Response to Public Comments

Responding to Public Comments

During the public comment period for the Paperwork Reduction Act (PRA) package for the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act section 1003 evaluation, the Centers for Medicare & Medicaid Services (CMS) received one set of comments from a law program that protects and advances the health rights of low-income and underserved individuals.

Comment I: The commenter recommends the inclusion of beneficiary perspectives in addition to providers via the use of a beneficiary survey, with a specific focus on whether beneficiaries are benefitting from increased availability of providers and whether there are additional barriers to care.

CMS response: Although we agree, the specific mandate from Congress is to evaluate strategies to increase provider capacity and, to decrease burden for everyone involved, we have streamlined the primary data collection to capture the effects on beneficiaries in the provider focus groups and in the secondary data analyses.

Action(s) taken: Because they will be measured in the secondary data analyses, impacts on beneficiaries are not reflected in the PRA submission. These impacts will be pursued via inquiries to providers in the focus groups.

Comment II: The commenter recommends ensuring that increased capacity for substance use disorder (SUD) treatment and recovery services is focused on community-based services and coordination between different placement levels. The commenter is particularly interested in increased capacity for outpatient/community-based services and judicious use of services such as residential treatment. Finally, the commenter recommends questions about what type of medications providers are using to treat beneficiaries and to what extent the SUPPORT Act section 1003 has increased the availability of Opioid Treatment Programs (OTPs).

CMS response:

• In the provider survey, we are asking providers about both the settings in which they deliver services and the types of treatment and recovery services they provide.

• For the focus groups, we will recruit providers from a variety of settings (e.g., residential, OTPs, behavioral health clinics) and ask setting-specific questions regarding barriers and whether they perceive increased capacity for specific settings. We will also ask a question about referral networks and other types of supports that providers would like to see.

• The provider survey is specifically targeted to providers who prescribe/dispense medications for the treatment of opioid use disorders (OUDs), including OTPs. It also assesses which medications they provide and whether there has been an increase in capacity to provide those medications.

• In addition to primary data collection, the evaluation includes secondary data analysis of Medicaid claims data and other data such as the Substance Abuse and Mental Health Services Administration’s OTP locator, and the planned analyses include examination of the provision of OUD treatment medications.

• We can add a question about coordination between different placement levels and whether the SUPPORT Act section 1003 demonstration has affected that coordination. However, we also will be examining coordination across levels and use of various placement levels in the secondary data analyses.

Action(s) taken: We have added a question about coordination between different placement levels and whether the SUPPORT Act section 1003 demonstration has affected that coordination. Much of this subject matter also is covered in analyses of secondary data.

Comment III: The commenter recommends exploring, over and above provider capacity, the extent to which utilization management, step therapy, and mandatory concurrent provision of behavioral health treatment create barriers to care. The commenter also recommends an examination of whether the section 1003 demonstrations enable providers to take advantage of expanded authority and flexibility to prescribe buprenorphine (i.e., nonphysician providers prescribing buprenorphine).

CMS response:

• Section 1003 of the SUPPORT Act specifies that the purpose of the demonstration project is to increase treatment capacity of providers to provide SUD treatment or recovery services; therefore, the evaluation must focus on provider treatment capacity.

• The provider survey specifically focuses on the provision of OUD treatment medications, including buprenorphine. The survey includes questions about the provider’s occupation (includes nonphysician providers), which medications the provider prescribes/dispenses, and whether the provider has a waiver to prescribe buprenorphine.

• The secondary data analysis plan includes looking at the number of buprenorphine-waivered providers in the state, the number of patients each provider treats with buprenorphine, and whether the provider is a physician or one of the nonphysician providers eligible to receive a waiver.

Action(s) taken: To the extent the comment relates to matters within the scope of the evaluation, they already are addressed in both the primary and secondary data analyses.

Comment IV: The commenter recommends that CMS evaluate the extent to which the demonstration has improved access to SUD services for individuals under age 21 years. The commenter specifically mentioned a historical lack of clear guidance to providers on how to treat SUD or the risk of SUD for individuals under age 21 years.

CMS response:

• The SUPPORT Act section 1003 legislation specifies three priority populations under the age of 21 years: individuals with neonatal abstinence syndrome, infants, and adolescents and adults between the ages of 12 and 21 years; therefore, secondary data analysis will include data reported for each of these priority populations.

• We can also add a question to the provider survey asking about any training or technical assistance providers have received with guidance for providing SUD treatment and recovery services to youth and young adults.

Action(s) taken: Added a question to the provider survey to assess whether the provider received any training or technical assistance with guidance for providing SUD treatment and recover services to youth and young adults.

Comment V: The commenter recommends that the evaluation include a focus on the extent to which the demonstration has addressed health disparities. The commenter mentions BIPOC, LGBTQ+, and pregnant and postpartum individuals as historically underserved populations, and they suggest that CMS examine whether there has been an increase in capacity for SUD treatment services for these populations.

CMS response:

• To address health disparities, section 1003 of the SUPPORT Act identifies several high-priority populations, including pregnant and postpartum women, infants with neonatal abstinence syndrome, adolescents and young adults, and American Indian and Alaska Native individuals. We will analyze grantee demonstration applications and reports to understand which populations states are prioritizing in their SUPPORT Act activities.

• In the provider focus groups, for states that have focused on any of these priority populations, we will ask about whether there has been an increase in capacity for the provision of SUD treatment and recovery services to these historically underserved populations.

• To the extent that data are available and accurate, in the secondary data analysis, we will conduct a subanalysis to understand trends in treatment and recovery capacity for individuals of different racial and ethnic groups, pregnant and postpartum women, and individuals of different age groups.

Action(s) taken: These topics are addressed in our primary and secondary data analyses.