Family physicians have the training, skills and compassion needed to help mitigate the nation's opioid crisis, the Academy reminded regulators this month. What they require now is greater investment.
"The AAFP urges CMS to consider strategies that invest in primary care and include strategies to grow the primary care workforce," the AAFP told CMS Administrator Seema Verma, M.P.H., in an Oct. 10 letter(9 page PDF) signed by Board Chair John Cullen, M.D., of Valdez, Alaska.
The letter was the AAFP's response to the agency's request for information(webcache.googleusercontent.com) on developing an action plan to prevent opioid addiction and enhance access to medication-assisted treatment. Section 6032 of the Substance Use-disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act,(www.congress.gov) passed in 2018, calls for HHS to develop such a plan to prevent opioid addiction, enhance access to MAT and emphasize treatment that minimizes the risk of opioid misuse and opioid use disorders.
The Academy's correspondence identified current Medicare graduate medical education caps and funding strategies as contributors to a decline in primary care residency positions -- an ebb that's had a broad ripple effect on a population struggling with a public health crisis.
- As the federal government builds the opioid action plan called for by a 2018 law, the AAFP urged CMS "to consider strategies that invest in primary care and include strategies to grow the primary care workforce."
- The Academy's detailed response to an agency request for information called on CMS to expand coverage of medication-assisted treatment in the primary care setting and reimburse physicians for the increased time, staff and regulatory commitments associated with MAT.
- "Mechanisms to cover the social needs of patients are critical," the AAFP said, listing housing, food insecurity and transportation limitations as among the issues that must be addressed.
Residency training should be aligned "to deliver evidence-based information on best practices in the management of chronic pain and opioid dependence," the AAFP said. And CMS should promote and help secure funding for CME offerings that address these issues, including appropriate use of naloxone.
The RFI was divided into sections on acute and chronic pain and substance use disorders (including opioid use disorder).
Acute and Chronic Pain
CMS, the Academy wrote, should
- promote payment models that enable -- and appropriately compensate -- physicians to provide patient-centered, compassionate care for chronic pain and opioid dependence;
- expand coverage of MAT in the primary care setting, with adequate reimbursement for the associated increased time, staff and regulatory commitments;
- expand access to naloxone and promote appropriate good Samaritan protections for prescribers and lay rescuers;
- work with state and federal licensing boards, the DEA and the Substance Abuse and Mental Health Services Administration to destigmatize MAT;
- work with state and national partners to improve the functionality, utility and interoperability of prescription drug monitoring programs and develop best practices for their use and implementation;
- expand research into chronic pain management, as well as into identifying and managing opioid misuse, with attention to populations at higher risk for undertreatment of pain and/or for opioid misuse; and
- increase patient access to nonpharmacological pain therapies and non-narcotic pain medications by eliminating prior authorizations.
Further, the Academy said, limited public and private insurance coverage of MAT in the primary care setting -- along with inadequate reimbursement for the increased time, staff and regulatory commitments associated with MAT -- remains problematic. And prior authorizations and insurance denials "often impede non-narcotic and nonpharmacological treatment."
"According to a 2018 AAFP survey of members, in a typical week, almost half of respondents deal with prior authorization delays and insurance denials for non-narcotic or nonpharmacological pain treatment," the letter said.
The Academy called on CMS to overhaul payment and coverage systems to address inequities in patient care. Patients struggling with acute or chronic pain, the letter said, should not be further undermined by administrative complexity and financial barriers as they seek, for example, physical therapy, massage and acupuncture, among other nonpharmacologic therapies.
Additionally, "CMS should also support telehealth to increase coordination between primary care physicians and pain specialists," the Academy said.
Substance and Opioid Use Disorders
Responding to the next section of the RFI, the Academy repeated its call for CMS "to promote greater patient access to cost-effective alternative therapies (nonpharmacological, nonopioid)," including mental health services, pain management specialists, patient education, evidence-based interventions to identify those at risk for addiction, and increased support for prevention policies and programs.
The Academy also expressed approval of the proposed opioid treatment programs called for in the SUPPORT Act, which next year establishes a new Part B benefit category for OUD treatment.
"However, current payment and coverage policies do not strongly encourage physicians to implement pharmacologic treatment for OUD in their practices," the letter said.
And as more states regulate the prescribing of buprenorphine beyond the already restrictive regulatory process, including by mandating patient counseling, family physicians -- particularly those in rural areas -- face new burdens.
"Current staffing within a medical practice fails to provide the needed social and behavioral health supports to provide office-based opioid treatment," the Academy said.
"Lack of reimbursement for services of certified peer specialists and minuscule reimbursement for case management services by social workers do not facilitate sustainable practice models for many programs (that) initiate these services through grant funding or outside funding."
Destigmatizing With Waivers
Echoing feedback the AAFP provided HHS in August, the letter said that increasing opportunities for waivered training courses during residency, as well as at national, state and regional CME meetings (including through online and other alternative models), also were needed to combat the opioid crisis.
The agency's RFI closed on an open-ended note, asking respondents to report what other issues it should consider "to improve coverage and payment policies in Medicare and Medicaid to enhance the identification of, treatment access by, and the treatment of beneficiaries with SUDs, including OUD."
The Academy answered with specific advice centered on family medicine's whole-patient approach to care and taking into account the Drug Addiction Treatment Act of 2000's education requirements(www.samhsa.gov) for buprenorphine prescription.
"Mechanisms to cover the social needs of patients are critical," the AAFP said. "For many individuals, barriers to recovery are not simply access to buprenorphine, counseling and treatment, but rather housing, food insecurity and transportation limitations.
"Recovery is further impeded by employment practices that stigmatize patients with substance use disorder who for many reasons have criminal records."
The AAFP repeated its advice that CMS address the issue with action on residency training and CME offerings and also suggested that the agency develop a list of DATA-waivered(www.deadiversion.usdoj.gov) family physicians who are willing to mentor newly waivered FPs and residents -- and pay them for this service.
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