Delaware residents face a troubling trend: Overdose deaths in the state continue to rise, with more than 400 people dying in 2018. The state’s overdose death rate is now tied for fifth-highest in the country, mainly due to opioids, including illicit fentanyl. Unfortunately, evidence-based treatment for opioid use disorder (OUD) is often out of reach for people in need. In fact, fewer than half of residents treated at outpatient facilities in 2016 for OUD received medication-assisted treatment (MAT), the most effective therapy; less than 1 percent of people in inpatient or detox facilities received this therapy during the same time frame.
Despite innovative policy changes and initiatives enacted by state officials, Delaware, like many other states, has yet to turn the corner on this public health crisis. Consequently, last July state leaders—including Governor John Carney, Lieutenant Governor Bethany Hall-Long, Speaker of the House Peter Schwartzkopf, and Senate President Pro Tempore David McBride—invited Pew’s substance use prevention and treatment initiative to partner with the state on finding ways to accelerate expanding access to evidence-based treatment for OUD. The partnership, which had Pew’s team work closely with the lieutenant governor’s Behavioral Health Consortium, led to a set of recommendations designed to catalyze Delaware’s statewide interventions, many of which have since been acted upon by leaders. These reforms will enhance the state’s efforts to build a robust, effective treatment system, and can be broken into specific categories.
Treatment system transformation
Too few clinicians in Delaware provide MAT to patients, in part because of inadequate reimbursements for services such as care coordination, in which providers work together to ensure appropriate patient care. The Pew team recommended the General Assembly direct the Division of Medicaid and Medical Assistance (DMMA) and the Division of Substance Abuse and Mental Health (DSAMH) to fund reimbursement for care coordination for substance use disorder treatment. Accordingly, DMMA will add a care coordination benefit for all Medicaid enrollees with diagnosed OUD into its budget planning process later this fall. Legislators have also since funded a cost-benefit analysis for a Medicaid pilot program to determine the return on investment from paying for this benefit, which may help make the case for its inclusion in the final budget.
DSAMH has also adopted a common assessment tool, based on widely accepted guidelines produced by the American Society of Addiction Medicine, for evaluating what kind of care individuals with substance use disorder require. Providers participating in the state’s Substance Use Treatment and Recovery Transformation, or START Initiative, are required to use this tool. Later this fall, DMMA will require Medicaid managed care organizations and contracted providers to use the tool as well. Having payers and providers use the same tool will help reduce fragmented patient care and result in a lower administrative burden on clinicians.
In addition, DSAMH intends to issue new regulations this month that will allow credentialed providers to administer methadone—one of three Food and Drug Administration (FDA)-approved drugs for OUD treatment—in partnership with opioid treatment programs (OTPs), federally regulated facilities where patients take medications for OUD under the supervision of medical staff and receive counseling and other care services. OTPs are currently the only facilities where patients can receive methadone, but new regulations will also permit “medication units,” where clinicians can administer the drug in other designated settings, including federally qualified health centers and correctional facilities.
Substance use disorder workforce
To increase access to buprenorphine, an FDA-approved treatment for OUD, the Governor signed House Joint Resolution 6. The bipartisan bill directs the Behavioral Health Consortium to increase the number of buprenorphine prescribers via changes to reimbursement, new state-sponsored training and outreach, and other reforms that would help mid-level providers to more easily prescribe the medication. The state’s medical licensing board is also working to ease restrictions associated with prescribing MAT via telemedicine, which can help reach patients in rural areas where providers are not easily accessible.
Coverage and reimbursement
Recommendations from the Pew team also focused on expanding access to substance use disorder treatment for residents with private insurance. Accordingly, in June, the General Assembly passed House Bill 220, which amended the Mental Health Parity Act to require all three forms of MAT in private insurance formularies—lists that outline which medications are covered by an insurer. Pew’s team is also helping the state organize a private insurance task force focused on improving substance use disorder treatment, which will encourage insurers to adopt the treatment assessment tool now used by DSAMH and Medicaid providers and improve care coordination, among other priorities.
Individuals involved in the criminal justice system—including those who are currently or recently incarcerated, or on probation or parole—have high rates of substance use disorder, yet evidence-based treatment is not readily available in correctional facilities. Therefore, Pew’s team recommended the General Assembly appropriate sufficient funding that would allow the Department of Corrections to expand treatment options across all correctional facilities and ensure that any person with OUD could access all three medications used in MAT. Since then, the General Assembly has secured funding to expand MAT delivery, and Senate Resolution 10 has directed the Department of Corrections to develop a strategic plan and budget request to enable correctional facilities to offer the full spectrum of MAT medications by 2021. In addition, Senate Resolution 11 directs the Department of Corrections and Medicaid to work with managed care organizations on a care management protocol that would assist people with significant health needs, including OUD, with re-entering the community. To support this effort, as of January 2020, Medicaid benefits for individuals entering the correctional system will be suspended instead of terminated, so that they can either seamlessly begin or continue OUD care upon release.
What’s next for Delaware
Fully adopting these reforms will help ensure that Delaware’s treatment system can effectively serve residents struggling with OUD, and begin to reverse the troubling trend of overdose deaths.
Beth Connolly directs The Pew Charitable Trusts’ substance use prevention and treatment initiative.