Why an OASAS License for a Low-Threshold Bupe Provider Is So Significant

July 7, 2020

REACH—a harm reduction-oriented health center in Ithaca, New York that prescribes buprenorphine, among many other services—is about to get a license from the state’s Office of Addiction Services And Supports (OASAS).

This license to operate as an official outpatient treatment center is going to make it possible for founder and CEO Justine Waldman, MD and her team to continue their low-threshold model of treating opioid use disorder (OUD) on a far better financial footing than before, with the new ability to bill for their full range of services.

That’s great for thousands of patients in Upstate New York, but the news represents something bigger still. Having covered substance use disorder treatment for 35 years nationally, I can say that this is not a typical OASAS license coming down the pike. Rather, it is the wave of the future.

“Harm reduction means we prescribe buprenorphine to our patients even if they’re not abstinent, even if they’re using benzodiazepines or alcohol or methamphetamine or other opioids,” Waldman told Filter. “We’re prescribing a medication that is hopefully going to save their lives. We want to keep them safe. If they’re doing transactional sex work, we ask if we can put them on PrEP. There is no punitive nature to our relationship with them.”

“Low-threshold” additionally means that counseling isn’t required (although it’s offered). And it’s this aspect of REACH’s work that makes the official seal of approval groundbreaking. This is the first clinic of its kind to receive such a license in New York. 

“We see ourselves as the safety net for all of rural New York.”

Ithaca is in Tompkins County, but REACH, which opened its doors in February 2018, currently treats patients from no fewer than 26 rural counties, reflecting the lack of similar services available elsewhere. Its numbers are astounding: 1,300 patients so far, with ten prescribers all waivered to treat up to 275 patients each. That means the clinic could have a total of 2,750 patients, and with telephone inductions now allowed, the patients can theoretically be anywhere in the state.

New York’s Behavioral Health Services Advisory Council Project Review Committee approved the license application at its June 26 meeting, and the license to operate as an 822 outpatient program, under article 32 of the Mental Hygiene Law, is set to be issued any day.

Longtime former OASAS general counsel Rob Kent championed REACH from the beginning, helping to push the agency toward official acceptance based on his belief in harm reduction. “When I first met the [REACH] folks at a conference, what I came away with was first, that they had a really good ability, based on their numbers, to reach people,” he told Filter. Many of the center’s patients had already tried other treatment programs, but they didn’t work. “These were people who really needed help, but they wanted to get it on their own terms,” he said. That is exactly what REACH offers.

However, REACH faced an uphill struggle to survive as a private medical practice, for which Medicaid only covers the prescriber and the medication.

“That system isn’t set up to pay for all the things Justine is doing,” explained Kent. “It wouldn’t pay for social workers, recovery coaches, counselors, peers and outreach workers and everything else, because private medical practices can’t bill for them.” In other words, the office-based opioid treatment (OBOT) model, with a private prescriber seeing the patient every month for a prescription, period, wouldn’t work here. With an OASAS license, in contrast, the clinic will be able to bill Medicaid for the many services it offers.

REACH has other sources of funding, certainly. It has a grant, for example, from the federal Health Resources and Services Administration (HRSA) to teach internal medicine residents about health equity at the Cuyahoga Medical Center. All residents rotate through REACH under the terms of this five-year grant.

OASAS also provided REACH with State Opioid Response funding to assist in the process of seeking licensure, and the center has another grant from Tompkins County to do COVID testing in the local homeless encampment, where treatment staff also do telemedicine inductions. “We do have a great testing site” for COVID, said Waldman.

But these piecemeal grants aren’t enough to sustain the full program long-term. The OASAS license and Medicaid MCO (managed care organization) rates are the only thing that will do that. To date, one third of REACH reimbursement has come from MCOs, and the rest from grants and research grants.

“Right now we’re anxious to get OASAS certification,” said Waldman. “We see ourselves as the safety net for all of rural New York.”

Access to medication can’t now be conditioned on compulsory counseling.

“In the harm reduction world most of this [funding] is tin cup—and that’s not a sustainable model,” Kent said. “Harm reduction is part of the continuum of OASAS treatment. Why don’t they work toward getting into a system that pays for services that they provide?”

So Kent and his colleagues at OASAS rewrote the licensing regulations over the years, in such a way that access to medication can’t now be conditioned on compulsory counseling. “Let them get it, when they’re ready,” is Kent’s attitude.

Waldman would like to be able give higher doses of buprenorphine—32 milligrams are required for many patients. “If we were in New York City I might go up to 32 milligrams, but there’s already enough problems giving 24, because providers think that contributes to diversion.” she said. The program does give a few patients 32 milligrams, “but we don’t do it as a norm.” The OASAS license doesn’t have a bearing on this issue.

In light of relaxed regulations due to the pandemic, telemedicine has become increasingly important to REACH’s operations, as its associate medical director, Elizabeth Ryan, MD, recently described for Filter.

“We’re trying not to have people come in,” said Waldman. She was speaking to Filter via Zoom, which gave some illustration of her warm personality. She had various pet birds on her shoulders and hopping around on a bed behind her, where a black cat was sleeping peacefully.

For REACH, the OASAS licensure will bring peace of mind. For other providers pursuing low-threshold, harm reduction models of care, it brings new hope.


Image via Pixabay

Alison Knopf

Alison has written about substance use for more than 30 years. She has also written for many years about medical coding. A freelance writer, she is also the editor of Alcoholism & Drug Abuse Weekly, and managing editor of Child & Adolescent Psychopharmacology Update and Child & Adolescent Behavior Letter—all published by WILEY. She also writes for Addiction Treatment Forum.

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