Bill would remove bed cap

More substance-use disorder patients would be treated at centers accepted by Medicaid

WARREN — A bipartisan bill introduced in the U.S. Senate would remove a cap on the number of people who can be treated at a Medicaid-accepted center for substance-use disorders.

The cap, known as the Institutions for Mental Disease (IMD) exclusion, was enacted in 1965 and makes it so treatment facilities that accept Medicaid patients can’t treat more than 16 people at once and still bill Medicaid.

The cap was originally enacted “because of the horrible living conditions in state mental health hospitals. People were being mistreated, warehoused and, in some cases, abused,” said April Caraway, executive director of the Trumbull County Mental Health and Recovery Board.

But local officials have been pushing for the cap to be removed as drug overdose deaths in Trumbull County started rising — from 36 deaths in 2012 to 135 in 2017 — while waiting lists for detoxifcation treatment services grew as well.

At the beginning of this year, Ohio Medicaid issued a “clarification,” stating the institution does not consider substance-use disorder residential treatment programs to be an IMD, therefore excluding it from the 16-bed cap, according to an April letter circulated around the state.

Despite the clarification, Caraway said the bill, introduced by U.S. Sens. Sherrod Brown, D-Ohio, and Rob Portman, R-Ohio, is still needed as an assurance.

“Today we have businesses licensed to detox and provide treatment to people with substance-use disorders with waiting lists because of the 16-bed rule. The 16-bed limit definitely needs to be raised so that certified agencies can provide treatment to more people and get paid for the treatment they provide,” Caraway said.

If the bill is passed, some changes include limiting stays in treatment facilities to 90 days (up from 15 days now), completely lift the bed cap as long as the facility is licensed by the state agency overseeing substance abuse and require transition plans for outpatient care. The bill also contains measures to restrict the possible costs associated with lifting the bed cap.

But Caraway urged caution.

“I do think that agencies should be cautious about how much they increase capacity because we don’t want people with addiction issues being subjected to the same horrors people with mental health issues experienced 50 years ago. Serving more people while maintaining high standards, low group sizes and monitoring outcomes is the right direction to take,” Caraway said.

Some treatment providers have already begun taking advantage of Ohio Medicaid’s clarification.

Cindy Woodford, CEO of First Step Recovery in Warren and consulting director for Parkman Recovery Center in Warren, said Ohio Medicaid’s clarification gave the treatment facilities more freedom to collaborate, to expand and lifted “huge burdens” from their operations.

“We’ve been operating under Medicaid’s new ‘interpretation’ of the IMD as it relates to substance-use disorder inpatient facilities since early this year,” Woodford said. “As a result of the state’s change in interpretation of the IMD, we’ve been able to collaborate and partner more directly with Parkman … We’ve been able to be more cost efficient while providing experienced leadership, policy development and implement other business, medical and clinical best practices from First Step Recovery directly, and not through the consultative process, without concern of violating state and federal law.”

Before the clarification was issued, local officials addressing the opioid crisis were pushing the state to apply for an exemption to the 16-bed cap, but the federal waiver is complicated to obtain and maintain.

Brown and Portman introduced a similar bill last year. The Medicaid CARE Act would have raised the cap to 40 beds at accredited residential addiction treatment facilities for up to 60 consecutive days.