Maine Plans to Cut OTP Rate, Limit Treatment to Two Years

Included in the massive cuts being proposed for MaineCare, the state’s Medicaid program, are a rate cut from $72 a week to $60 a week per patient in an opioid treatment program (OTP), and a plan to limit medication-assisted treatment (MAT) with methadone or buprenorphine to two years.

The plan has the united support of Gov. Paul LePage, Department of Health and Human Services Commissioner Mary Mayhew, and Director of MaineCare Stefanie Nadeau.

There are some historical points that are important here, all focusing on the fact that for some reason, opioid addiction has been prevalent in this rural state. Kim Johnson, the former Single State Authority for the Substance Abuse Prevention and Treatment Block Grant (SSA), who has since gone to the Network for the Improvement of Addiction Treatment (NIATx), was an ardent supporter of OTP expansion in the state to respond to this demand. Guy Cousins, current SSA for Maine, also is a strong supporter of OTPs. (The SSA in Maine is the director of the Office of Substance Abuse.) But Governor LePage entered office with a different viewpoint.

Maine was one of the first states to note opioid overdoses. In 2006 the Community Epidemiological Work Group meeting heard a presentation about overdoses of methadone and morphine—this was methadone prescribed for pain, because Maine was, like many states, substituting the less-costly methadone for more-costly analgesics in hospital formularies.

With an increase in buprenorphine prescriptions in the state to treat the growing opioid addiction came an increase in buprenorphine abuse. The manufacturer sent researchers to the state who determined that many people abusing buprenorphine were actually using it for something akin to its intended purpose—to stave off withdrawal symptoms. Despite the support of Ms. Johnson and Mr. Cousins, there still was—and still is—a woeful shortage of OTPs in Maine.

It’s ironic that a state with a severe opioid addiction problem, which is the heart of the prescription drug abuse epidemic, would decide to cut back on treatment. The people who should be leading the education of residents are sending the wrong message. This takes us to NIMBY (“not in my backyard”). It took CRC Health Group a year to win a settlement allowing it to open an OTP in Warren, Maine; yet the town is still delaying an administrative review of the proposal.

Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), sent MaineCare Services an eloquent letter on June 14 protesting the two-year limit and the rate reduction, citing the Research Triangle Report findings that quality OTP treatment should cost $143 per patient per week, and that 85 percent of the costs are for labor. “In our judgment the State of Maine has engaged in a disastrous course which will have severely detrimental consequences to the patients in treatment and their families.”

And noting that limiting treatment to a two-year period “goes against all established evidence,” Mr. Parrino also called it a dysfunctional policy. More than 45 years of research have found that more than 75 percent of patients will relapse if their treatment is terminated, he wrote. “Many studies have demonstrated that this high a relapse rate applies to both patients who voluntarily end their treatment and patients who are involuntarily discharged.

“If Maine is of the judgment that it might be saving money by doing such a thing, this is a very risky bit of business since the State will inevitably push patients back into emergency rooms, which are far more expensive,” wrote Mr. Parrino. It would also push people into the criminal justice system, he said.

If Governor LePage asks Maine’s experts in addiction—Mr. Cousins and Marcella Sorg, PhD, of the Margaret Chase Smith Policy Center, come to mind—what they think, we are sure he would obtain good information. It would also help make the state’s population aware that their friends and neighbors are the people who need help. Gov. LePage could also look at the state’s own report on drug use issued in March, which shows that after alcohol, opioids are the second-highest treatment drug named at admission to treatment.

Why don’t governors ask their staff with expertise in addiction before making changes in addiction policy? Could it be because they don’t want to hear the answer?

For the Maine report on drug use trends, go to http://www.maine.gov/dhhs/osa/pubs/data/2012/EpiProfile2012.pdf

We look forward to your comments.

MaineCare at Core of Pain-Pill Epidemic – Prescription Drug Abuse and Related Health Care Costs are a Drain, But Funding for Treatment Also Saves Money

Treatment is the only way out of the spiral of opiate addiction, doctors say. But it isn’t cheap.

MaineCare payments for all substance abuse treatment totaled more than $100 million in the fiscal year that ended last June, according to figures provided by DHHS. Prescription pain relievers account for about one-third of the admissions for substance abuse treatment in Maine, second only to alcohol, according to the Office of Substance Abuse.

The biggest cost to MaineCare, however, is health care services related to abuse and addiction, from emergency department visits for withdrawal and overdoses, to treatments for hepatitis C and collapsed veins to the care provided to pregnant addicts and their babies.

http://www.pressherald.com/special/opiates/Sunday/MaineCare-at-core-of-pain-pill-epidemic-.html

Source: Portland Press Herald – October 16, 2011

Federal Agencies Join Forces to Award $13 Million to Enhance Drug Courts

The U.S. Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration (SAMHSA) and the Bureau of Justice Assistance (BJA) at the U.S. Department of Justice announced in October ten new grant awards to enhance adult drug court services, coordination and treatment.  

Building on the drug court model, SAMHSA and BJA developed a funding approach for courts that simplifies the application process and improves coordination of the services designed to help people overcome addictions. The grants will be used to provide alcohol and drug treatment, recovery support services supporting substance abuse treatment, screening, assessment,  case management, and program coordination to adult defendants/offenders.

