Intensive outpatient (IOP) treatment is an established modality and is well understood and supported by commercial payers. However, according to experts, payers tend to favor IOP over residential care because of cost concerns, which has positioned the service for new growth potential.
The American Society of Addiction Medicine (ASAM) suggests that IOP (Level II) should include a minimum of nine hours of treatment per week, and some state licensure requirements expect providers to maintain that minimum. Often comprised of a mix of group and individual counseling sessions, the treatment is recommended for 90 days or more, depending on patient needs—longer than the typical residential length of stay but without the cost of round-the-clock care.
There is considerable variation in the specific features of IOP, but it could serve as an entry point to care, a step-down level or a step-up level. Its flexibility can be an asset in that some patients might benefit from shorter, more frequent visits, while others might fare better with longer, less frequent visits.
Among the 13,873 facility operations included in SAMHSA’s 2015 National Survey of Substance Abuse Treatment Services, some 6,261 indicate they offer IOP (45%). However, in many cases, potential patients might not even realize IOP is an option, so marketing efforts by treatment centers should include information about how the level of care is different than residential services.
“It’s seen by both treatment centers and payers as an alternative to inpatient and residential, but more often it’s seen as part of a continuum of care,” says Jeffrey Walter, principal of consulting firm JLW Associates and former CEO of the Rushford Center in Connecticut.
Walter says in the Northeast, IOP was established around 1990 as a step-down transition from residential care to help patients maintain recovery with more support than 12-Step meetings alone. Additionally, IOP was a reaction not just to clinical needs but also to changes in reimbursement.
“Payers were less willing to pay for 30 days of residential treatment,” he says.
An IOP experience might cost as little as $2,000 in some markets—depending on patient needs—so it’s viewed by insurers as an affordable, flexible option.
“We have high rates of reimbursement and few rejections for claims,” says Anne Marie Dine, director at Foundations Atlanta Midtown, which opened in 2014. “And part of it is that insurance is realizing this is a niche of the market where we provide a valuable service to help people figure out how to live their lives.”
Studies have found IOP to have good efficacy, and Walter says it’s not an either/or situation clinically. Using ASAM criteria can help clinicians decide when IOP is appropriate and when residential care is appropriate.
“Residential is most effective for people who don’t have support for recovery at home and in the community,” Walter says. “If you put a client in IOP only, and they go home to an unstable environment, the chance of relapse is high. But IOP for someone who has support at home, it’s a way to get treatment and still stay at work and at home. And the cost of it is much lower, and that’s where the payers come in.”
Even Medicaid pays for IOP, he says.
One growth opportunity might include IOP paired with medication-assisted treatment (MAT). The use of MAT is increasing, thanks to favorable legislation and new grant programs, so the need for the recommended concurrent therapeutic support will likely grow as well.
“In the past, there has been reluctance for residential programs to allow patients to take those medications while in treatment,” Walter says.
In the future, he sees a greater uptake of IOP paired with sober living arrangements.
With the increase in treatment access across the country, it’s not surprising there’s a parallel increase in IOP and outpatient services in general, says David Rotenberg, MA, MBA, CAC Diplomate, chief clinical officer for Caron Treatment Centers.
“Where you have sober living, you often have IOP attached,” Rotenberg says. “They go hand in hand, and they’re a winning formula for longitudinal recovery.”
He says traditional IOP might be six to eight weeks, but as the industry seeks to improve outcomes, longer engagement is a helpful strategy. Stepping down a patient into IOP after a residential stay allows for better monitoring than less intensive care plans.
“There’s a piece to the opiate/heroin epidemic, and there’s a piece to medication management that goes along with recovery from opiates,” he says. “There’s a need for longer-term monitoring, specific to that epidemic.”
Rotenberg says Caron’s three IOP programs are not in a growth mode and do not constitute a significant source of revenue. Rather, they serve as a resource to maintain services that are needed in the continuum of care for the respective communities. About 900 patients use Caron’s IOP services each year.
“IOP or outpatient is often the first taste of treatment, and like anything in life, ‘Psychology 101’ tells you that first impression is everything,” Rotenberg says. “And we know that it will flavor the person’s willingness to engage in treatment at that moment and impact their motivation.”
The critical first impression will also influence the person’s attitude toward returning to treatment in the future—which has a high likelihood considering the chronic nature of addiction, he says. Outcomes aren’t the only measure of success for IOP. Patient engagement and changing attitudes about seeking treatment are also key factors.
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