From AIS Health: Remote Substance Use Treatment Faces Quarantine Test

Reprinted with AIS Health permission from the June 1, 2020, issue of Health Plan Weekly 

To recover from addiction, people with substance use disorders (SUDs) need support from providers and their peers. As quarantine has become a way of life, and gatherings have been banned in most states for the foreseeable future, both are hard to come by. One possible solution is telehealth, but experts say that remote, tech-aided treatment for addiction is still largely unproven — and most payers and providers don’t have experience with it.

“Because of the unexpected nature and unprecedented nature of the situation, there are very limited data on evidence-based approaches on how to treat patients under these circumstances,” said Carlos Blanco, M.D., during a May 18 webinar about continuity of care for SUD patients, organized by the National Institute for Health Care Management (NIHCM), a health care think tank. Blanco is the director of the Division of Epidemiology, Services, and Prevention Research at the National Institute on Drug Abuse, a branch of the National Institutes of Health.

“Related to that, [there is] a lack of epidemiological and outcome data,” on the present status of people with SUDs, Blanco added. “So although we suspect that there have been increases in substance use and substance use disorders [during the COVID-19 pandemic], we don’t have the data to know this for sure. Also, there’s a lack of outcome data regarding the treatment modifications that have been made.”

SUD Treatment Goes Remote

The federal government has made moves to facilitate SUD treatment via telehealth while patients are self-isolating. They include changes in reimbursement rules for virtual or telephonic behavioral health visits, Centers for Disease Control and Prevention guidance designed to facilitate virtual support meetings, and new regulations that allow providers to prescribe initial buprenorphine therapy for opioid patients remotely. (Starting a new patient on methadone still requires an in-person visit.)

However, as Blanco explained, the lack of data means there is a fly-by-night quality to SUD treatment during the pandemic. Providers and payers are being forced to provide treatment that may not work, and patients may not know they can use the new modalities.

Blues Plan Sees Lower Use of Treatment

Arkansas Blue Cross and Blue Shield has seen reduced utilization of SUD treatment during the pandemic, despite the payer taking measures to improve access, including waiving cost sharing for in-network SUD treatment.

“For inpatient and partial and residential [SUD treatment], we’ve had about a 12% decrease during the COVID-19 pandemic of people being admitted to behavioral health facilities and substance use disorder facilities,” said Arkansas Blue Cross and Blue Shield Corporate Medical Director Herbert Price, M.D., during the NIHCM webinar. Price said the plan has tried to facilitate remote and outpatient SUD treatment for members who would worry about entering an inpatient facility during the pandemic.

“We’ve expanded outpatient substance use disorder treatment [and] we opened up some telephone codes that we’d never covered before as a plan,” Price added. “We opened up telemedicine to substance use treatment order providers…the telemedicine codes that were opened up have always been in existence, but we removed a lot of the requirements.”

A slide deck accompanying Price’s presentation indicated that Arkansas Blue Cross Blue Shield’s telemedicine behavioral health visits, which includes but is not exclusive to SUD treatment, increased from practically no visits in February to nearly 14,000 in April.

“There’s an increase, as we went to telemedicine, in [telemedicine] services provided to opioid and stimulant use disorder [patients] that was not there when it was primarily office-based visits. So this has increased [telemedicine] access to this population during the COVID-19 crisis,” Price said.

Still, commercial plans are only part of the picture. Jerry Vitti, CEO of Healthcare Financial, Inc., is worried that the Medicaid population does not have access to high-quality telehealth SUD care. According to a 2015 report by the federal Medicaid and CHIP Payment and Access Commission, Medicaid plans are the largest provider of behavioral health and SUD treatment nationally. Vitti says telehealth SUD treatment is far behind telehealth treatment in primary care.

“The need is crying out for telemedicine. It’s not anywhere near where it is in primary care. It’s not as available, period, and the rate of adoption is slower, while you have this kind of exploding need. There’s a technology and a treatment gap that’s growing,” Vitti tells AIS Health.

