H.R. 6: SUPPORT for Patients and Communities Act: The Substance Use‐Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act

Section 2005. Medicare coverage of certain services furnished by opioid treatment programs. This provision expands Medicare coverage to include Opioid Treatment Programs (OTPs) for the purposes of delivering Medication‐Assisted Treatment (MAT) to expand access to treatment options for Medicare beneficiaries. Currently, OTPs are not recognized as Medicare providers, meaning that beneficiaries receiving MAT at OTPs for their opioid use disorders must pay out‐of‐pocket. In 13 states, the highest rate of opioid‐related inpatient stays is among the over 65 population. Under the provision Medicare will pay the outpatient OTPs through bundled payments made for wholistic services, including necessary medications, counseling, and testing.     

Medicare and Amyloid PET Imaging: The Battle Over Evidence

We examine a recent dispute regarding the Centers for Medicare and Medicaid Services’ (CMS) refusal to unconditionally pay for amyloid positron emission tomography (PET) imaging for Medicare beneficiaries being assessed for Alzheimer’s disease. CMS will only pay for amyloid PET imaging when patients are enrolled in clinical trials that meet certain criteria. The dispute reflects CMS’s willingness in certain circumstances to require effectiveness evidence that differs from the Food and Drug Administration’s standard for pre-market approval of a medical intervention and reveals how stakeholders with differing perspectives about evidentiary standards have played a role in attempting to shape the Medicare program’s coverage policies.     

Medicare and the affordable care act

The recently enacted Patient Protection and Affordable Care Act made modest changes to improve Medicare and obtained a substantial share of funding for the Act's broader reforms from future spending reductions in the program. Drug benefits and preventive services were improved. While painful, the spending reductions will have only moderate impacts on beneficiaries and should help achieve the goals of health care reform: encouraging better primary and preventive care, making providers conscious of finding ways to increase the productivity of care delivered and changing the relative levels of payment across certain providers. Additional costs to beneficiaries will arise from changes in private plan payments and increasing income-related premiums.     

Briefly Noted

Last week, Safehouse, a Philadelphia nonprofit that will open a supervised injection site in the city (see ADAW, Oct. 15, 2018), has hired an executive director, Jeanette Bowles, Ph.D. According to radio station WHYY, Bowles will help with fundraising and finding a site. “I believe in it so much,” Bowles said. “We see this working in other places, and the evidence supports it so strongly, that we don't have progress in public health without some controversy and scrutiny accompanying it.” Whether the Department of Justice will allow the site to operate remains unclear. “I've joined the team that respectfully disagrees with the Justice Department,” Bowles said. “Sitting in the office and doing the work separate from the community has never been my approach or style,” she said. “Being embedded with the community and developing those relationships and having my feet on the ground has always been most important to me. That's how the best public health work is done, through building bridges with community members.” Bowles earned a bachelor's degree from Temple University; obtained his master's in social work from the University of Pennsylvania; did postdoctoral work at the University of California, San Diego; and for her Drexel dissertation focused on opioid overdoses in the Kensington section of Philadelphia. The city, in giving the go‐ahead for the injection facility, said it would have to be run by a private nongovernmental entity.     

Briefly Noted

We asked Jerry Rhodes, former top executive at CRC (now Acadia) and a leader in opioid treatment program management, what he thinks of methadone as a medication to be used in primary care to treat opioid use disorder (OUD), as some people — including former Office of National Drug Control Policy Director Michael Botticelli — recommended last year (see ADAW, July 16, 2018). “I take issue with that,” said Rhodes. “Methadone is a dangerous drug in an unregulated environment,” he told ADAW. Buprenorphine is prescribed this way, but “buprenorphine is a relatively safe drug, and methadone isn't,” he said. A veteran of many battles over methadone, including the near‐elimination of opioid treatment programs, Rhodes told ADAW that “you don't give unfettered access to methadone” to patients with OUD. “Be careful what you wish for” is his advice. This has the potential to cause harm, he said. “Only people who don't understand the history of its utilization would recommend this.”     

