The opioid crisis continues to cast a long shadow over the United States, but recent data offers a glimmer of hope. Last month, the federal government reported a nearly 11% decrease in overdose deaths during the first eight months of 2024. This marks the second consecutive year of declining fatalities, a positive shift that reflects the tireless efforts of addiction treatment providers and policy changes aimed at addressing opioid use disorder. For those involved in opioid treatment, this reduction in overdose deaths represents significant progress.
“It’s fantastic news,” said Jason Kletter, president of BayMark Health Services, one of the largest opioid treatment providers in the U.S. with more than 400 facilities across 35 states. In a conversation with Addiction Treatment Business, Kletter expressed that the news should be celebrated as a major milestone in the ongoing fight against opioid addiction.
However, while the reduction in overdose deaths is undoubtedly encouraging, a closer look at the data from the Centers for Disease Control and Prevention (CDC) raises concerns that deserve attention. Specifically, there has been a troubling increase in fatal overdoses among older adults, particularly those aged 65 and older. In fact, in the second half of 2023, overdose deaths among this demographic rose by 9%. This uptick comes at a time when Medicare Advantage patients—seniors relying on the public insurance program designed to function like private insurance—are encountering significant barriers to accessing medication for opioid addiction. A recent report by the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) underscores these concerns, pointing to systemic gaps in treatment access for this vulnerable population.
Making Strides: Efforts to Reduce Overdoses
Despite these challenges, there are notable successes in opioid addiction services. BayMark Health Services, which operates residential and outpatient opioid addiction services, has played a critical role in addressing the opioid crisis through a multi-faceted approach. In addition to traditional residential programs, BayMark also operates office-based opioid treatment (OBOT) programs, where patients can receive medication-assisted treatment (MAT) for opioid use disorder.
This two-pronged approach has allowed BayMark to expand access to treatment across the country. With more than 400 facilities nationwide, BayMark’s footprint is substantial. But even with this extensive network, Kletter points out that there are areas where the company has been unable to expand, not because they don’t want to, but because it’s not a financially viable business decision.
“If you’re going to pay for rent and a physician, nurse, and counselor, you need to have a minimum threshold of services that you can bill for,” Kletter explained. The cost of maintaining these facilities, especially in rural or less-populated areas, is often too high for the demand to justify the investment. This has led to significant gaps in treatment availability, particularly in rural and underserved regions.
Gaps in Treatment Access: The Rural Crisis
One of the most pressing issues highlighted by the HHS-OIG report is the lack of opioid addiction services in rural areas, particularly in states like Georgia, Kansas, and western Texas. These areas are grappling with an absence of providers who offer the crucial medications used to treat opioid use disorder, such as methadone and buprenorphine.
The report urges the Centers for Medicare & Medicaid Services (CMS) to focus on counties that have limited treatment options and consider expanding resources and funding to these areas. Kletter believes this is a crucial step that CMS should take. For several years, he has suggested that CMS create an enhanced reimbursement rate for rural areas located a significant distance from the nearest treatment facility, thus making it more feasible for providers to set up shop in these regions.
“Enhanced reimbursement would incentivize providers to open up services in these areas and allow them to remain viable,” Kletter said. “By geographically targeting these underserved areas, we could make a real difference.”
The Reimbursement Challenge: Medicaid and Medicare Struggles
While rural access is a key issue, another significant barrier to opioid addiction services is the inadequate reimbursement rates for Medicaid and Medicare patients. Kletter noted that, while approximately 70% of BayMark’s office-based providers accept Medicare and Medicaid, many providers—particularly in private practice—are unable to make the economics work. Low reimbursement rates from Medicaid often prevent providers from being able to afford the necessary staff and services for treatment, creating a vicious cycle where opioid use disorder remains untreated.
The HHS-OIG report also highlighted this issue, pointing out that only 37% of office-based providers prescribed buprenorphine to Medicaid enrollees in 2022, despite buprenorphine being a key medication used in opioid addiction treatment. The problem, according to Kletter, is that many providers do not receive enough compensation to cover the costs of treating Medicaid patients.
“There are stand-alone private practice doctors who are authorized to prescribe opioid medications, but the reimbursement doesn’t cover the costs,” Kletter explained. “Without the financial support, many providers are forced to turn patients away.”
The OIG report called on CMS to collaborate with states to ensure reimbursement rates are sufficient to attract and retain providers in the opioid addiction services space. Kletter agrees with this recommendation, emphasizing that adequate reimbursement is essential to maintaining a viable treatment infrastructure.
Medicare Advantage: A Barrier to Treatment for Seniors
Another area that remains problematic is access to opioid addiction services for seniors who are enrolled in Medicare Advantage plans. Medicare Advantage is a publicly subsidized insurance program designed to function like private insurance but for people over 65. For seniors who need medication-assisted treatment (MAT) for opioid use disorder, Medicare Advantage plans impose significant hurdles.
Under Medicare Advantage, patients are often required to get a referral from their primary care provider (PCP) before they can access MAT. This process can cause significant delays, and in some cases, the required authorization is never granted. Kletter described the prior authorization requirement as a “huge problem,” particularly because it often leads to patients giving up on treatment altogether and returning to drug use.
“If a patient is required to get a primary care referral and we can’t get it in time, it’s not uncommon for the patient to give up, and we lose them back to drug use,” Kletter said. The added layer of bureaucracy often proves to be an insurmountable barrier for many seniors who are already vulnerable.
The issue of prior authorization is one that Kletter believes CMS must urgently address. Streamlining the process and ensuring that patients can access opioid addiction services without unnecessary delays would improve outcomes and ensure that seniors with opioid use disorder have the same level of access to care as other patients.
Progress, But More Work to Be Done
In her response to the HHS-OIG report, CMS Administrator Chiquita Brooks-LaSure acknowledged the progress made in increasing access to opioid treatment medications, citing the overall rise in patient access to MAT. While Kletter agrees that progress has been made, he argues that the pace of change is not fast enough, particularly for the most vulnerable populations.
Brooks-LaSure also noted that CMS is working to provide more data to improve treatment access. Specifically, she called for an updated Substance Abuse and Mental Health Services Administration (SAMHSA) database that would provide better information on opioid treatment locations and help patients and providers navigate the treatment landscape more efficiently. Additionally, she emphasized the need for a published analysis comparing Medicaid reimbursement rates between states to identify areas that require improvement.
Kletter, too, believes that transparency and better data collection are essential. He suggests that CMS should prioritize making it easier for patients to find opioid addiction services, particularly in rural areas, and to ensure that providers are adequately compensated for the care they offer.
Conclusion: A Call to Action
While the reduction in overdose deaths is a cause for celebration, the opioid crisis is far from over. With rising overdose deaths among seniors and ongoing barriers to treatment in rural and underserved areas, there is still much work to be done. Addressing issues like Medicaid reimbursement rates, Medicare Advantage requirements, and geographic treatment gaps is essential to ensuring that everyone who needs care has access to it.
The progress made in the last couple of years is encouraging, but as Jason Kletter said, “It’s something to celebrate.” But it’s also something to continue working on. Only by addressing the systemic issues hindering access to treatment can we hope to make a significant impact on the opioid crisis and save more lives in the process. The road ahead may be long, but every step forward is a step in the right direction.
