Concerns about costs rise as Concord hub-and-spoke system gains steam

Monitor staff
Published: 4/17/2019 6:31:55 PM

Four months into its creation, Concord’s hub-and-spoke substance use treatment system is picking up some steam. Walk-in patients to Riverbend Community Health – the capital area’s “hub” – are up and 41 patients have been referred to services so far, the organization says.

But as New Hampshire officials continue to roll out the program and present it as a key asset in turning around the state’s opioid epidemic, a growing difficulty looms: payments.

Announced last year, and bolstered by $57 million in federal money over two years, the hub-and-spoke system was designed to allow an easy entry point for treatment services for those in need. The nine hubs can be accessed on foot or referred via phone; those hubs then assess and refer patients to local treatment options acting as spokes.

It’s a system geared toward simplicity and easy access for those who may not have ever accessed such services. But each initial visit can rack up a bill, and not all of those visiting have adequate insurance.

Since Jan. 2, Riverbend has been forced to bill 20% of the patients who have set up those initial appointments – in the Concord organization’s case, about $230 per visit.

“Either they have a very high deductible, co-pays, or they don’t have any insurance,” said Sarah Gagnon, Riverbend’s vice president of clinical operations, at a roundtable with U.S. Rep. Annie Kuster in Concord on Wednesday.

For those walking in without insurance at all, some options exist. They could be eligible for Medicaid, which provides coverage for those up to 100% of the poverty level, or Medicaid expansion, which provides coverage for those up to 138% of that level.

Still, it’s complicated, officials say. Due to a new waiver passed by the Legislature and approved by the federal Centers for Medicare and Medicaid Services last year, New Hampshire’s Medicaid expansion program no longer allows for retroactive coverage for those who sign up later, meaning patients must sign up on the day of their first appointment or bear the full cost. That can add 45 minutes onto the existing work of assessing the patients and adding them to the hub’s case management.

“We’ll help with sliding scale (payments) and we’ll help them pay if they can, but it’s important to know that somebody coming into to the Doorway will be charged for the assessment,” Gagnon said. “So for the client experience, somebody seeking recovery to get a bill” makes it difficult, she added.

For a system designed to coax people out of the woodwork and into treatment, the insurance question can be a snag. It’s one of the first questions that callers to the organization receive. “It’s very much putting up a wall and saying ‘okay I’m not coming in here,’ ” said Shanna Large, director of substance use disorders” at Riverbend.

Riverbend is legally required to charge for those services, said Peter Evers, Riverbend’s CEO. But in many cases it won’t press too hard. Annually, the facility is forced to absorb between $1 and $2 millions in revenue hits due to unclaimed bills, Evers said.

“We’re not exactly aggressive in collecting that money,” Evers said.

Then there’s the reimbursement problem. Organizations that serve as hubs in the system are required to carry out case management. That mandate, set by the federal grant program, can be costly. But around 80% of the employees who carry out that case management are not presently eligible for reimbursement through Medicaid, Riverbend officials say. That’s because the workers are not certified recovery support workers, a position that requires extra training.

Not getting reimbursed means more costs for the hubs to eat. The end result: The case management that Riverbend provides as a condition of the federal grant must be paid for out of the organization’s pockets, Evers said.

Sitting next to Kuster, Department of Health and Human Services Commissioner Jeffrey Meyers vowed to look into ways to cover the bills for the underinsured. “I want to look into this because I’d like to determine one way or another whether we can cover it,” he said. The New Hampshire department is looking to see whether an additional $12 million in requested flexible funds can be put toward absorbing unpaid bills, a spokesman later said, though operators of the hubs and spokes are skeptical the federal agency will consent.

Despite some financial concerns, Concord operators said the capital city’s hub is working smoothly. 136 Concord-area people have called the 24/7 “211” number or walked into the facility since the program started; 73% of those showed up to their initial appointment.

About 34 visitors came in with alcohol addiction, compared to 42 with an opiate-use disorder, 18 who used stimulants, one for marijuana use and three for other substances, according to the organization.

At an Executive Council breakfast meeting Wednesday, Gov. Chris Sununu said the program still had kinks to be worked, but praised the numbers it had pulled in. And he said that an additional $11.9 million in state opioid-response money – announced last month – was an early indicator that the federal government was interested in the approach.

“One of the reasons they gave us this big increase was to say, ‘This model is very innovative. What you’re proposing is very different. Try it, try it quickly, show some results, and we can take it across the country,’ ” Sununu said.

(Ethan DeWitt can be reached at, 369-3307, or on Twitter at @edewittNH.)

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