Caron in‐network with Aetna

Caron Treatment Centers is an in‐network provider for Aetna, effective Oct. 1, the Pennsylvania‐based program announced last week. “The COVID‐19 pandemic is taking a toll on the mental health of Americans,” said Doug Tieman, CEO and President of Caron Treatment Centers. “Unfortunately, isolation and anxiety make addiction worse, and we are already seeing a spike in substance use and substance use disorders. It's imperative that families have access to affordable, high‐quality, life‐saving treatment programs and support services.” The expansion of in‐network insurance relationships is among several recent moves by Caron to make treatment more accessible. Caron is also an in‐network provider with Highmark and the Blue Card program, which covers persons entitled to benefits as a member of any other Blue Cross and/or Blue Shield plan licensed by the Blue Cross Blue Shield Association, Independence Blue Cross, AmeriHealth Administrators, Independence Administrators, UPMC, Blue Cross Blue Shield, Employer Groups of Penn Medicine and Tower Health. “Accessing quality substance use disorder treatment has always been difficult for many families,” continued Tieman. “With more than 20 percent of the treatment sector reducing or closing services and programs as a result of the pandemic, it's even more difficult. This in‐network agreement with Aetna allows their members to access Caron at a time when they are needed the most.”     

The Willingness to State an Opinion: Inequality,Don't Know Responses,and Political Participation

Most explanations of inequality in political participation focus on costs or other barriers for those with fewer economic, educational, and “cognitive” resources. I argue, drawing on Pierre Bourdieu's work on “political competence,” that social position in the form of income also structures political participation through differences in the sense that one is a legitimate producer of political opinions. I test whether income differences in participation persist net of costs by examining nonparticipation in a setting in which barriers to participation are low: answering political survey questions. Lower‐income people are more likely than others to withhold political opinions by saying “don't know” net of differences in education, “cognitive ability,” or engagement with the survey exercise. Further, political “don't know” rates predict voting rates, net of other predictors. Efforts to democratize participation in American politics must attend not only to the costs of involvement but also to class‐based differences in individuals' relationship to political expression itself.     

Briefly Noted

A project that began a year ago (see ADAW, Jan. 15, 2018), Shatterproof's rating system of addiction treatment programs took another step last month when the nonprofit announced it would start out with a pilot, now that it has $5 million. Saying the current addiction treatment system is broken, Shatterproof founder and CEO Gary Mendell said the project was made possible by funding from two foundations (the Laura and John Arnold Foundation and the Robert Wood Johnson Foundation) and a coalition of five insurance companies. “People who need help for addiction don't know what to look for or where to turn,” said Sam Arsenault, director of national treatment quality initiatives at Shatterproof, in the Dec. 18 announcement of the project. “We are taking rating system best practices from health care and other business sectors and applying them to addiction treatment. This will not only provide critical information to individuals looking for care but also drive a long overdue transformation of the addiction treatment industry.” The Shatterproof Rating System will utilize data from three sources: insurance claims, provider surveys and consumer experience, with collaboration from the National Quality Forum (NQF), a membership organization composed of payers. Initially, the program will begin with a pilot, with analysis done by RTI International. “Consumers can find information and accurate data on the quality of nursing homes, hospitals, physicians and most other types of providers,” said Tami Mark, director of behavioral health financing and quality measurement at RTI International. “It's time that patients have reliable information on addiction treatment.”     

A federal survey deficiency citation is needed for resident-to-resident aggression in U.S. nursing homes

Resident-to-resident aggression (RRA) in nursing homes is a prevalent and concerning public health problem. A rapid growth in the number of research studies has led to advancements in understanding and awareness of these incidents. However, no state survey deficiency citation (F-Tag) currently exists to capture RRA in a structured way in the Centers for Medicare & Medicaid Services’ (CMS) nursing homes F-Tags Coding System. This omission represents a major barrier to State Survey Agencies, CMS, consumers, and care advocacy organizations’ efforts to keep vulnerable and frail residents safe and free from psychological harm. The commentary makes the case for development and implementation of a new RRA-specific F-Tag by identifying 20 problem areas and the ways in which this F-Tag could address them. The new F-Tags Coding System (part of the new Federal Nursing Home regulations) represents a rare and time-sensitive opportunity to bridge this major gap in practice, research, and policy.     

Least Restrictive or Least Understood? Waist Restraints,Provider Practices,and Risk of Harm

Since implementation of The Omnibus Budget Reconciliation Act of 1987, restraint use in American nursing homes has reduced dramatically. The reduction in vest restraints has resulted in an increase in “least restrictive” devices such as waist restraints. Although this analysis of U.S. Food and Drug Administration Adverse Event Reporting Data Files found that waist devices pose the same potential risk for asphyxial death as vest restraints, few health professionals and consumers are aware of this outcome. Post-marketing device reporting needs better data quality and surveillance, which can certainly benefit the Centers for Medicare and Medicaid Services in their efforts to regulate and enforce standards of care that reduce deaths and injuries to vulnerable nursing home residents.     

