This is an exclusive BHB+ story.
Overdose deaths may be down, but an influx of synthetic drugs is exposing how quickly addiction care providers must adapt to new complexities and how slow payer systems are to evolve.
Synthetic substances such as 7-OH fentanyl products, xylazine, nitazenes, tianeptine and synthetic benzodiazepines continue to grow in prevalence, potency and usage across the U.S. Both providers and payers are grappling with fast-moving realities across the market of synthetic drugs: that they all differ in mortality, toxicology and prevalence, so treatment and therefore reimbursement, cannot be a one-size-fits-all approach.
“From a payer perspective, access is always the first concern. If reimbursement and benefit design don’t keep pace with patient needs, it becomes harder to build and sustain the provider networks needed to deliver timely, high-quality care,” Debbie Witchey, president and CEO of the Association for Behavioral Health and Wellness, told BHB. “Patients end up in higher-acuity, less effective places for care. That’s why it’s so important that payment models evolve alongside the realities of today’s substance use challenges.”
The ABHW is a nonprofit membership organization and advocacy group that represents the interests of health plans and specialty behavioral health companies.
Yet, it is in the best interest of payers to pay attention to this growing trend. Even with a decline in overdose deaths broadly, synthetic substances continue to be one of the primary drivers of overdose mortality with fentanyl and other synthetic opioids accounting for around 70% of lives lost.
On the ground, providers previously told Behavioral Health Business that, in some cases, they’ve seen a 100-fold increase or 225% jump in clients presenting with addictions to synthetic substances like 7-OH. While 7-OH addiction presents like opioid addiction and can follow similar detox protocols, several providers said their clients have needed more support in recovering from synthetic substances including longer lengths of stay etc., which some payers are not ready to provide.
Reimbursement realities
One of the existing pain points with synthetic drugs in general is that existing ones are growing in use and new ones are being manufactured often faster than policy and protocols can move. Providers are the first line of defense in treating addictions to these substances, but that treatment can be undermined by payer systems not working in unison.
The growing issue of addiction to synthetic drugs is also one for which there is no existing playbook. Groups like the American Society of Addiction Medicine and others are actively working to study treatment and presentation of addiction to synthetic substances. But lacking formal guidance at the moment, many providers are building the plane as they fly it, and as a result, payers are playing catch-up.
“From a payer’s standpoint, and from a provider’s standpoint, [collaboration] is the only way anything really changes,” Mike Garafalo, the director of behavioral health operations at Fallon Health, told BHB. “It has to be in unison, the payers, the policies, the regulators and the actual treatment providers.”
Fallon Health is a Worcester, Massachusetts-based provider of health insurance and health care services.
Garafalo said that he and his colleagues at Fallon Health are working to keep a pulse on existing care trends like the rise of synthetic drug addictions and regularly meet with provider partners via a group dubbed the SUD Consortium. The purpose is to measure what’s happening on the ground, learn what patients need and what barriers exist to getting there. That communication between providers and payers helps Fallon tailor existing reimbursement policies accordingly, he explained.
“It’s always like a look back period from the insurance company, by the time they get the data then they have actionable measures, it’s further down the road,” Garafalo said. “Whereas a detox might see that faster. So, I think that constant communication is crucial. … There’s a lot more that goes into making change on the payers’ side, whereas from the provider side, if four people present this week, you have to figure out how to deal with that, because that’s what is in the community and is coming next.”
Of course, reimbursement determinations go beyond just conversations. To facilitate real reimbursement rate or policy changes, payers need to see outcomes data that show how synthetic drug addictions require more intensive care or longer lengths of stay. From there, they also want to see how providing more intensive care to a patient leads to reduced emergency room visits, relapses or readmissions.
“Plans will be looking at evidence that extended or higher-intensity care is actually moving the needle – fewer readmissions, fewer overdoses, and better long-term stability for members,” Witchey said. “As this trend is better understood, that kind of clarity will help guide how to approach treatment and support for this population.”
Many payers are still early on in assessing what level of care synthetic substance addictions require and until that is more widely understood and agreed upon, it’s unlikely payers will change how they are authorizing care anytime soon.
While the provider and payer playbooks around this are still being written, many providers are continuing to use existing reimbursement codes or catch-all categories, or simply providing services without submitting for reimbursement to help patients.
“Providers have started doing it by using codes for drug billing. That’s how they are trying to bill it,” Pankhuri Sharma, principal director at Humana, told BHB. “I don’t know what the reimbursement rates look like for that, but still, at this time, we do not have clear standardized guidelines from the FDA and clear clinical guidelines. Until then, I don’t see payers picking this up.”
Humana is a for-profit health insurance company based in Louisville, Kentucky.
Capacity and care models
Addiction treatment providers are not only working to understand how to care for differing presentations of these substances, but they also continue to grapple with staffing shortages and the capacity to manage existing care models.
The system itself is not only facing financial strain, but also operational and clinical ones, particularly around synthetic substances, which makes payer catch-up an ongoing battle in this vein as well.
“Many programs aren’t set up to manage the medical complexity of synthetic‑drug withdrawal,” Witchey said. “Also, current treatment systems don’t always provide the long-term, coordinated care needed for increasingly complex and chronic substance use disorders. We need to expand access to evidence-based treatment and ensure our care models evolve as drug trends change. Gaps in continuity of care and ongoing provider‑capacity challenges continue to limit access to high‑quality SUD treatment.”
Existing mechanisms, like catch-all codes for reimbursement or partial reimbursement approvals do not fully cover the utilization needs of a growing population of patients who are addicted to synthetic drugs.
“Even if it’s getting approved, it’s more partial and does not fulfill the entire need,” Sharma said. “We need to talk about these are the payers getting some requests, and this is what they’re doing with it, and this is what they see the next steps to be because, as I’m talking about it, I am realizing that it is becoming an emerging issue, and we can’t just wait until regulations catch up.”
Sharma said that as the payer playbook for this is being written, an interim, ad hoc solution for the field could be to pull in the top providers and payers to share data and discuss these trends in conjunction.
Witchey echoed that, noting that payment models must evolve in tandem with the realities of clinical addiction presentations today.
“Clinical guidelines and individual patient needs drive decisions, and payers are still assessing what level of care these substances require,” Witchey said, “Over time, if data show that longer or more intensive services reduce ED visits, relapse, and readmissions, that evidence will help shape how care is authorized.”