New Health Care Laws: How Will They Affect Office-based Treatment with Suboxone?

Last week, one of my office-based buprenorphine patients asked me how I thought the new healthcare laws would affect my business. I’ve considered this question with a mix of anxiety and hope. Until we have more details, I’m not certain I’ll like the new changes. And of course since I’m a healthcare provider, I’ll look at changes differently than if I were an insurance executive.

I told my patient that it will be excellent for my patients in buprenorphine (Suboxone, Subutex) treatment who don’t have insurance now, and are paying out of pocket. My patient then remarked that I’ll be much busier, because more pain pill addicts will be able to afford treatment.

“No,” I said, “I can still only have one hundred Suboxone patients at any one time, so I can’t add any new patients.”

My patient was quiet for a moment and said, “So if an addict calls you because he just got insurance to pay for his treatment, you couldn’t see him anyway?”

“That’s right, unless I lost a patient for some reason, and had an open spot for him.”

“So even if addicts get insurance, they can’t use it? That’s crazy. Why does the government have that law?”

I explained to him about the newness of the DATA 2000 Act, and that some lawmakers were skittish about this program from the beginning. They were worried Suboxone “mills” would open, where hundreds of addicts were treated with little physician oversight or precautions.

Lifting that limit would be the easiest way to get more opioid addicts into treatment.

My private practice, where I treat opioid addicts with buprenorphine (Suboxone, Subutex), is a bare bones operation. Because of the one hundred patient limit, I have enough patients to keep me busy for one day per week. On the other days, I work at opioid treatment programs. I enjoy my own office practice because of the autonomy, and because I have some great patients that I’ve known for years. But at my own office, I make far less than half what I make at the opioid treatment programs.

I have the usual fixed overhead of rent, utilities, answering service, internet, etc., and most of the money I take in goes towards that. I have a part-time health care coordinator, who makes appointments for patients, calls them to remind them of appointments, does most of my office drug screens, screens my after-hours calls, handles the filing, copying and other record-keeping tasks, and deals with those pesky pre-authorization requests that insurance companies make. (She and the counselor have decided I ought not to be allowed to talk with the insurance companies, since I often erupt into profanity).Then I have the best LCAS (Licensed Clinical Addiction Specialist) counselor in the world who works with me on Fridays, doing individual counseling (he’s my fiancé). Since I don’t file insurance, but rather give the patient a receipt so they can file it themselves, I avoid that personnel expense.

And I don’t accept Medicaid or Medicare as payment for treatment. I feel guilty for admitting that, but I don’t think I could stay in practice if I accepted what these government programs pay for treatment. When I first opened my own office in 2010, I saw a handful of these patients for free, since trying to file and going through the necessary red tape isn’t worth the pittance these programs pay for an office visit.

So if my uninsured patients get Medicaid, I’ll have to decide how to deal with that problem.

It’s not legal for me to ask patients with Medicaid and/or Medicare to pay for treatment out of their pocket unless I opt out of those programs completely for a period of years. I can’t do that because some of the other treatment facilities that I work for do bill Medicaid.

So do I start taking Medicaid, with all its headaches, red tape and low re-imbursement? I don’t know. I don’t like the thought of it, but it will perhaps become a necessity. It will depend on reimbursement rates. Plus, I’ll be paid even less since I don’t have electronic medical records. Government programs have decreed that doctors without meaningful use electronic medical records will receive less money for Medicaid/Medicare patients than doctors with these programs.

I’m not against electronic medical records. I use them effectively at both of the opioid treatment programs. One program is completely paperless, and I like that much more than I ever thought. But in my small, one hundred patient office, I can’t afford any software for medical records. It’s not practical or feasible

Since I was trained and still am board-certified as an Internal Medicine doctor, I could fill my other days with primary care patients. I was talking to another doctor who was starting her own Suboxone practice, and she was wondering how to get by financially, only practicing Addiction Medicine. She too is a former Internal Medicine doctor. I suggested she could always do some primary care.

“Just shoot me in the head,” she said, summarizing my feeling exactly. I’ve never liked primary care as much as addiction medicine, to put it mildly.

Addicts are easier to deal with, and are often nicer people than the average soccer mom, demanding an antibiotic to treat her viral upper respiratory infection. But my biggest reason for preferring addiction medicine is that addicts get better. I never saw the big changes in health when I worked in primary care, like I do in people treated for addiction. Primary care feels like a step backwards. I don’t want to go back to treating non-compliant diabetics, and overweight people who won’t exercise. I’d prefer to keep my present patients, in whom I see an intense desire to get well.

