First Posted 9/15/2013

I’ve written the first two parts of a three-part column about unintended consequences.  Part one described why discounts demanded from insurers for front-line services (e.g. office visits) create challenges for independent primary care practices that don’t have other sources of revenue, particularly revenue from procedures.  Part two explained why physicians employed by health systems are less likely to provide buprenorphine treatment of opioid dependence than are small, independent docs.  The combined effect is that doctors who prescribe buprenorphine are more likely to be independent practitioners who do not participate in insurance panels or Medicaid.

I hinted that I would eventually tie all of this into an unintended consequence of the Affordable Care Act.   I don’t want to debate politics, but a situation arose last week that illustrates the type of problems that arise when a profession, bound by complex regulations accumulated over decades, is crossed with a complicated new law.

Many patients covered by Medicaid choose to pay out-of-pocket for buprenorphine treatment.  In some cases non-Medicaid doctors are the only doctors available, but there may be other reasons for choosing one doctor over another beyond insurance coverage.   Likewise, patients in non-Medicaid insurance programs have the option to see doctors out of their network, if not satisfied with in-network choices.

Some people believe it is unfair for non-Medicaid doctors to see Medicaid patients through ‘private contracting.’   I described some of the factors that shaped the current system in the first two parts of this series.  Buprenorphine-certified physicians tend to be independent practitioners who lack the profit generators of healthcare ‘systems.’   And there is no way to provide the care warranted by opioid dependence— care that prevents diversion, that supports the type of behavior change needed to stem active addiction—for the $30 per 20-minute visit provided by Medicaid.  We can WISH that the numbers added up, but they don’t.  It might be possible to make a practice driven by volume, say if each patient was seen for five minutes by a doctor with roller skates.  But I suspect that high-volume, low-physician-contact practices would result in less sobriety, and more diversion of buprenorphine.

People in Wisconsin who are addicted to heroin and on Medicaid have several choices.  In parts of the state where no doctors prescribe buprenorphine, patients can 1. Stop heroin on their own or through AA/NA;   2. Purchase illicit buprenorphine and engage in ‘self-treatment’ (one type of diversion); 3. Try to find a residential treatment program that accepts Medicaid, and beat the 95% failure rate of such programs; or 4. Go to methadone clinics that are covered by Medicaid (and try to maintain employment around early-morning clinic visits).  Methadone clinics are high-volume practices that CAN function under Medicaid levels of reimbursement; clinics receive $70-$80 per week to see patients in rapid succession each morning. Medicaid even reimburses patients’ travel expenses for methadone maintenance.

In some parts of the state, doctors who prescribe buprenorphine provide another choice. Patients who choose buprenorphine pay up to several hundred dollars per month for buprenorphine treatment— far more than for daily visits for methadone.    But even with that cost, some patients prefer buprenorphine treatment over methadone.  Some patients are poor candidates for daily methadone because of sedation or other side effects.  Some patients can’t comply with methadone dosing schedules, and at the same time re-establish employment and self-sufficiency (and isn’t self-sufficiency the essence of rehabilitation?).  For people who pay over $100 per day for heroin, choosing buprenorphine for $200 per month may be a bargain.  Patients who to stop smoking or get help for other mental health conditions through buprenorphine-certified psychiatrists do even better in the cost equation—not counting the health benefits.

Several weeks ago, many state Medicaid agencies posted statements on their web sites that ‘because of the Affordable Care Act, services and medications prescribed by non-Medicaid physicians will no longer be covered by Medicaid’.  The statement reflected changes in practice mandated by a little-noticed provision of the new law.  Patients on Medicaid who went to pharmacies for buprenorphine refills were told that they would have to pay out of pocket– $300 to over $500, depending on their dose of Suboxone.  The situation was worsened by older Medicaid rules, that for example prevent patients on Medicaid from purchasing medication out-of-pocket, or that prohibit substituting cheaper generic buprenorphine for Suboxone Brand Film.

Patients turned away from pharmacies called their doctors and were told their options; to stop buprenorphine and go into withdrawal, or to search for a pharmacist that might sell Suboxone or buprenorphine for cash, knowing that paying out of pocket might result in permanent loss of Medicaid benefits (not to mention the cost of the medication).  Doctors had decisions as well; whether to enroll in Medicaid—something that many practices simply would not survive—or to stop prescribing to their Medicaid patients, leaving them to go into withdrawal within hours.

Doctors looking for clarification found inconsistent answers.  The Wisconsin Psychiatric Association had no clue that the rule change existed, let alone a solution.  The Wisconsin Medical Society didn’t bother to answer emails.  Officials at the state Medicaid program said ‘those patients can go on methadone, or they can go to doctors who accept Medicaid.’  Attempts to explain the background provided in my two prior posts were answered by the comment that ‘there are plenty of doctors who prescribe buprenorphine and who accept Medicaid.’  I said ‘no, there aren’t.’    They answered ‘yes, there are.’
There aren’t.

After several days of hand-wringing by doctors (and diarrhea, body aches and sneezing by patients), the web page for the Medicaid program of a different state described a solution that had been devised to accommodate the new law.  Doctors could enroll in Medicaid in a ‘limited status’ where they didn’t have to sign a provider agreement, as long as they didn’t expect any payments from Medicaid for those patients.  After all of the confusion, some doctors decided to play it safe by not taking Medicaid patients in the future.

Maybe someone feels better that fewer Medicaid patients are paying out of pocket for buprenorphine treatment.  But I suspect at least some former buprenorphine patients feel worse, after losing their job in order to stand in line for methadone each morning.  Is the country better off, forcing such ‘fairness’ on people unfortunate enough to suffer from opioid dependence?  That’s for someone else to decide… or more accurately, that is a decision that someone already made, that we all have to live with.

Unfortunately there are many situations like this one, where patients’ options or outcomes are impacted by unintentional, unforeseen problems caused by conflicting regulations.  In this case, the consequences (no medication, withdrawal) were more immediate than in some other cases.  But the infinite number of individual circumstances, combined with thousands of regulations, means that there will be a constant stream of cases that fall outside of the FAQ section of the Affordable Care Act.  In the past, finding solutions to for such problems required a call to an insurance company or in rare cases to state agencies.  But now, nobody who is available by phone understands the questions, let alone knows the answers.  And SOLVING a problem requires an Act of Congress.   How is THAT going to work?


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