By Alison Knopf
Opioid treatment programs (OTPs), like other health care providers, are not required to provide patient care without charge. If a patient can’t pay, and has no insurance and no Medicaid coverage, the OTP can—humanely—withdraw the patient from methadone.
Key parts of this story are Medicaid expansion and Medicaid payment for OTP services—both are state-by-state policies. For this story, we talked with one state that expanded Medicaid (Rhode Island), and two that didn’t (Georgia, where Medicaid will soon cover OTP services, and Tennessee, where Medicaid doesn’t cover patient care in OTPs). We also talked with federal regulators.
The Substance Abuse and Mental Health Services Administration (SAMHSA), in their accreditation guidelines released last year (https://atforum.com/2015/04/new-otp-accreditation-guidelines-will-not-allow-mid-levels/), allows involuntary withdrawal for nonpayment. “Our guidelines acknowledge that programs that are dependent on payment from patients to operate have to have recourse for administrative withdrawal,” said Melinda Campopiano, MD, acting director of the Division of Pharmacologic Therapies at SAMSHA’s Center for Substance Abuse Treatment.
“Our expectation is that they will do everything possible to bring that patient up to speed financially,” Dr. Campopiano told AT Forum. “But if they cannot do that, we expect that they will use a medically appropriate and humane withdrawal period.” Depending on the existing dose of methadone, this would be as long as 21 days, and possibly longer, she said.
In general medicine, if a physician is going to terminate a relationship with a patient for any reason, the physician must provide the patient with 30 days of care while the patient looks for a new provider, said Dr. Campopiano. “We can’t hold opioid treatment programs to a higher standard.”
However, she noted that unlike general medical practice, most OTPs—at least until recently—did rely on having patients pay for their own treatment. “There’s been an increase in insurance coverage, due to the Affordable Care Act [ACA], and it’s our hope that will bring less need for administrative withdrawal.”
When there is administrative withdrawal, patients should be given naloxone in case of relapse, and if possible, naltrexone, either oral or the extended release version (Vivitrol), according to SAMHSA.
In states where Medicaid pays for methadone, OTPs make every effort to enroll eligible patients in Medicaid, said Deb Crowley, past president of and current board delegate to the Tennessee chapter of the American Association for the Treatment of Opioid Dependence. In Tennessee, where no public money is spent for methadone in an OTP—not Medicaid funds, not the block grant—every OTP has its own guidelines to try to help the patient pay, said Ms. Crowley. “The bottom line is, if they can’t pay, we can’t carry them long term.”
Ms. Crowley said that CARF-accredited OTPs must give patients referrals to three other programs where they can get treatment, but noted that those programs are not required to take the patient. “It’s up to the patient to follow through,” she said.
Some patients may not understand that although methadone itself is inexpensive, they are paying for a lot more when they go to an OTP, said Ms. Crowley. OTPs, in order to be licensed and accredited, are required to provide services such as counseling. “Unlimited doctor visits, group and individual counseling—unlimited if necessary—are not optional. Can you go to a psychiatrist or a psychologist three times a week, if you need to, for $15 to $17 a day?”
In Rhode Island, where Medicaid was expanded, administrative withdrawals have become a thing of the past. For patients who are self-pay—which some still choose to be, especially if they have commercial insurance but don’t want the payer to know they are in treatment—the possibility of a “financial withdrawal” exists.
The number of financial withdrawals has decreased significantly since the beginning of the ACA, said Michael Rizzi, president and CEO of CODAC Behavioral Healthcare in Cranston, Rhode Island. There was a group of self-paying patients prior to the ACA—people who didn’t qualify for “subsidized” treatment because their income exceeded established limits, they made too much money for Medicaid, or programs had reached their cap on subsidized capacity. For the most part, they paid out of pocket. But now everyone has increased access to health insurance. “Thankfully, financial withdrawals are becoming rare due to Medicaid expansion,” said Mr. Rizzi of administrative withdrawals for financial reasons.
For those paying out-of-pocket, treatment in a Rhode Island OTP can cost $85 to $95 a week. For patients who self-pay, this is a $4,500 a year out-of-pocket expense. So in the years before the ACA, when someone was unable to pay, most programs would create a payment plan, said Mr. Rizzi. “If patients fell behind—missed one or two weeks—we would work out a weekly payment plan allowing them to pay down what they owed over time. The opioid treatment providers realize that this is not an easy life-change,” he said, of withdrawing from methadone. “We want to help patients stay in treatment in a way that is not financially burdensome.”
Sometimes patients who couldn’t pay would seek to transfer to another provider in the state—there are only five OTPs in Rhode Island—so would leave one OTP, with an unpaid balance, and go to another. “Programs try to be creative, meaning not waiving or forgiving fees, but trying to enable the person to see how to meet the responsibility for payment in as painless a way as possible,” he said.
When a patient wouldn’t pay or agree to a payment plan after missing payments for two weeks, CODAC would begin methadone withdrawal. This gave patients six weeks of “free treatment,” four of them spent withdrawing from methadone. In some cases, patients could halt this process if they fulfilled their payment requirements.
OTPs in Georgia, which did not expand Medicaid, don’t have a position on administrative withdrawals. AT Forum spoke with Jonathon P. Connell, who is chief executive officer of Private Clinic, an OTP based in Albany, and president of Opioid Treatment Providers of Georgia (OTPG). Speaking for his own clinic, but not for the OTPG, he discussed the issue of administrative withdrawal.
There are patients who are not covered by unexpanded Medicaid—such as adults without dependent children—and most of them are self-pay, said Mr. Connell. If patients are pregnant, OTPs treat them regardless of their ability to pay. For other patients, Private Clinic has a “helping hands” program, under which dollars are designated to help patients.
“We look at it on a case by case basis,” in terms of who can participate, he continued. “If they lost their job, and have been participating and actively working in the program, we will reduce their fees. For someone who is genuinely on a fixed income, like welfare, we may reduce their fees for a period.”
For most new OTP patients, the costs of treatment are far less than the amount they were spending on drugs, said Mr. Connell. “The average person we see has been spending from $100 to $400 a day on drugs. When they come to us and spend $12 a day, they see it as a savings plan.” However, what Mr. Connell has learned after 16 years in the OTP field is that the longer someone stays in treatment, the harder it is for them to pay. “The number-one reason people leave treatment is money,” he said. “It’s a very tough issue.”
The bottom line: there are people who taper from methadone, and do so successfully, at first. But the vast majority—more than 80%—relapse.
Excerts from the SAMHSA’s accreditation guidelines for OTPs on administrative withdrawal is available at: https://atforum.com/samhsa-guideline-2-9-2016/
Substance Abuse and Mental Health Services Administration. Federal Guidelines for Opioid Treatment Programs. HHS Publication No. (SMA) PEP15-FEDGUIDEOTP. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015.