August 15, 2019
A key Illinois Medicaid panel has recommended that the State move away from costly and often ineffective hospital detoxification services to treat opioid addiction.
The Medicaid Advisory Committee on August 2 urged the State’s Medicaid agency to revise its reimbursement practices to discourage traditional hospital detox stays and provide financial incentives for evidence-based care such as medication-assisted treatment. The panel also recommended that the Illinois Department of Healthcare and Family Services (HFS) require that discharged patients be connected with appropriate community services.
Hospital-based detox—more formally known as opioid use disorder withdrawal management—involves weening a patient off of all opioids. Medications such as methadone are administered in tapering doses to minimize drug cravings and withdrawal symptoms. Hospital-based detox permits individuals to stay in a facility for several days and receive professional care. But research has shown that detox does little to change long-term drug use and is often associated with repeat hospital admissions. Detox for opioid addiction can also be dangerous because of increased risk of overdose due to lower tolerance to the drug, if the patient relapses.
Medication-assisted treatment is a widely accepted form of care for opioid use disorder in which patients under outpatient medical supervision take medications such as buprenorphine over a long period of time. Patients can begin to take these drugs when they go to the hospital. The medications reduce withdrawal symptoms and cravings without producing the euphoria caused by the abused drug. Illinois lowered many barriers to medication-assisted treatment in the Heroin Crisis Act of 2015, which eliminated the one-year lifetime limit for buprenorphine and related drugs.
Illinois hospitals received $36.2 million in Medicaid reimbursements for detox services in the fiscal year ended June 30, 2018, according to HFS. That year 9,730 patients spent 46,581 days in the hospital for detox care, or an average of 4.8 days each at a cost of $778 per day. Among the 186 hospitals reimbursed for detox services, the top 15 accounted for 58% of the 13,867 admissions. (These figures are based on detox services for all substance use disorders, including alcohol addiction; agency officials said available data do not break out care for opioid use.)
The cost and effectiveness of detox services have been longstanding concerns of Illinois Medicaid officials. An HFS study found that approximately 2,400 individuals cycled in and out of ten Cook County hospitals in 2010 for detox care, averaging more than seven admissions each. Among those patients, 200 had an average of 48 admissions each. With each hospital stay lasting almost three days, the average cost per admission was about $2,000.
As part of a sweeping 2012 cost-containment measure called the Smart Act, Illinois restricted inpatient detox stays paid by Medicaid to one every 60 days or a maximum of six per year. The Smart Act led to an immediate and significant drop in detox stays at the ten most affected hospitals, although some of the hospitals reported that individuals who previously used detox services were intentionally getting arrested for petty crimes so they could get food and shelter at Cook County Jail. Despite the legislative changes, HFS’ annual reports for FY2014 and FY2015 noted that detox services continued to be the most prominent clinical service for readmissions.
The recent recommendations from the Medicaid Advisory Committee came at the request of HFS, which asked for advice on how to improve outcomes for individuals with opioid use disorder and reduce unnecessary use of crisis services. The panel formed a subcommittee that began meeting in May and presented its recommendations at the August 2 meeting of the full Medicaid Advisory Committee. HFS requested the quick timetable so it could submit any related rule changes to federal regulators at the end of August, along with its proposal for an Integrated Health Homes program. That program would provide care coordination services for Medicaid beneficiaries with complex health needs, including substance use disorders.
HFS officials said they would review the detox recommendations and report back to the Medicaid Advisory Committee at its next meeting, in November. The panel recommended the use of financial incentives to encourage hospitals to provide evidence-based care, such as medication-assisted treatment, but it did not explicitly endorse medication-assisted treatment or specify a particular payment model.
Heartland Alliance, an anti-poverty organization that offers medication-assisted treatment, had proposed that the Medicaid panel take a stronger stance against detox. Heartland suggested a medication-first policy that over time would have allowed detox in only certain circumstances. However, at the August meeting a representative of the Illinois State Medical Society said the doctors’ organization was pleased by the outcome of the committee’s work.