California’s Innovative Approaches to Tackling the Opioid Crisis within the Safety Net
by Robby Franceschini
June 5, 2019 — Like many other states, California is still suffering the brunt of the opioid crisis as overdose death tolls continue to climb. While the state’s deaths from prescription opioid overdoses have declined each year since 2014, heroin and synthetic opioids have pushed the overall total number of deaths up to from 2,031 in 2016 to 2,199 in 2017. To address this on-going crisis, California is expanding access to buprenorphine, one of the most effective therapies for opioid addiction.
Pain management providers have identified buprenorphine, which is often offered in combination with other drugs like naloxone, as key to medication-assisted treatment (MAT) to reduce and suppress cravings for opiates.
Despite federal legal restrictions that prevent providers from prescribing buprenorphine without a license—and over virtual connections without a federal waiver or prior in-person visit—more individuals are gaining access to the drug. In 2018, providers dispensed over 5.5 prescriptions for buprenorphine and combination drugs in California, according to CURES data.
Within the state’s safety net, Californians are able to access buprenorphine through several programs, some of which include telehealth services within their offerings.
California’s Programs and Initiatives
Drug Medi-Cal Organized Delivery System Pilots (DMC-ODS)
Historically, Medi-Cal beneficiaries have had access SUD treatment through Drug Medi-Cal, a fee-for-service program the state auditor found to have program integrity and quality assurance issues. In 2015, CMS granted California a section 1115 waiver to deliver SUD services to Medi-Cal beneficiaries through the Drug Medi-Cal Organized Delivery System (DMC-ODS). In DMC-ODS, counties voluntarily elect to serve as managed care plans for beneficiaries in their jurisdiction. Benefits go beyond those of the traditional DMC program to include case management and buprenorphine treatment programs. To date, the vast majority of counties have opted into DMC-ODS, with limited exceptions in the state’s rural north and parts of the Central Valley.
DMC-ODS includes some coverage of telehealth services and counties are able to provide their contracted services via telehealth beyond any state requirements. For example, Marin County has turned to third party vendor Bright Heart Health to manage many beneficiaries’ SUD needs. And just last year, the Governor signed a bill requiring DMC-ODS to cover counseling and therapy services provided by certified providers via telehealth.
California MAT Expansion Project
To address access to treatment needs for California counties hit hardest by the opioid epidemic, DHCS secured funding through the Substance Abuse and Mental Health Services Administration (SAMHSA) to initiate the California MAT Expansion Program (CMAT).
A key part of CMAT is the California Hub & Spoke System (H&SS), where SUD experts at hubs provide ongoing care and maintenance treatment to beneficiaries at spokes, located at medical offices in mostly rural locations. Many hubs utilize telehealth modalities to provide MAT services and care coordination to beneficiaries, and training to providers at spokes to gain waivers to dispense buprenorphine to beneficiaries. Other features of CMAT include expanding buprenorphine access points in hospital EDs and county jails.
Researchers have identified telehealth as a promising tool for addressing the opioid epidemic, specifically its role in providing MAT. Agencies such as HHS have allocated grants to expand telehealth adoption for this specific need. However, the Ryan Haight Act still poses a barrier to prescribing controlled substances like buprenorphine using telehealth and geographic restrictions in the Medicare program prevent reimbursement for services provided in large swaths of the country. Telehealth advocates can press for expanded reimbursement across programs, reforming the Ryan Haight registration system and state law restrictions on originating sites.