Under this program, grantees will receive two separate awards; BJA will fund the drug court component and SAMHSA will fund the substance abuse treatment component. 

http://www.samhsa.gov/newsroom/advisories/1110125550.aspx 

Source: Substance Abuse and Mental Health Services Administration – October 12, 2011

How Methadone Treatment is Funded in OTPs

fundingOver the years AT Forum readers have asked how methadone maintenance (MM) treatment in opioid treatment programs (OTPs) is funded, and why some patients pay for their treatment while others receive it free.

The answer depends on the patient’s income and insurance status, the state’s funding scenario, and even the program’s status (profit or not-for-profit).

MM treatment is usually financed from a combination of public and private sources and patient self-pay, and the combination varies by state and by OTP.

“Public” funding includes funding from the federal Substance Abuse Prevention and Treatment block grant, the state block grant match, Medicaid, and other state, county, and local funding. Some states have no “public” funding for OTPs.

“Self-pay” means the patient pays out-of-pocket (for some or all of their treatment).

“Private” is what is paid by private insurance companies, private managed care companies, or directly by employers, or by a combination of these.

Public Funding

Medicaid coverage of addiction treatment varies from state to state, according to a 2008 report prepared for the National Council of State Legislatures: Medication-Assisted Treatment (MAT)for Opiate Addiction and the Public Financing of that Treatment. Author Suzanne Gelber, PhD, Avisa Group, tells AT Forum that not all states offer Medicaid funding for OTPs. States can opt not to offer Medicaid substance abuse coverage, even under parity. The most recent data were
collected by Dr. Gelber of Avisa in 2005 and published in 2008 by the Avisa and the National Council for State Legislatures on a special website (http://www.ncsl.org/default.aspx?tabid=14132). At that time  36 states used Medicaid funding, at least in part, for methadone treatment in OTPs (for the table, go to http://www.ncsl.org/Default.aspx?TabId=14144).

Federal Substance Abuse and Mental Health Services Administration (SAMHSA) funding to each state comes via the Substance Abuse Prevention and Treatment block grant (see sidebar). Block grants allow states to fund treatment for patients who are not covered by Medicaid, or to supplement Medicaid funding. There is no requirement that any block grant money be used for OTPs or MAT for opioids. Block grant funds from SAMHSA require a state contribution through a complicated formula that varies state by state.

For Profit = Patient Self Pay

Today, some patients are paying for their OTP treatment. Many are going to private for-profit OTPs, a trend that started in the 1990s and has gathered speed in recent years. In 1994, Rick Harwood, now director of research for the National Association of State Alcohol and Drug Abuse Directors, wrote a definitive analysis of MM funding (http://www.nap.edu/openbook.php?record_id=4899&page=162). At that time, only 17 percent of the total estimated cost of MM treatment was funded by patient self-pay. Thirty percent was paid by the block grant, 31 percent by state funds, 12 percent by Medicaid, and 7 percent by local funds, for a total of 80 percent of MM paid by public funds. Only 2.5 percent was paid by private insurance.

But a lot has changed in the MM treatment field since then, and a much bigger portion is now paid by patients directly, Mr. Harwood says. “A whole wave of private for-profit clinics have opened, and their patients pay, often in cash,” he tells AT Forum. Of the 286,000 patients in OTPs in 2008, approximately half attended private for-profit programs, and paid for their treatment out-of-pocket, at posted fees ranging from $13 to $25 a day or more. In fact, he says, due to sliding scales, the fees paid may be lower than advertised rates.

Mr. Harwood confirms that patient fees today definitely represent a bigger slice of the pie, and the pie itself has grown: $480 million a year was spent on MM in 1992, compared to Mr. Harwood’s estimate of about $1 billion a year today. But he points out that nobody really knows, because the information isn’t routinely collected. “It’s disappointing, because this is an important and very understudied topic.”

Only recently has SAMHSA resumed collecting financial data from a sample of its treatmentprograms. But there will be very few OTPs in this system, says Mr. Harwood. Furthermore, there will be no separate estimates for medication-assisted treatment.

Health Care Reform Will Increase Medicaid and Private Insurance Coverage

By 2014, the funding scenario will change once again. Under health care reform, virtually everyone in the country will be eligible to be covered by Medicaid, Medicare, or private insurance–at least, that is what the planners at SAMHSA say. In states that have health care reform now, such as Massachusetts, public funding has still been necessary for substance abuse treatment, since many people who need that treatment have not purchased health insurance. Payers know that MM is cost-effective when it’s part of a system of health care and behavioral health care; using it reduces unnecessary hospitalizations, ambulance costs, mortality, and emergency department visits. Theoretically, OTPs will receive more funding from Medicaid and private insurance, and fewer patients will have to dig into their own pockets to pay. All OTPs, whether for-profit or not-for-profit, will have to be able to bill Medicaid and private insurance companies by 2014.

Resources

For an analysis of how much money is spent per patient per year, depending on whether a program is public, private not-for-profit, or for-profit, see Wechsberg WM, Kasten JJ. Methadone Maintenance Treatment in the U.S.: A Practical Question and Answer Guide, New York, NY: Springer Publishing Co; 2007 (not available online).

Additional information on types of payment sources accepted by OTPs, showing a clear pattern of self-pay, can be found at the Substance Abuse and Mental Health Services Administration website (http://www.oas.samhsa.gov/2k10/222/222USOTP2k10.htm).

Also see the National Drug Abuse Treatment Utilization Survey (NDATUS), (For a summary of NDATUS gathered financial information circa 1996 based on the work of Rick Harwood and others. For the methadone data, see http://www.nap.edu/openbook.php?record_id=4899&page=162.

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