I’m addicted to seeing the big changes that I see when I work in addiction medicine. I hope the new changes in healthcare will allow me to stay in the business of helping people change. Like the rest of the U.S., I’ll have to wait and see.

Advertisements

5 responses to this post.

  1. Posted by dbc91726 on July 3, 2012 at 5:35 pm

    Oh crap, that is right. Now, instead of only ‘productive’ members of society having access to treatment, there will be floods – something methadone clinics already handle. Actually I suspect most would go to methadone clinics, but still Suboxone clinics will feel up fast. I suspect there will be a portion who refuse to take any insurance (no insurance covers it in my state at this time), and hike up costs.

    As for your finances, I don’t care how much you make, but I know that some Suboxone doctors, based on simple math, are making a heck of a lot of money – mostly due tot he patient limit, and limited number of doctors wanting anything to do with Suboxone.

    Lastly, I do caution everyone – do not believe any doctor who says when you get off Suboxone you’re just ‘off’ no problems. I was on less than 2mg every other day and didn’t sleep for 2 weeks. Now, it was *nothing* like full agnost withdrawals, but still not pleasant. You must be tapered down real low, because at real low doses buprenorphine has its most efficacy. Any time I see doctors prescribing 32mgs a day to people, I just shake my head… as anything over 8mgs is normally a waste, even for those with the highest opiod tolerance. I know, I know, they think they need that much.. and *maybe* some need 16mg, but from my experience, 8mg is the ceiling, and it actually feels more potent the less you do. The good thing about 8mg, is that if you have a strong mind, you can dose every other day (despite this being contraindicated).

    Reply

  2. Posted by dbc91726 on July 3, 2012 at 5:38 pm

    Oops, spelled ‘fill’ wrong ;p. Of course, these new strips are a problem because they are very difficult to cut, and from my experience are problematic due to that. I also wonder how quickly they start to oxidize once they are opened. Overall, I’ve found the strips a pain to deal with, and glad I was going out of the program about the time they came in.

    Reply

  3. Posted by dbc91726 on July 3, 2012 at 5:42 pm

    Lastly, I should note that the discrepancy in doses is often due to very different levels of bioavailability per patient. Depends how long you keep it in your mouth, how little saliva hits it (according to my last doc), etc.. Remember, the highest you’re gonna get sublingually is 40%.. and NO, there’s no safe way to increase that. That’s just it.

    Reply

  4. I would not be ashamed of not taking Medicare! Not at all! I have no insurance and pay dearly for monthly treatment. As a patient and looking and observing you as a medical doctor- I don’t feel like you should take Medicare and not get paid for saving addicts lives!

    I know for fact that a suboxone dr in Memphis tn accepted tn care. He received a 7.00$ check for a patients visit!!!!!! He framed it!!!! I can’t make that up! No I don’t blame you one bit!

    Also- this remark may get much hate and I know it is often said that if doctors will accept tn care- all addicts will get well!

    My opinion is that is if I had a card that would pay for my subutex- I would not be as committed to staying clean as I am today when I suffer to come up with the money!

    I know people claim “IF” I had it, I wouldn’t have anything wrong with me, not true!

    If I had tn care- I could go to a dr for free- and if I relapsed- who cares- I wasn’t out any money. All I would do is get in with another dr accepting tn care and start all over!

    This I know would be a great problem! Not to mention all the people that I see with tn care- 85% of them are taking govt money, seeing suboxone drs, getting med filled, ONLY to sell it on streets at 100% profit!

    I don’t know how your state is, but I have seen this over and over in Memphis tn! And I am from halls. I literally feel sorry for the drs who accept tn care! Literally!

    Now before anyone jumps on me! 🙂 my solution to making this treatment more available is for the manufacturer to make it cheaper!

    When I started in 2007- I was paying 1200$ / month! For treatment!

    Thanks to generic, I am now paying
    $700/mo for treatment! This is cheaper than most bc my loved pharmacist gives me a break on the subutex cost!

    Walgreens subutex has went up to 742$ and that’s for generic!!

    So I feel like Medicare is Not the solution and know if you accept it- you will regret it!

    I feel like if treatment was free, people wouldn’t take it as serious! For example- I was out 600$ in dr visits bc my dr abandoned me- but bc I have been out that much money/ I don’t want to find a new dr or relapse or anything.

    (Although in my current situation, I have no choice to find a doc) but I am just saying. I take it seriously!

    Drs should get paid the most! It’s not RB answering patients calls, or counseling patients, or even responding to addicts in a blog. It’s not RB that spends countless hrs worried about what to do with one patients situation and if there is anything else to be done!
    I personally think the money should go to y’all!

