder Treatment Demonstration includes two key payment components. The care management fee provides a per beneficiary per month (PBPM) payment of $125, paid quarterly, to provide services for OUD treatment, in addition to the existing Medicare coverage for OUD, which includes access to medication assisted treatment (MAT), behavioral therapy, and care management. The new care management fee can be used to supplement existing coverage by addressing social determinants of health, such as child care, transportation, housing, and job training. This PBPM is a flat rate and will not be risk adjusted.
To tie the PBPM to quality, CMS will apply a performance-based incentive in the form of a 5% quality withhold in Performance Year 1 and a 10% withhold in all subsequent years. CMS has not yet determined the quality measures but indicated that they may be related to MAT; emergency department use and follow-up visits for OUD; and initiation, engagement, and retention in treatment.
The demonstration is open to physician groups, hospital outpatient departments, and a wide range of community providers. However, participants in the Comprehensive Primary Care+ Model, Primary Care First, and the Maryland Primary Care Program will not be eligible to join this demonstration. Due to the limits on the number of participants, CMS will prioritize applicants in counties and states with high prevalence of OUD. The demonstration will include Medicare beneficiaries who have Parts A and B coverage as well as an OUD diagnosis. CMS has $10 million in annual funding, which the agency estimates will support the enrollment of approximately 5,487 beneficiaries on an annual basis. The demonstration will qualify as a Merit-based Incentive Program APM.
This demonstration is scheduled to begin Jan. 1, 2021, and will run for four years through Dec. 31, 2024. Applications are due Sept. 30, 2020.