Service Models

Planning for financial sustainability should be addressed from the beginning of the implementation process. As the practice begins to develop an implementation plan, they should identify practice models or other strategies that will help recover costs. For example, the West Virginia University Comprehensive Opioid Addiction Treatment (COAT) model uses group medication management sessions to maximize efficiency. Seeing patients for medication management visits as a group may generate revenue to help offset costs from other services that are not reimbursable.

Another strategy is to minimize lost revenue due to no-shows for scheduled appointments by setting aside walk-in hours for MAT services. Because many patients with opioid use disorder, particularly those new to treatment, have significant instability in their lives, maintaining appointments may be difficult. Allowing walk-ins can help increase patients’ access to treatment while allowing providers to treat and provide billable services to more patients.

Practices need to consider which services are reimbursable under Medicaid and determine which providers under Medicaid offer them. Also, at times it may be necessary or preferable to create staff roles that will provide nonreimbursable services. For example, a patient engagement specialist or care coordinator may take on the responsibility of patient outreach and followup but allow other providers to practice at the top of their license and spend more time billing for their services.

Four examples of sustainable, high-volume service models are described below, each of which has been recommended by the Centers for Medicare & Medicaid Services. Additional information on each model is available at sources cited at the end of this section. These models include:

• Vermont Buprenorphine-Spoke: This model is for the primary care portion of the Vermont Hub and Spoke model that includes two levels of care: regional opioid treatment programs that serve as the "hubs" and community primary care clinics that function as the "spokes." The hubs also provide methadone, typically have extensive experience in opioid use disorder treatment, and function as Medicaid Section 2703 Health Homes. Community clinics provide office-based buprenorphine treatment and some level of counseling and psychosocial services. Learn more about the Medicaid Innovation Accelerator Program’s Medication-Assisted Treatment Clinical Pathway and Rate Design Approach (PDF 65.48 KB), the Vermont clinical pathway (PDF—93.33 KB), and Vermont financial assumptions (Excel—2.68 MB).

• Massachusetts Primary Care Clinic Nurse Care Manager Model: This model, also known as the Massachusetts Collaborative Care Model of Office Based Opioid Treatment With Buprenorphine, uses nurse care managers to conduct followup, outreach, and care coordination. While only the waivered provider may prescribe medications, the nurse care manager can assume many of the other duties, allowing the waivered provider to treat more patients. Both the nurse care manager and the waivered provider spend more time practicing at the top of their license.

  Specific responsibilities of nurse care managers include:

  • Performing the initial assessment,
  • Delivering patient education,
  • Making referrals to behavioral therapy,
  • Monitoring adherence to treatment plans,
  • Completing relevant paperwork, and
  • Communicating with other members of the care team.

  This model can work well in federally qualified health centers that use a Medicaid prospective payment model that allows flexibility for services delivered and in other settings in which nurse visits are reimbursed.² Learn more about the Medicaid Innovation Accelerator Program’s Medication-Assisted Treatment Clinical Pathway and Rate Design Approach (PDF—65.48 KB), the Massachusetts clinical pathway (PDF—73 KB), and Massachusetts financial assumptions (Excel—2.68 MB).

• Baltimore Buprenorphine and Extended Release Naloxone Initiative: This model has some similarities to a hub and spoke model in that it typically involves collaboration between opioid treatment programs and primary care. Specialty substance use disorder treatment centers are responsible for assessment, induction, and stabilization. Patients are then transferred to primary care for the maintenance phase of treatment. Separate bundled payment rates are provided for intake and assessment, induction, and ongoing services such as maintenance and discontinuation of medications. Learn more about the Medicaid Innovation Accelerator Program’s Medication-Assisted Treatment Clinical Pathway and Rate Design Approach [PDF—65.48 KB], the Baltimore clinical pathway (PDF—111.86 KB), and Baltimore financial assumptions (Excel—38.82 KB).
• Opioid Health Homes: Three States—Maryland, Rhode Island, and Vermont—have developed Medicaid health homes that aim to serve individuals with opioid use disorders. The specific models vary by State in terms of health home structure, definition of the provider team, required services, and enrollment criteria. While all three States include a form of bundled payment for services from the health home, the specific payment models vary slightly. Learn more about key features and considerations of approved health home models (PDF—595.3 KB) in these States. Also, the Urban Institute clearly summarizes how to use Medicaid health homes to address the opioid epidemic. A report on the Medicaid Health Home State Plan Option (PDF—400 KB) evaluates health homes in general and includes a discussion of what has been learned from the three States that implemented the model for opioids.

When developing their MAT program, practices should consider how programs will be financially sustainable over time, including the stability of program funding sources. For example, the recent opioid crisis has led to an influx of grant funding to States. While this grant funding can be vital toward an initial investment to start a MAT program, it will not last.

The configuration of a clinical and support team, salaries, overhead costs, and reimbursement rates are all important considerations. In addition, financial sustainability often depends on the scale of the practice, that is, the number of patients the practice can treat. For example, one analysis of a treatment model that included physicians, behavioral clinicians, and case managers concluded that a practice would need at least 60 patients to cover the cost of needed staff. These sorts of analyses are based on program- and State-specific assumptions of personnel salaries and other programmatic expenses, as well as payers’ reimbursement rates for services provided to patients served.

As you develop your program, you might want to develop your own financial sustainability model, similar to those from the Medicaid Innovation Accelerator Program cited above, that reflects salary, cost, and reimbursement data for your practice. You will need to work with your budgeting and financial staff to develop such models, in collaboration with clinical staff, so that models are designed to meet the needs of the patients served.