Medicaid’s Limits for Non-compliance


The opioid treatment program where I work accepts Medicaid as payment, starting a few years ago. Overall, it’s been so beneficial for hundreds of our patients. However, when Medicaid patients have repeatedly positive drug screens, Medicaid overseers threaten to cut off their funding for treatment.

Our state’s Medicaid system is divided into counties, and these counties contract with agencies to provide oversight for the mental health and substance abuse treatment dollars. I’ve had several conversations with the doctors who do peer review for payment to our program.

We discuss patients’ progress, and whether more Medicaid money will be approved for their treatment. This agency says they have the right to cut off payment for treatment of Medicaid patients who don’t become drug-free within a reasonable period of time. So far, they haven’t cut off payment for any patients, but we have many patients at risk for this. If patients lose Medicaid coverage, they can remain in treatment with us, but have to pay out of their own pocket.

I feel torn about this issue.

On the one hand, I know my patients will do better if they are able to stay in treatment on MAT. If Medicaid quits paying for their treatment, many will leave treatment and go back to illicit drug use. I know from various studies that patients who leave MAT have high relapse rates. Relapses back to illicit opioid use can cost more to the Medicaid system than staying in treatment. Plus, patients who leave treatment are at greater risk of overdose death.

On the other hand, as a taxpayer, I understand why people object to using tax dollars, in the form of Medicaid, to pay for addiction treatment if the patient is still using illicit drugs. Some people may feel this is a government subsidy to continue drug use.

Most people feel we do have an obligation to the disabled and the poor to provide medical care. But should we apply different criteria for payment of substance use disorder compared to other chronic medical illnesses, which also have behavioral components?

The doctors who decide when to stop paying for MAT could use similar criteria to decide when to stop paying for other medical care of chronic illnesses.

Imagine this conversation:

“Hello, this is Dr. X. I am calling regarding approval of payment for the treatment of Mrs. Sweet, the diabetic you are seeing. I’ve authorized ninety days more of payment for her, but if her blood glucose readings and her hemoglobin A1C don’t improve, I will be recommending we stop paying for her treatment. She will have to pay for her diabetic medication and her medical care from her own pocket.”

“I don’t understand. I’ve been treating Mrs. Sweet for years…her diabetes is about as well-controlled now as it has been for years.”

“Our point exactly. She isn’t showing any improvement. You told her to follow a diabetic diet, lose weight, and exercise, and she hasn’t done any of these things. If she’s not willing to follow physician recommendations, Medicaid won’t approve payment for the medical care she needs for diabetes.”

Can you imagine the outrage at such a decision?

Let’s use an example of another chronic illness: heart disease. Let’s say I have a patient who has coronary artery disease. He had one heart attack and had to have a coronary stent placed. He has very high cholesterol, but despite dietary instructions, he continues to eat fatty foods and plenty of red meat. He also isn’t compliant taking his cholesterol medication.

He has another episode of chest pain, goes to the hospital, gets admitted with another heart attack, but the Medicaid overseers say his medical care will not be paid for, since he hasn’t made the changes recommended by his physician.

Are these scenarios starting to hit a little close to home?

Let’s be careful when we start deciding who deserves or doesn’t deserve to have their medical treatment paid for, if we use behavioral change as the yardstick for such decisions. Few of us with chronic illnesses do everything perfectly.

It’s part of human nature.

4 responses to this post.

  1. Reblogged this on My Sharing Blog.


  2. Posted by Caroline Kent on August 7, 2017 at 2:47 pm

    Once again, you have described the stigma in the treatment of opiate addiction beautifully.
    We know addicts will do better on MAT, regardless of their other drug use. Yet, for these patients, we hold out punitive, even life-threatening consequences if they do not or cannot follow the rules that are imposed partially to keep them safer but are also imposed to threaten them into compliance.
    Keep up the good work!


  3. Posted by Bowza on August 8, 2017 at 12:10 am

    I try to explain that to people all the time ,I’m a firefighter/emt we have countless overdoses a year and the people I work with have no respect for drug addiction. I have had it affect my life personally so I know it’s a disease just like any other medical issue but I don’t think people will change there minds until it happens to them or someone they love. No one wakes up and says I want to be a junky! And just like diabetes and heart disease and anything that bad habits can bring it on drug addiction is no different you made a bad choice to start but stopping isn’t a simple choice it’s a struggle infact drug addiction should get more compassion because it’s 100 times harder to deal with but human beings are cruel creatures and like to feel superior and look down on others that weren’t as fortunate to of avoided addiction they forget that the opioid epidemic was caused by big pharmaceutical companies


  4. Posted by Wayne Walker on August 8, 2017 at 12:59 am

    I understand what you are saying and have been at a clinic for substance abuse for over 5 years. Yes the treatment at the clinic has kept me from buying on the street. I am disabled and have to pay for treatment out of pocket. The clinic has a program that has a grant to help pay for treatment but you have to be denied medicaid. The program should be those only with a hardship. Some of Those receiving the grant or on medicaid, have a free ride if they are able to work. A clinic member stated, “I don’t need to work now since I got the grant. ” Everyone should and deserve treatment but the clinic should have a time frame to be weaned off the medication that will suit the persons needs. The ones that work hard and barely make ends meet, get no help it should be given out fairly. Medicaid is a good program but the people that cant follow the rules deemed by Medicaid should not be allowed to continue, most of Those that don’t care and are there for a free ride. This country needs better insurance and everyone needs fair treatment.


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