    They should lower prices! We all know if hydros can be made for $20 a bottle, they can make subutex that low if they wanted too.

    Don’t get me wrong: I personally don’t think it should be that low bc again that’s gonna lead to more abuse: but there is a HUGE gap between $742. And $20! They can come down a heck of a lot and still make money!

    I have watched RB for 5 years, and I hate to tell you I am not impressed with them at all. They have caused undue stress to many from their ” we’re gonna stop making this or that” or everyone has to go to films Etc BS! And their claim on films being safer/ BS!

    The only reason I will post this next statement is for your research! I know of a 2 year old that let a subutex dissolve halfway! It was an 8mg pill! The child vomited once, and nothing else happened. The parent frantically called poison control and watched the child the next 72 hrs! the child was OK! thank God. she was more irritable 30hrs after ingestion but she was ok and breathing was not supressed. Buprunorphene ALONE is very unlikely to cause death due to overdose!
    So their LIE about safety to me is BS.

    Please to anyone reading this- keep medicine locked up! Away from children! This child had unzipped a purse and got one out of a supposedly safety bottle! A grave mistake on the parent but it could have been a lot worse! This child was mine! I have been on subutex five years with no relapse and this “accident” and stupidity on MY part is the WORST thing that has happened to me in the whole recovery process! I was scared for my child’s life.
    No one thinks a child will let such a nasty pill lay in their mouth/ well unfortunately if they see us do it: they want to do it too. Sad but true.

    As a parent who has made this mistake: I assure all of you the last thing I need is hate or nasty comments. Out of all the things I have done wrong in my life- this hurt me the worst! And still does! But I learned from it, and all meds are in a locked safe! And then inside a combination fire proof safe on inside of big safe!

    Don’t think your child cannot reach your medicine on an high shelf! Or in a cabinet, truck, etc: they Can and will!

    For further research / and since its not available on Internet. I will also say I own a preschool. And have seen two other children who let subutex dissolve. Both of them were ok too! These “thank God” were not my children or my medicine- but thought I would add that bc you said you couldn’t find on Internet. A 18 month old child in another prek had actually swallowed the whole 8mg pill :/ scary but she vomited, threw fits for 3 days, and cried on day 4. On day 5 she woke up the happy child she was before ingestion :/

    I am writing this with caution and pray no one attacks me, I am not stating that subutex is NOT dangerous! I am just stating personal eye view accounts that I witnessed! Subutex ( even though I am in withdraw now from it) is the safest way to treat addiction! I can not even imagine what would have happened to my daughter if that had been another type of pill!

    At 130 lbs, I was allowed to take 7 1/2 subutex per day. I know the stupidity of this now! However back then I had no suppressed breathing or overdose.

    The drs and I agreed that the govt was way off on their ceiling affect! Which is 32 mg/ day!

    Since I have weaned down/ I will humbly admit I was wrong along with the dr! Their truly is a ceiling affect- meaning you will get nothing more like pleasurable feelings after 32 mg/ day!
    Oh the medicine I wasted and spent all my money on! I was wrong! And I can’t believe I just admitted this truth!

    Now I will say that I can tell a huge difference between 5 and 4 per day: but I am betting that’s just the addict in me being rebellious and that 32 mg really truly is where the ceiling affect cuts off!

    These are just my personal opinions 🙂 and I hope they make sense and don’t offend anyone. God Bless!
    Nacole

    Reply

  5. Posted by amroke on November 10, 2013 at 6:07 pm

    It’s such a shame that the 100 patient rule exists after all of this time. I think suboxone treatment is a god send. It allows people to live a somewhat normal life and be treated like a human being. Kudos to you doctor for sticking it out! I myself am a wife and mother if two girls who got addicted to pain pills when I was thirty while dealing with endometriosis and cysts among other things. One and a half years if my life dealing with this and taking pain pills made me suffer for the rest if my life! Finding a doctor that takes insurance is near impossible in my area. I have to go to the next state over for my treatment and even then my BCBS union blue only covers the visit, NOT the pills which if not for prescription discount cards would cost 600 bucks a month. I pay 200 with the free card. Something must be done about this. I know lots of people, far more than our country would like to admit, that are addicted to opiate pain killers. The treatment is severely lacking. The reason my ins says they won’t cover it is because the FDA only approved it for short term use. Bullocks! I’ve been on it for 5 years and I have no ill side affects from it that I know of the good out ways the bad. Please continue to help, you are doing a wonderful thing! Need more like you.

    Reply

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: