By Alison Knopf
California technically doesn’t have waiting lists for opioid treatment programs (OTPs). When a program is full, the operator can ask the state for an increase in slots. If the request is granted—and it usually is—the program then pays for the extra slots in a new license.
This flexibility is very helpful to OTP providers. “We adjust our capacity up or down each year,” said Jason Kletter, PhD, president of BayMark Health Services. “If I only have 200 patients, I’m not going to pay for a license for 500,” said Dr. Kletter, who is also president of California Opioid Maintenance Providers (COMP), a membership organization of OTPs in the state.
“We’ve never had a problem with waiting lists in California,” Dr. Kletter told AT Forum. “BayMark is at only 73% capacity.”
“Narcotic treatment is a Drug Medi-Cal benefit in California ,” said Thomas Renfree, interim executive director of the County Behavioral Health Directors Association. “And because Drug Medi-Cal is an entitlement program, this does not allow for waiting lists for narcotic treatment.” If an OTP has more patients than it can handle in a clinic, new patients are entitled to treatment elsewhere.
Counties in Charge
But that doesn’t mean the transition happens smoothly for everyone. In California, under the terms of the 1115 Waiver for the Drug Medi-Cal Organized Delivery System, said Mr. Renfree, counties act as managed care plans for their residents, which authorizes the county to select the network of providers with whom the county will contract to provide services to its residents. At the same time, each county is responsible to ensure that every eligible beneficiary has timely access to all covered services when medically necessary, including narcotic treatment. Each county is also financially responsible for services provided to its residents, whether in county or out of county.
Under ordinary conditions, if one clinic is at capacity, it asks the county for additional capacity, which refers that request to the state, as indicated above.
But Alex Dodd, CEO of Aegis Treatment Centers, said there’s a glitch in this system. “We talk to the county and say the clinic is at capacity, we need your support for additional capacity,” Mr. Dodd told AT Forum. For example, in the Aegis OTP in Modesto, which has historically been full, new patients would historically have been referred to an Aegis clinic across the county border. However, under the Medicaid waiver, counties are not required to pay for treating patients from other counties, because each county gets a set amount for its Medicaid beneficiaries. Stanislaus County and Aegis are working together to open a new clinic in Ceres.
In fact, Stanislaus County, where Modesto is located, has a county-run program, and Aegis refers patients there if its clinic is at capacity, said Mr. Renfree. But what if the county-run program itself is at capacity or the patient wants to be in an Aegis program? “If the client wants to stay with Aegis and doesn’t want to go to the county-run clinic, they may request to receive services in the contracted Aegis facility across the border, he said. Stanislaus County understands that it is not good medical practice to disrupt patient care if the beneficiary has a good relationship with a particular clinic, and it is key to maintain continuity of treatment.
Building New Clinics
Another problem comes from NIMBY (not in my back yard)—not from the behavioral health policy makers, but from local supervisors. “The first thing you try to do is use your existing facility to accommodate the increase in capacity,” said Mr. Dodd. “But sometimes the clinic runs out of physical capacity, in which case you have to build a new clinic somewhere.” Aegis is currently trying to do this in two counties: one is being supportive, and the other is “dragging its feet,” he said.
Why would a county drag its feet about a new OTP during an opioid epidemic, especially when the investment is going to be borne entirely by a private company? “The main reasons we have found historically are stigma-related,” said Mr. Dodd. “If the board of supervisors is not in favor of treatment, they respond to political pressure.”
California has 19 grants categorized as State Targeted Response to the Opioid Crisis (STR) grants; Aegis is administering six of them. “By and large, this program is well done,” said Mr. Dodd. “But the biggest thing the government could help with next is a public awareness campaign to spread the word about treatment to patients and families. If it were up to me, I’d have a big advertising campaign.”
And Mr. Dodd would like to see more leadership from the governor’s office. When Howard Shumlin, then governor of Vermont, gave his state-of-the-state speech in 2014, “the only thing he talked about was the opioid epidemic,” recalled Mr. Dodd. “Unless there is that political leadership, unless number one says this is a big problem, the public servants are not going to take that direction.”
The big push using STR in California has been on a hub-and-spoke system, in which OTPs are the hubs and office-based opioid treatment (OBOT) prescribers are the spokes And in fact, aside from adding OTP capacity in the north, the biggest focus has been in expanding the spokes, said Dr. Kletter. The same is likely to be true of the new State Opioid Response (SOR) grants.
The STR grants have helped bring visibility and therefore support to the need to expand OTPs, especially north of San Francisco, where Aegis is using STR money to begin setting up programs, and where the relatively small and very rural counties have united. BAART (the predecessor to BayMark) tried to set up an OTP in Humboldt County about 25 years ago, recalled Dr. Kletter, but the county didn’t want it then. “Now, the STR grant gives some money to share with local communities, which garners support from those communities,” he pointed out.
The biggest problem facing OTPs is not funding: it is stigma and NIMBYism. There’s a segment of the population that will never be convinced to support a local OTP, said Dr. Kletter, “especially when they think their property values and safety are threatened.”
How to get past that? Community meetings are one way, but this can mean facing groups that are as friendly as “pitchfork mobs,” he said. Maybe the only solution would be to attach strings to funding, in which localities would have to agree to treatment programs to get their Medicaid dollars.
In the meantime, the main actors in OTP expansion are the private for-profit chains, in California as in the rest of the country. If these programs have plans for expanding and want to grow new clinics to meet the demand, they are going to need support, not only in funding, but in public awareness from government leaders. California’s regulatory system is flexible enough to allow new programs, and the law requires treatment on demand for Medicaid patients; advocates hope the momentum from federal STR and SOR grants continues to advance the needs of OTP patients.