Continued Challenges to OTPs in Maine
Written by Jennifer Minthorn, Maine AATOD Board Delegate
October 29, 2016
As the opioid epidemic reaches its pinnacle here in the State of Maine with fatal overdoses reaching record number so far this year, efforts continue at the administration level to criminalize the problem. There has been a real focus on the enforcement side which we know from history that this “War on Drugs” approach has been a public policy failure. The Maine legislature approved monies last session to hire thirteen additional DEA agents and a small share of funds for prevention and abstinence-based treatment while the funding for the one treatment we know to be effective for opioid dependence, methadone maintenance, was left out of their equation to address the opioid crisis. The Governor of Maine has publicly come out to the media to say that he has been trying to close methadone clinics since he got into office. This has been evident given all of the legislation that has been brought forward over the last four years:
Several of the methadone providers in Maine formed the “Coalition to Ensure Fair Access to Opiate Addiction Treatment” when these efforts to close methadone clinics started. Although the coalition has been able to prevent some legislation from being passed that would negatively impact methadone treatment, it has not been able to restore the funding back to this needed service. The coalition will continue to work at the state and federal levels to advocate for the needs of the patients they serve and hope to someday restore full access to opiate addiction treatment without any limits and with the proper funding to adequately provide the full array of services methadone maintenance treatment was intended to provide when it was created over a half of century ago.
In a state where the addiction rate per capita is the highest in the country, the Maine State Legislature continues to attempt to limit access to opioid dependence treatment. In 2012, the 125th legislature passed bills limiting Medicaid coverage to two years for Buprenorphine and Methadone. This year, the 126th legislature proposed four additional bills related to medication assisted treatment but through our coalition’s efforts, additional cuts were not enacted.
Although we were successful in preventing further cuts to medication assisted treatment, the bill from 2012 that would limit reimbursement for Methadone Treatment to two years was put into effect August 1, 2013. Patients with MaineCare will not have insurance coverage for this treatment modality unless the state approves a prior authorization to extend their coverage past the two years. The law did not indicate that it was retroactive, therefore, the limits on Methadone Treatment doesn’t impact patients until January 1, 2015 since the two year clock started on January 1, 2013. The law pertaining to the limits on Suboxone Treatment has already gone into effect since the language in the law specified that it was retroactive. Patients who already had two years of treatment with Suboxone have had to work with their prescriber on a tapering plan in cases where the patient didn’t meet the criteria set forth in the prior authorization or in cases where their prior authorization wasn’t approved.
Other changes that are impacting methadone treatment in Maine include the state moving to a brokering system for MaineCare transportation and the fact that Maine has chosen not to expand Medicaid as part of the Affordable Care Act. Patients were not getting transported for dosing during the initial implementation of the new brokering system since they lost a lot of their drivers with a revised reimbursement structure that would reduce their payments. We are hopeful that the transportation issues will get resolved since this is a patient access issue that violates federal Medicaid laws. Fewer patients will have access to needed medication assisted treatment since they will not qualify for MaineCare after the State decided not to expand Medicaid. This is troubling at a time where Heroin is making a comeback with less prescription drugs available through new rulemaking regarding prescription for treating pain. The increase in overdoses from Heroin that is being seen statewide over the last year will continue to increase even more as access to opioid treatment is impeded.
The Methadone providers in the State of Maine have had an arduous year. The state legislature passed laws that made MaineCare (State Medicaid Program) budget cuts to medication assisted treatment while concurrently passing laws that restrict opioid prescriptions. One of the budgetary measures was a 15% rate cut to the weekly bundled rate for methadone treatment resulting in a total of 25% cuts to the rate over the last two and a half years. The weekly bundled rate is now $60 for all federal and state required services (physical, clinical assessment, dosing, medication monitoring, nursing assessments, counseling, care coordination, etc). In addition, there is a lifetime two year cap placed on Methadone and Suboxone Treatments unless the state determines that it is medically necessary based on a prior authorization process.
In reaction to these bills being proposed back in the beginning of the year, three of the organizations in the state that make up ¾ of the clinics in Maine, formed a coalition to ensure fair access to Opiate Addiction Treatment. Our advocacy efforts have been successful in getting the state to implement the two year cap prospectively verses retroactively. This means that our patients have another two years before they have to get a prior authorization to continue receiving funding for their methadone services instead of starting a detox beginning in January 2013. As a result of specific language we were able to get added to the law, representatives from the OTPs have been invited to the table to help with drafting the prior authorization criteria. The coalition has worked to bring our concerns to the attention of the Centers for Medicaid and Medicare (CMS) though letters of support from local, state and federal level representation. At this time, CMS is still reviewing the State Plan Amendment that includes the cuts to methadone treatment. Instead of approving the SPA after 90 days, CMS issued an extension for another 90 days to conduct a review of the materials submitted against the federal regulations to determine if the state will get approval for these and other cuts to the State run Medicaid Program.
As the country moves towards improving access to treatment through the Affordable Care Act, the State of Maine is passing laws to restrict access to care. At a time where opioid addiction is at epidemic proportions, it is our hope that the State of Maine will realize the impact of any kind of restriction on theone treatment for opioid addiction that has proven effectiveness. The treatment community is hoping that the State Plan Amendment is not approved. At this time, the clinics are under a state waiver from the Office of Substance Abuse and Mental Health Services to allow them to function at a much higher client to patient ratio- up to 1:150 versus the required 1:50. Staff morale and burnout are of utmost concern at this time.