An Examination of the Woodwork Effect Using National Medicaid Long-Term Services and Supports Data

A common concern in long-term services and supports (LTSS) policy is the “woodwork effect,” which has two components: (1) more people will use publicly funded services if access to home- and community-based services (HCBS) is expanded; and (2) the additional beneficiaries will increase the growth rate of LTSS expenditures. Medicaid LTSS beneficiary and utilization data starting in 1999 indicate modest growth in beneficiaries and expenditures, after adjusting for inflation and the number of people with functional impairments. The data do not provide strong evidence that the shift in Medicaid funding toward HCBS significantly increased or decreased overall Medicaid LTSS spending.     

Clinical and Ethical Considerations for Delivering Couple and Family Therapy via Telehealth

Studies have generally supported telehealth as a feasible, effective, and safe alternative to in‐office visits. Telehealth may also be of particular benefit to couples/families interested in relational treatments, as it addresses some of the barriers that may be more prominent for families, such as childcare and scheduling difficulties. Therapists interested in expanding their practice to include telehealth should understand ethical and practical considerations of this modality. This article discusses areas unique to the delivery of telehealth to couples and families. Each broad domain is then elaborated upon with case examples from actual clinical practice and specific recommendations for addressing potential difficulties. Authors recommend further empirical research examining differences in modality outcome, as well as feasibility of the suggestions proposed here.     

New OBOT program to open in Tennessee in response to COVID‐19

Spero Health is opening a new OBOT (office‐based outpatient treatment) center for patients with opioid use disorder (OUD) in Savannah, Tennessee, in response to the high demand for treatment in the COVID‐19 pandemic. This clinic will utilize telehealth and in‐person visit options. Spero Health has more than 35 clinics thro‐ughout Kentucky, Ohio, Indiana and Tennessee, treating more than 7,000 patients a month. Spero Health accepts TennCare, the state's Medicaid plan, and most commercial insurance plans.     

Examining the Nursing Home Physical Environment Through Policy-Driven Culture Change

A critical need exists to challenge approaches to nursing home care due to rigid organizational factors and hospital-like culture. It has been argued that resident care needs to move toward a person-centered approach by addressing the organizational, social, and physical environments in nursing home facilities, a process often known as culture change. In response to this need, the Centers for Medicare & Medicaid Services (CMS) has created funding for pay for performance (P4P) nursing home incentive programs to allow nursing home providers to receive CMS reimbursements for culture change in the facilities. Through care staff interviews, site observations, and a document review, this qualitative study assesses the impact of a Midwestern state P4P incentive program in three participating nursing homes. Using an environment and behavior (E-B) policy orientation framework, this study examines culture change through a focus on policy, the physical environment, place attachment, and social and psychological processes in the study settings.     

CDC begins to backtrack on its pain guideline,saying it was ‘misapplied’

Last month, the federal Centers for Disease Control and Prevention (CDC) took what many view as a first step toward retracting its now‐infamous “Guideline for Prescribing Opioids for Chronic Pain” issued in 2016.     

Telephone therapy: call for help.

1. Many disabled people are unable to take advantage of community resources because they cannot leave their homes, but the telephone can provide a link to psychotherapeutic services. 2. In both telephone and office therapy, the therapist orients members to the group, suggests an arena in which goals might be established, encourages verbalizations, sharing of concerns, strategies for solving problems, and assesses the psychodynamics of the therapeutic situation. 3. Psychotherapy via telephone can provide significant benefits to people who formerly were barred from services. Telephone therapy requires the therapist's commitment to the challenge of mastering a new technique and to altering fee structures to allow those on fixed incomes to be served.     

The Design of Mainstream Housing for Downsizers

ABSTRACT

In the United Kingdom, the supply of new homes to the housing market tends to be focused either on “general-needs” housing on the one hand, or on special-needs housing for the elderly on the other, with relatively few people moving into homes that will support their independence as they age. Against the backdrop of the UK's chronic housing shortage and the UK government's recent Housing Standards Review, this case study of a mainstream housing development—which meets so-called “Lifetime Homes” in “Lifetime Neighborhoods” standards—identifies specific design and locational features that have attracted “downsizers” to buy into it, as well as those they subsequently found problematic.