APA’s Government, Policy, and Advocacy Update (April 2023)

The Substance Abuse and Mental Health Services Administration (SAMHSA) has proposed a rule to make permanent some regulatory flexibilities for opioid treatment programs to provide patients with extended take-home doses of methadone. APA provided comments on the rule, supporting several of its provisions while also offering recommendations.

“Methadone is a particularly effective form of MOUD [medications for opioid use disorder],” APA’s letter stated. “Unfortunately, the regulations governing methadone access have created significant barriers to care for many of those who need and want treatment.” The flexibilities for prescribing methadone that SAMHSA has allowed during the COVID-19 public health emergency “served as a starting point for reimagining methadone access in this time of vital need,” the letter continued.

Specifically, APA expressed support for SAMHSA’s efforts to change regulatory language to reduce stigma toward people who use drugs or have an opioid use disorder (OUD); SAMHSA’s collaboration with the Drug Enforcement Administration to facilitate mobile medication units and increase methadone treatment for underserved populations; and SAMHSA’s proposal to eliminate the requirement that patients must have a one-year history of OUD to qualify for methadone treatment.

Further, APA questioned some provisions, including limiting methadone treatment to people with moderate to severe OUD and excluding those with mild OUD. In the letter, APA also suggested that SAMHSA provide guidance on methods to ensure quality counseling services through, or coordinated with, the opioid treatment program.

In a letter to Chiquita Brooks-LaSure, M.P.P., the administrator of the Centers for Medicare and Medicaid Services (CMS), the AMA, APA, and nearly 120 organizations representing physicians across the country expressed their strong support for proposed rules that would reform the prior authorization process for Medicare Advantage plans and Medicare Part D.

In particular, the organizations expressed support for provisions that improve the coverage criteria for medical necessity determinations and protect access to care. Other provisions that the organizations support would protect patients from care interruptions, treatment delays, and unanticipated medical costs.

“Recent [AMA] survey data show that 93 percent of physicians report care delays or disruptions associated with [prior authorization],” the letter stated. “AMA data also show that 34 percent of physicians report that [prior authorization] has led to a serious adverse event (e.g., hospitalization, permanent impairment, or even death) for a patient in their care. … Moreover, the Office of Inspector General 2022 report found that 13 percent of [prior authorization] requests denied by Medicare Advantage plans met Medicare coverage rules.”

CMS recently released a request for information on essential health benefits (EHB) established under the Affordable Care Act. In its response, APA highlighted barriers that patients face to accessing mental and substance use disorder (SUD) services, the importance of telehealth in improving access to these EHB services, and the potential for the Collaborative Care Model to address gaps in coverage.

APA noted administrative barriers such as prior authorization, workforce issues, and lack of parity. “Patients often experience a delay in accessing care due to the persistent shortage of psychiatrists and coverage across the country,” APA’s letter, addressed to Brooks-LaSure, stated. “As demand for their services increase, psychiatrists continue to meet capacity limitations.”

Further, APA signed a coalition letter urging CMS to consider children’s needs when addressing EHBs. The letter emphasized that children require services and care specifically suited to their unique developmental needs.

“Amid the children’s mental health emergency, there is a strong need to reduce the current gaps in coverage related to pediatric mental health services,” the coalition’s letter stated. “EHB requirements can play an important role in addressing these coverage gaps by incorporating coverage of pediatric mental health services in the ‘pediatric services’ category.” ■