Posts Tagged ‘Cures Act’

Temporary Grace: the CURES Act

 

 

 

 

 

 

The 21st Century Cures Act, signed into law by President Obama late in his presidency, provided money to help people with opioid use disorder get treatment. In April of this year, states got this money, in the form of STR (state targeted response to the opioid crisis) grants. Eighty percent of this money is to be spent for treatment, meaning more people with opioid use disorder should be able to access treatment.

And this is happening.

In North Carolina, the money was allotted to LME/MCO organizations. These organizations also manage our Medicaid dollars in various regions of the state. As I understand it, these organizations help to decide which treatment programs receive CURES dollars.

Our opioid treatment program (OTP) immediately applied for access to this money for patients. Since we’ve already gone through the vetting process to be approved to accept Medicaid patients by our LME/MCO agency, it didn’t take long to become approved for CURES dollars.

We’ve admitted around eighty people on the CURES grant who had no other way to pay for treatment. To qualify for CURES, they needed to apply for Medicaid, and then bring in the refusal letter, saying that they didn’t qualify to receive Medicaid. (Being a red state, in North Carolina a person can be making very little money at their job and still not qualify for Medicaid.)

These eighty people, instead of having to pay their daily treatment fee, have it paid for them through the CURES grant.

This is fantastic. This is wonderful. We’ve re-admitted many patients who were in treatment with us in the past, but who dropped out for financial reasons. We’ve admitted patients with long-standing opioid use disorder who have never been able to afford treatment. It is thrilling to see these patients stop using opioids and start to engage in treatment. The great majority of patients admitted under CURES have shown improvement.

It’s not all been roses, though. Some of these patients are extremely ill with long-neglected mental and physical health issues. It’s been a challenge to find places to refer them for primary care. Some patients have burned bridges with many of the primary care doctors in the area. Others with serious health issues refuse to see a doctor. Substance use disorder isn’t the only disease with denial. I sense these patients are often scared to hear a bad diagnosis from a doctor, and prefer to ignore their ailments.

Some people admitted with CURES dollars have severe mental illness, to the point that it can interfere with treatment and affect other patients. We’ve tried to strike a balance between helping patients with serious mental illness, while still maintaining a safe and comfortable treatment program for our patients. Often these patients refuse to be referred to the facility that contracts with our LME to provide mental health care. In other words, their mental illness interferes with their ability to get care for their mental illness. It can be terribly frustrating. I’m not a psychiatrist, and I’m not qualified to help them with these serious conditions.

We’ve admitted a handful of homeless people with opioid use disorder under the CURES grant. Our small town has one facility that will house people for up to two weeks, so at best that’s a very short-term solution. We can refer them to neighboring towns, but they don’t have transportation to dose with us every day, so they must transfer their care for opioid use disorder to another facility approved for CURES money. Some homeless people would rather live outside in a familiar area than move to a different town. With winter coming, it’s a grave concern.

Our patient census shot up relatively quickly, and our OTP has growing pains. We are struggling to hire more personnel, particularly to reduce wait times for dosing. I don’t have time to see every patient as I would like to, so the company I work for is looking for a physician extender to help me.

As is human nature, some people try to take advantage of grant money. I’ve had a few “patients” start on sublingual buprenorphine, only to see them attempt to divert their dose. When I confront them, and tell them I’m no longer willing to prescribe buprenorphine but would be willing to switch them to methadone, they get angry and leave. I believe – but can’t prove – these people intended to get buprenorphine to sell on the black market, where it goes for around $30 for an 8mg tablet.

We also must live with the uncertainty that this grant could be snatched away by a president intent on undoing everything the last president did. I tell patients benefitting from the CURES grant to look at this opportunity as a temporary thing, and that if possible, they need to try to find a way to pay for treatment themselves if the grant falls through. I hope it doesn’t, but the future of healthcare overall is in a period of transition, and opioid use disorder treatment is no exception.

Our whole staff feels more stress, and I try to remind them – and myself – of the larger picture. Experts say only 10-20% of people with opioid use disorder are presently getting help for their illness, and now with CURES, I believe that we are reaching a chunk of those who haven’t had care in the past.

It’s an opportunity that I’ve never seen in the sixteen years I’ve worked treating opioid use disorder. Despite our growing pains, we will continue to do all we can to access treatment dollars for people who can’t afford it otherwise. This CURES program should have this same effect across the country, enabling people with opioid use disorder enter treatment, often for the first time.

 

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Trump and the Opioid Grants: What Will Happen Next?

"Du-oh!"

“Du-oh!”

 

 

 

 

 

The front page article in the January 9, 2017 issue of Alcoholism and Drug Abuse Weekly is the jumping-off point for this blog entry. This excellent article outlines in plain language how the $ 1 billion Cures Act allocations were supposed to be used.

But on January 20, 2017, President Trump placed a sixty-day freeze on regulatory actions and executive orders that have been published but not yet taken effect. I scoured the internet to try to figure out if Obama’s Cures Act falls into this category. I’m still not certain it does.