“The quality of [SUD] care is largely dependent on continuously following up with folks,” Vitti says. “For folks with barriers, that’s especially hard. You have to figure out how to connect with them. In normal times, it’s hard to figure out how to connect with folks who have these dependencies. In these times, where there’s less face-to-face, there’s more need in the community [for follow-up care]. And unfortunately, the gap is growing between the need and the provision of telemedicine.”

Basic continuity of care is something that providers and payers can start doing immediately, according to Abner Mason, CEO of ConsejoSano, a health care tech startup that provides culturally competent and multilingual patient communications. ConsejoSano identifies and contacts patients via phone and text on behalf of contracting providers and payers.

“We’ve been able to generate, over the last eight weeks or so, 35,000-plus telemedicine visits for safety net providers,” Mason tells AIS Health, including a large number of behavioral health visits.

As Vitti observed, follow-up care is an obvious use case for remote SUD treatment, and so far it is the most studied area of remote SUD treatment. However, leading researchers in the field agree with Blanco’s assertion that moving remote treatment from a supplementary role to a central one is an unprecedented test.

“[Telehealth SUD treatment has] been conceived as aftercare [and] supportive treatment,” says Andrew Quanbeck, Ph.D., an assistant professor at the University of Wisconsin-Madison. Quanbeck is a systems engineer who studies technological implementation for health care providers and is the co-author of several peer-reviewed papers on SUD care via mobile apps. “For the most part, it hasn’t been envisioned or designed to be a replacement for what’s usually the more in-person, intensive kind of treatment regimen that most addiction treatment starts out with,” he says.

Quanbeck tells AIS Health that he’s confident telehealth can play a leading role in follow-up care, but he’s uncertain about how effective the modality will be as the star.

“It is accurate that what we’re doing is a massive natural experiment on a large scale to take parts of what’s traditionally been the in-person elements of treatment and move it to telehealth. So as a researcher, my standards for evidence are pretty high, and we are in pretty uncharted territory in terms of knowing whether you can, this quickly, switch from in-person modality to telehealth and expect it to have the same effectiveness,” Quanbeck explains.

According to Kevin Hallgren, Ph.D., a clinical psychologist and a researcher at the University of Washington’s Behavioral Research in Technology and Engineering (BRiTE) Center, practitioners face an array of challenges in adapting SUD treatment to a telehealth modality. Hallgren has researched the integration of mobile technology with behavioral health treatment, including SUD treatment.

Hallgren says the wide variety of SUD treatment settings present unique challenges in the move to remote treatment, as do the nuances of treating a patient with a specific dependency: opioids require a different approach than alcohol, for example.

“There are many types of substance use treatment settings. There are many types of SUD treatment patients — finding the right match for the right person at the right time in the right setting is a very complicated thing,” Hallgren tells AIS Health.

“There is, not that I know of, a one-size-fits all recommendation that I can offer. I don’t think there’s a specific app — or even class of apps — that I could say, ‘this is the way to go.’”

Thus, Hallgren worries that the health care industry could make a mistake by moving too quickly toward unproven telehealth services during the pandemic. “All of a sudden [telehealth SUD treatment has] been required. We have to do it. And so people are trying their very best to make it work, and they’re having some success and some challenges,” Hallgren says. “We may go back to more in-person, face-to-face treatment, but we know that certain things are now very viable to do remotely…When social distancing is over, we’re going to have another time to figure out what we’re keeping.” And while health plans will check that providers took the necessary steps to bill for remote SUD services, that “is different than saying what works clinically,” he adds.

But Quanbeck says making a  switch to telehealth SUD treatment is necessary during the current crisis. “The pandemic is obviously forcing things out of necessity,” Quanbeck says. “I think that you can make a reasonable case that telehealth is likely better than doing nothing and leaving people completely on their own for months at a time. So I think it’s definitely the right thing to do.”

Find the NIHCM webinar at https://bit.ly/2yKevn6. Read federal guidance for SUD telehealth visits at https://bit.ly/2Ma5gzH and buprenorphine and methadone provision at https://bit.ly/2ZKWeBd​​​​​​​. Contact Mason and Vitti via Joe Reblando at joe@joereblando.com, Hallgren at khallgre@uw.edu and Quanbeck at arquanbe@wisc.edu. ✧

by Peter Johnson