The Maine Department of Health and Human Services has given addiction treatment agencies less than two months to get ready for payment changes that the agencies say could threaten the existence or quality of their programs in the middle of an opioid crisis.
The overhaul would, in effect, reduce the amount of funding for addiction services provided by more than a dozen organizations across the state, such as Wellspring in Bangor, which operates residential homes and a detox center, and Day One, which works with young people using substances, including those committed to Long Creek Youth Development Center in South Portland.
“By an administrative switch of a pen, they are gutting the system of treatment in the middle of an opioid crisis,” said Malory Otteson Shaughnessy, executive director of the Alliance for Addiction and Mental Health Services. “The bottom line is that it is just a complete overhaul, a change in the system with no forewarning and no timeline for transition.”
Six of her member agencies have shared with her their early estimates of expected losses: The tally from just the handful of organizations is roughly $3.5 million, she said.
Currently the agencies sign an annual contract with the state to receive regular sums throughout the year to provide services such as counseling, residential care and detoxification, especially to uninsured patients. The allotment can be adjusted if organizations go slightly over or under their projections for the amount of care they provide, but it gives them a fairly stable source of funding to count on throughout the year.
Now, DHHS has said it will stop paying those predictable sums throughout the year and instead reimburse agencies for each individual service they perform, starting July 1. It notified organizations’ finance personnel throughout May of the upcoming change, Shaughnessy said, catching the directors of the organizations off guard.
“No one had given any notification of any kind to any providers, nor had providers been asked for input on impact,” Shaughnessy said.
The contracts with the state were put in place to ensure providers could maintain a treatment infrastructure for those who needed it but had trouble paying, according to interviews with providers. The contracts allowed agencies to serve those without insurance, provided cover for them if clients didn’t show up for appointments, and filled the gaps when MaineCare rates didn’t meet actual costs. MaineCare is the state’s Medicaid program.
Now, changing from a model that funds programs to one that funds specific services raises a number of questions, providers said, including the following: What will providers be able to bill for, who will they be able to serve, will the reimbursement be enough, and can they make the transition in time?
Emily Spencer, a DHHS spokeswoman, said the change in payment structure “prioritizes the client, bringing them a greater quality of care through a more patient-driven and consumer-centric approach.” She said that the department has “successfully shifted multiple systems” to the fee-for-service model, including mental health services.
The new structure will lend providers “the opportunity to benefit from a system of care with demonstrated outcomes, with additional reimbursements available based on those outcomes and corresponding volume,” she said, and informing providers of the change in May gave them “plenty of time to adjust.”
Overall revenue for the providers has not decreased. “All of them have the same revenue available to bill against,” she said.
At Wellspring the change will have the greatest impact on the organization’s detox center in Hampden, called New Horizon, which opened in January and now may have to close, according to Suzanne Farley, Wellspring’s executive director. It offers 10 beds for people who have first been evaluated at an area hospital emergency department, and allows them to withdraw from drugs and alcohol in a safe environment. Withdrawing suddenly from alcohol can be deadly.
With the new fee-for-service model, the center will only get reimbursed when clients are in a bed, Farley said. But the center is not yet at full capacity, meaning it won’t receive the funding that it needs to grow and become established in the Bangor area. So it may have to shut its doors instead.
“There’s no way I can survive on a fee-for-service model for a program that’s only been up and running for five months,” she said. She asked DHHS for more time to transition to the new payment model, she said, but “right now I’ve heard nothing back.”
It would be a waste of tax money and community effort if New Horizon stopped running, Farley said. It took $200,000 to rehab the facility and another $120,000 to operate it during the first five months. MaineCare doesn’t cover the center’s services. Virtually no clients have health insurance that Wellspring can bill.
“City officials, legislators, law enforcement, hospitals — everyone was at the table advocating for the opening of this center. It received 100 percent approval at the legislature in both the House and the Senate. It seems very shortsighted that the state would want to put me in a position where I can’t sustain operations because of a fee model change with very little notice,” Farley said.
Wellspring also operates six-month residential substance use treatment programs for roughly 30 men and 30 women each year. It’s still analyzing the numbers but anticipates it will lose funding under the new payment model, Farley said. That’s because, even though the organization has waitlists for residential services, it often takes a couple days to track people down and get them in the door — time for which the agency won’t be paid.
“The opioid epidemic is not over. The fact that we would restrict access to services at the same time that we have great numbers dying in our state just doesn’t make sense,” Farley said.
Crisis and Counseling Centers, based in Augusta, anticipates it will lose $150,000 to $175,000 next year “at the very best,” said Michael Mitchell, the organization’s chief executive officer. He is concerned about how the new payment model will change the agency’s intensive outpatient program for those with substance use disorders, which last year served roughly 500 people.
“When someone’s ready to deal with their substance abuse issues, time is of the essence. With that you’ve got to have capacity all the time. That’s the part we’re concerned about. What does that mean when we don’t have a billable unit walking through the door?” he said.
Patients in the intensive outpatient program have often experienced the devastation that comes with long-term substance use, have other mental health challenges, are not employed and do not have private health insurance. They may be involved in the criminal justice system or child protective services. They frequently have experienced trauma. Helping people with complex needs and coordinating with other systems doesn’t always fit neatly into a billable service, Mitchell said.
“If it comes down to trimming back the quality of the service, we would have to make some decisions,” he said.
At Day One, based in South Portland, staff are also trying to figure out how to adapt their operations to the new payment model and what it will mean for clients. The organization provides individual and group counseling to more than a thousand young people each year in schools, office settings and Long Creek. It’s the only agency that provides substance use counseling in the youth detention center.
“This will have a dramatic impact on how Day One delivers care to its clients, and we’re going to have to change the way we do things to be able to access this funding,” said Greg Bowers, Day One’s chief executive officer. “This is going to be incredibly difficult. What makes it more difficult is the lack of notice and the lack of time to analyze the impact and to plan for what we may do — and then time to actually make the transition.”
The new payment model would have Day One bill for face-to-face time with clients at established MaineCare rates, Bowers said. But it’s not clear how Day One would pay for the behind-the-scenes work, such as coordinating with school officials, parents and the juvenile justice system, that makes the counseling possible.
“Oftentimes in dealing with clients like this, at this age, it’s a very difficult process,” Bowers said. “Oftentimes the clients we see are resistant to the service we’re providing, and it takes a lot of investment of time to build trust, to work with other people or resources that are in their lives, to coordinate the care that’s needed to be successful.”
“How are we able to deliver those services? And how is the quality of the care going to be impacted with those changes? To me that’s an important question,” he said.
Maine ranks among the top 10 states for its rate of opioid-related overdose deaths, according to the National Institute on Drug Abuse. In 2016, there were 25.2 opioid-related overdose deaths per 100,000 people, nearly double the national rate of 13.3 deaths per 100,000 people.
“It just seems we want to keep our focus on the treatment and improving the treatment and expanding access,” Bowers said. The payment model changes are “going to be a big distraction from that.”
Maine Focus is a journalism and community engagement initiative at the Bangor Daily News. Questions? Write to firstname.lastname@example.org.