When the pandemic hit the epicenter of New York City in mid-March, Nicholas Stavros’ 24-7 clinics across the country were already preparing. “We got in front of this right away,” said Mr. Stavros, CEO of Community Medical Services (CMS), based in Scottsdale, Arizona.
CMS has programs in several states, so keeping up with federal regulatory changes and state-by-state nuances has been a challenge. Each state has a peak for COVID-19, he noted. “The worst thing you can do is wait until the state is peaking to put people on extended take-homes,” he told AT Forum. If you do that, you have a large mass of people coming in on one day to get their 28 or 14 days of take-homes. So, at CMS, a schedule of clinics that transitioned from regular to extended take-homes was set up, so it didn’t happen all at once.
“We transferred staff, clinic by clinic, to help out,” he said. For example, one clinic would transition on a Monday, the next on a Tuesday, and so on.
There was also a lot of confusion at first, with programs wondering how to define “stable” (28 days) and “less than stable” (14 days) and how reimbursement would work.
“Those are good questions,” said Mr. Stavros. But at the time, the main point was to get patients out of the path of the virus. “We said ‘We don’t know, but we’ll build the airplane as we’re flying; we’ll work it out and learn as we go.’”
CMS has already been conducting counseling meetings and medical visits virtually, so telehealth adoption was not a problem, said Mr. Stavros. “We have all the equipment, all the platforms.” Much of the behavioral health industry is behind the times compared to the rest of medicine, he noted. But this is where private equity investment has been very helpful to OTPs—including to CMS.
“Private equity doesn’t just want a return on its investment,” he said. “They makes money off the sale of a company, not the yearly cash flow.” So the more sophisticated an OTP can be, the more valuable it is to the investor, even if there is a net negative income year after year, as long as reinvestment is geared towards quality growth and adding value. CMS’s partner, Clearview, understands this. “’We want you to have good systems,’” is the message.
Some patients still come in daily, but the daily census was cut in half by May, said Mr. Stavros. Every single decision on take-homes is made by the medical and clinical team, taking into account federal and state regulations, he said.
Avoiding COVID-19 is a prime concern. “Our patient population is a lot more vulnerable to the virus than the general population,” noted Mr. Stavros. OTP patients already may have hepatitis C, HIV, compromised immune systems, and a higher risk of getting sick if they are exposed to the virus. But OTPs are prepared—far more than pharmacies, he said. “Can you imagine a pharmacy that saw 2,000 patients a day?”
Mr. Stavros knows that the financial fallout from the increased take-homes won’t be good for OTPs. “A lot of the agencies that are not giving out extended take-homes tend to try to take a moral high-ground, and say that the other clinics are just ‘dose-and-go,’” he said. But in reality, these OTPs are the ones usually benefitting financially from not giving take-homes. Patients pay only if they come to the clinic. They’ll pay for their medication, but for only 1 visit instead of the 14 or 28.
Still, those clinics who are requiring patients to come in daily are exposing their patients to the virus—the precise reason that SAMHSA and the DEA loosened the regulations. “That’s not right,” said Mr. Stavros. “We know we’re going to take a revenue loss, because you get paid less for take-homes than for patients coming into the center.” But this is a case in which OTPs have to take the hit, he said, unless a state can figure out a way for Medicaid to fix reimbursements—and that would be in states where Medicaid has expanded.
“We’ve done a few home deliveries, a few curbside deliveries,” said Mr. Stavros. In one case, a patient in Wisconsin—who turned out not to have COVID-19—might have been positive. “He wasn’t, but we acted as if he was—he said he had just gotten out of the hospital, where he was told to self-isolate, so we gave him curbside delivery with PPE [personal protective equipment] for our staff.”
CMS also required that all patients getting extended take-homes have lockboxes to transport their medications. Sometimes, the lockboxes had to be provided by CMS because the patient wouldn’t pay. “But the harm reduction agencies throughout the country came through for a lot of our patients,” donating lockboxes, said Mr. Stavros.
Mr. Stavros’ recommendation for all OTPs—when and if this is over, because there will definitely be some other resurgence—is: “Have a plan.”