In what appears to be insult added to injury, Maine opioid treatment program (OTP) patients not only face having to prove themselves in order to stay in treatment for more than two years, but, due to a cutback in Medicaid, 400 of them will be left with no access to state-paid treatment no matter how well they are doing.
Two years ago, the Maine legislature passed bills supported by the governor to limit Medicaid (called MaineCare) coverage for methadone or buprenorphine to two years (see ADAW, October 22, 2012; January 14, 2013).
Last year, the legislature proposed banning Medicaid coverage for buprenorphine or methadone altogether — thanks to the work of advocates, this bill failed, as did a bill that would have eliminated the prior-authorization extensions.
Maine has chosen not to expand Medicaid under the Affordable Care Act, and this means that some patients who were eligible will no longer be. There was also a rate cut to treatment. Maine has a severe opioid problem, which the OTPs are meant to address (see ADAW, March 18, 2013; July 13, 2013).
Four hundred people in OTPs are among those who are losing Medicaid coverage as a result of the cutbacks to MaineCare. We asked John A. Martins, spokesman for the Maine Department of Health and Human Services, in an email what the state’s plans are for those patients.
“Substance use and abuse is not new in Maine or across the nation and occurred long before Maine’s initial expansion of the MaineCare program in 2002 to cover those who are losing coverage,” said Martins. “We remain committed to effective and efficient use of non-MaineCare resources to improve education and successfully prevent addiction and intervene early before addiction occurs.”
Switch between modalities
There is a two-year cap for Medicaid-supported methadone and buprenorphine treatment in Maine; however, with prior authorization, patients who are doing well in treatment may continue. “The state does not wish to pay for treatment if it is proven to be ineffective for that member,” said Martins. “If after two years they are still not successful in their treatment, then the state will no longer pay for that treatment.”
However, patients can switch from one modality to another. “For example, someone who is not successful using Suboxone can still be treated at state cost for medication-assisted treatment at a methadone clinic, and vice versa,” said Martins. “Our policy per legislation is that for two years, without question, members can receive treatment. To continue treatment beyond those two years, the member and the provider will have to demonstrate that it is effective.”
Asked what concerns Maine has about patients turning to heroin or other opioids and overdosing if they lose their treatment medication, Martins responded, “We are always concerned about any overdose.” But, he said, the reality is that addiction has been on the rise in Maine over the last three decades, with opioid addiction surpassing even alcohol addiction. “The nature of active addiction is that people will seek substances to stave off the symptoms that come with withdrawal,” he said.
The state is working to “integrate physical and behavioral health” to help prevent, intervene with and treat substance use and abuse, said Martins. It’s just a matter of funding. “We remain committed to effective and efficient use of non-MaineCare resources to improve education and successfully prevent addiction and intervene early before addiction occurs,” he said.
The situation in Maine is in stark contrast to that of Vermont, where Governor Peter Shumlin issued a clarion call to address that state’s opioid problem in his State of the State message (see ADAW, January 13). “I cannot speak to Vermont’s approach,” said Martins. “From a MaineCare perspective, we have a comprehensive treatment coverage approach,” including Suboxone, methadone clinic services, Vivitrol and abstinence-based counseling. “Perhaps our policy difference is that we require that the member demonstrate success and response to treatment to continue coverage after two years,” said Martins.
How will Maine keep patients who are tapered off their medication due to losing coverage from relapsing? “We promote individuals taking responsibility for their own recovery,” responded Martins. “We continue to build a continuum of services that promote wellness and recovery. We continue to support services that are recovery-oriented.”
New OTP in Sanford
It’s always possible that patients who lose Medicaid coverage will figure out how to pay for it out of their own pockets. OTPs across the country in states that don’t cover OTP treatment follow that model — they are mostly for-profit, and only take paying patients.
Spectrum Health System, based in Worcester, Massachusetts, opened an OTP in Sanford, Maine, on January 16. The need is there. “We’re hopeful that the legislature will reconsider the cap and overturn it,” said Kristin Nolan, executive director of outpatient services. The facility is currently allowed to have 225 patients, and if there is a demand for more slots, Spectrum will go to the town and get it increased, said Nolan. “The town has been open to meeting with us,” she told ADAW, adding that it’s hard to predict how many patients will want treatment. “We opened a clinic in a rural area in Massachusetts — we expected 200 and we’re treating 400.”
For a year, the trend in Massachusetts has been from prescription opioids to heroin, because the heroin is less expensive, said Nolan. Spectrum has eight OTPs in Massachusetts, and the one in Sanford is its first out of state.
Opioid addiction is growing — Spectrum has seen a 15 to 20 percent increase in the overall census of the past year, said Nolan, who would much prefer that Medicaid cover treatment for patients.
We asked to speak to someone at the Center for Substance Abuse Treatment (CSAT), which regulates OTPs, about the pressures on patients and OTPs in Maine. Substance Abuse and Mental Health Services Administration spokesman Brad Stone, after several days, got back to us and said, “The consensus is that this is really a CMS matter.” CMS spokesman Mark Weber did not respond in time for our deadline.
Patients on methadone or buprenorphine in Maine are facing losing Medicaid coverage and their treatment.