Since 2018, the CA Bridge program has been building treatment capacity for opioid use disorder (OUD) in hospitals throughout California. Through technical assistance, clinical training, and a navigator program that guides treatment navigators based in emergency departments (ED), CA Bridge has created a path to reduce barriers to treatment. Funding support for the program has evolved over time, and CA Bridge has worked closely with the state’s Medicaid agency to develop an approach that leverages Medicaid for service reimbursement.

NASHP’s recent webinar Sustaining Emergency Department Buprenorphine Services: Panel Discussion with California Leaders, featured the lessons learned in developing this approach from both a state Medicaid leader and a CA Bridge clinician. Presented in partnership with the Foundation for Opioid Response Efforts (FORE), the webinar examined the policy challenges and state solutions to providing and funding evidence-based care for OUD in hospital EDs. Key takeaways for states are summarized here:

Funding and Sustainability

• State approaches to funding for these services require collaboration among state Medicaid agencies, hospitals and other providers, insurers, and other stakeholders. While federal grants and state dollars can support initial development of program components, Medicaid reimbursement for services delivered in these settings — particularly navigation services — is necessary to achieving sustainability. Recognizing that the need for ED-based OUD services exists across payers, states can also collaborate with commercial payers to consider opportunities for commercial approaches to reimbursement that includes navigation services.
• Medicaid prescribing policy decisions can reduce barriers to treatment in EDs (and beyond). Payment requirements like prior authorization for medications for OUD (MOUD) or limits on dosing can pose challenges to prescribing. Removing prior authorization for buprenorphine is associated with a significant decrease in SUD-related ED visits per year, an approach that state Medicaid programs and commercial insurers can take to remove a barrier to treatment access.
• Provide direct guidance and communication from state agencies to providers and health systems that clearly defines allowable clinical and billing practice. Leverage Medicaid managed care guidance, dear colleague letters — like this one from the CA Department of Public Health, and information notices to clarify that buprenorphine induction in the ED is allowed and encouraged.
• Ensure that providers can maximize options to bill Medicaid. Code G2213 specifically allows clinicians to bill for MOUD induction in the ED. California is seeking approval from the Centers for Medicare and Medicaid Services (CMS), to allow for reimbursement of community health workers, which provides opportunity to bill for navigator services.
• Consider opportunities to identify blend other OUD funding resources that can be used to support SUD care in ED settings. California used federal State Opioid Response (SOR) funds for training and technical assistance at the outset of the CA Bridge project. Once hospitals saw value in this approach, they advocated for further state funding, which led to a $40 million appropriation in general funds in the 2022 state budget to hire navigators. California’s Medicaid agency also allocated $40 million for these services in their recently-submitted spending plan for an enhanced federal match for home and community based services (HCBS). States also have broad authority to use opioid settlement funding to fund various aspects of these programs that are not reimbursable through Medicaid not able to be supported through grants.
• Initiating MOUD in EDs can reduce costs in other parts of the healthcare system. Prescribing buprenorphine in the ED not only increases access to MOUD but also decreases SUD related hospital admissions and provides connections to care in the community.

Provider Engagement

• ED settings are a critical access point to initiating MOUD and ongoing care across the OUD treatment continuum. ED providers are well-poised to begin a course of MOUD that can be a first step in community-based care. This also provides an opportunity for states to cultivate access to MOUD by creating a safety net for community providers who may be hesitant to start prescribing.
• State policymakers can help identify and support provider champions. Clinicians make a practice of learning from their peers. State leaders, particularly those within provider licensure boards, can identify leaders in this space who are be able to promote the value of ED-based care and myth-bust misconceptions about MOUD on an individual basis.
• Use transparent data to tell a policy-to-practice story. California leaders leveraged the state’s overdose dashboard to provide treatment information on a county-by-county basis, demonstrating need and gaining buy-in among providers and stakeholders.

California policymakers identified the ED as a critical point on the SUD care continuum to provide access to MOUD and connect individuals to community-based care. As the CA Bridge model has evolved, state leaders have developed policy to guide the process of implementation in hospitals and ensure sustainability over time. As states consider new treatment initiatives and use of funding resources — particularly opioid settlement funds — EDs present an opportunity for intervention that can be supported through one-time infrastructure dollars and sustained through Medicaid and/or private insurance reimbursement with the right policy in place. Technical assistance and training resources are available to state policymakers through CA Bridge, so states are encouraged to reach out with questions. Watch the full webinar.

Acknowledgements

The authors would like to thank the leaders from California and CA Bridge who provided their time and input to this webinar and blog, and the Foundation for Opioid Response Efforts (FORE), which provided grant support to CA Bridge to expand their technical assistance to multiple states, and grant support to NASHP for the State Opioid Policy Center. The views and conclusions contained in this document are those of the authors and should not be interpreted as representing the official policies or stance, either expressed or implied, of FORE.