The Cures Act, passed in late December as one of President Obama’s last actions had strong bipartisan support. Under this act, the Substance Abuse and Mental Health Services Administration (SAMHSA) is to administer funding for grants to each state. These grants are called State Targeted Response to the Opioid Crisis Grants, or Opioid STR for short.

The amount allotted to each state isn’t based on opioid overdose death rates, but rather on treatment gaps in each state. “Treatment gap” is a term for how many people need addiction treatment in a state compared to how many people are actually getting it. The bigger the gap, the more money that state will be allotted out of the $1 billion pot, to be disbursed over two years.

The states with the biggest treatment gaps are California, due to receive nearly $45 million, and Texas and Florida, both to receive around $27 million.

If dollars were spent based on per capita overdose death rates, the three top states would be West Virginia, New Hampshire, and Kentucky. This, of course, led to some criticism of the way money allocations were decided. Some people feel that the states that need money most desperately won’t get a big enough piece of the money pie.

As the ADAW article points out, some people feel the method of allocation is unfair to states where action has already been taken to treat substance use problems, out of their own state budget. By proactively treating problems, these states won’t qualify for as much of this federal money as states that ignored their opioid problem.

Other complaints are that states which decided not to expand Medicaid will now be awarded more than their share of this federal money, since their treatment gap is wider due to fewer citizens with substance use disorder who qualify for Medicaid to pay for substance use disorder treatment.

Probably no method of dividing the money can be perfectly fair to all states. I think the Cures Act does as good a job as is possible under the circumstances.

However, I am troubled by one aspect of this money distribution.

Each state can spend their federal money as they see fit.

In the ADAW article, H. Westley Clark, past director of SAMHSA’s Center for Substance Abuse Treatment, said, “State attitudes towards agonist medications will be a controlling factor.”

Oh dear. This could be bad.

States which have held a strong bias against methadone or buprenorphine as treatment for opioid use disorders may decide not to spend money on this evidence-based form of treatment.

But now, with President Trump’s sixty-day moratorium on new legislation, no one knows what will come to pass. There are so many uncertainties.

In the January 23, 2017 issue of ADAW, the front page article outlines how the repeal of the Affordable Care Act (ACA) could adversely affect the treatment of opioid use disorders. As we know, Trump campaigned on a promise to kill this healthcare Act. No one knows what he will decide to do, or how it will affect the 30 million people who have health insurance through the ACA now.

As the ADAW article points out, much of the gains in funding for treatment of substance abuse and mental health illnesses came from the ACA, and from the Mental Health Parity and Addiction Equity Act which preceded it. This last Act made it illegal for insurance companies to cover physical health problems while denying coverage for mental illness and substance abuse. Other laws made it illegal to refuse coverage for pre-existing illnesses. Denial of coverage for pre-existing conditions was common practice until relatively recently. When insurance companies could pick and choose who they wanted to insurance, patients who needed health insurance the most couldn’t get it.

Would canceling the ACA affect patients with substance use disorder who are already in treatment? Yes, of course, though I’m not sure to what degree. I know it would be more of an issue for my patients in office-based treatment with buprenorphine than for my patients enrolled at the opioid treatment program.

In the opioid treatment program setting, I don’t know of any patients with Obamacare who were able to get reimbursed for what they paid to our treatment program. These patients paid out of pocket even if they had insurance. I don’t know what the problem was, but I do know I had some bizarre conversations with physician reviewers. One physician said my patients with opioid use disorder, treated with methadone, needed to go a cheaper route, and get methadone prescribed in a doctor’s office. Of course, this is illegal, and has been since 1914, but that fact didn’t budge the reviewer.

Some of my office-based buprenorphine patients were able to enter treatment only because they got Obamacare. I would estimate I have eight to ten patients on Obamacare at present. They get reimbursed for the office visit and drug screening charges they pay to me, and get their medication paid for at the pharmacy, except for a co-pay.

Some of these patients have high deductibles, and still have to pay out of pocket for part of the year, but once they meet the deductible, have their opioid use disorder treatment paid for.

We’ve had the usual difficulties with prior authorizations with these patients, but it’s been no more difficult than patients with traditional insurance.

What would happen to my patients with Obamacare if it suddenly disappears? I assume most couldn’t afford treatment and would drop out. Data about patients who leave treatment for any reason shows relapse rates in the 85-90% range, so most of these people would go back to active addiction. I’ve become very attached to these patients, and this idea breaks my heart.

About a month ago, I was talking to Kristina Fiore, a reporter for the Wall Street Journal, who has done some outstanding reporting on the nation’s opioid use disorder epidemic. She called me for some background information for an article she was researching. Near the end of our conversation, she said something to the effect that everyone is always talking so negatively about our present opioid addiction situation, and she needed to know about reasons for optimism.

I thought about what she said for a few moments. Then I told her the only positive thing I saw was more money being released for desperately needed treatment.

Now, even this one positive aspect feels very uncertain.