Interview With Todd Mandel and Peter Lee from
Vermont Department of Health's Office of Alcohol and Drug Abuse Programs (ADAP)
June 1, 2008
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Introduction
Vermont was one of the last states to adopt medication-assisted treatment (MAT) for opiate dependence. It opened its first methadone clinic in 2002 in Burlington and approximately 500 patients in the state now are in methadone programs. Vermont also is home to more physicians who are authorized to dispense buprenorphine, and almost 1,200 patients take it. Before services were expanded, the state transported some of its Medicaid clients who needed MAT to clinics in Massachusetts and New Hampshire, at great cost to the state. Vermont still is grappling with waiting lists at some of its clinics and with making the transition from an acute care treatment model to a chronic care model.
This interview is with Peter Lee, chief of Treatment Services for the Office of Alcohol and Drug Abuse Programs (ADAP) of the Vermont Department of Health, and Dr. Todd Mandell, ADAP's medical director. The interviews have been edited for length and clarity.
Vermont is one of the more recent states to expand into medication-assisted treatment for opiate addiction. What made the state decide to expand its services, and what has the state been doing since then?
Todd Mandell
We realized we had some catching up to do because we identified more than 2,000 people as candidates for medication-assisted therapies. We began to recruit and train physicians to use buprenorphine and opened a center to help them with the induction process. We currently have the highest number of waivered physicians in the country. [Editor's note: A waivered physician is a doctor that has received federal approval to provide MAT using Schedule III, IV or V medications. The specific qualifications for a waiver can be read at http://buprenorphine.samhsa.gov/waiver_qualifications.html.]
Two mobile programs in northeast Vermont deal with providing treatment to patients who we can’t get to treatment. We opened an opiate induction center in central Vermont to evaluate and induct physicians who then can work from their primary care offices. We've evaluated more than 400 people since the center was opened in 2006. Senator Bartlett gave one-time funding of $150,000 to my office so we could recruit physicians, provide Continuing Medical Education credits and give them an incentive to take a day off from work. We paid for training for 38 physicians, with stipends ranging from $250 to $500. We talked them through the on-line course, provided a hard copy of the training in advance, and then rented or borrowed computers so they could participate. We work through each module, stress important points and cover additional information.
We spent $315,000 to set up our coordination of office-based medication-assisted therapy (COB-MAT). We divided the state into six regions and had a coordinator work with the waivered physicians in each area to say, "Doc, your patients are getting where they're supposed to be, there aren't enough services, or the patient is not going to the services. Let's figure out how to approach this." This lasted for only a year, but we identified some ways to better predict candidates for office-based treatment. At the same time, Senator Bartlett allocated $500,000 to state Medicaid, which we set up as a capitated fund for physicians to receive higher reimbursements for using buprenorphine, based on acuity and number of patients seen.
Peter Lee
Doctors told us they weren't being reimbursed enough. Frankly, I was taken aback. It's a problem that doctors are viewed as being wealthy—"What do you mean you’re not being paid enough?" When I listened to them, however, they were absolutely right. They weren't talking about their own reimbursement as physicians but about reimbursement of the practice. When addicts first come in, they require a good deal of extra up-front office staff work. There are more phone calls, people lose their prescriptions and many other incidents in early recovery take office staff, nurse and nurse practitioner time. Thus, doctors wanted some increased reimbursement for those efforts, which really is reasonable.
Todd Mandell
At the same time, a methadone program opened in New Hampshire, right over the border, that takes Vermont Medicaid and a program also has opened in Brattleboro, VT. My boss determined with Medicaid that the amount of money saved by transporting patients from various parts of Vermont to Brattleboro—instead of the previous closest treatment center in Greenfield, MA, just south of Brattleboro—would allow us to pay for more people to go treatment in Brattleboro and not leave the state.
Peter Lee
Vermont has traditional Medicaid and the Vermont Health Access Program (VHAP). Traditional Medicaid is a richer benefit than VHAP. It provides transportation for necessary medical appointments. We were able to include methadone treatment as a medically necessary appointment. The Medicaid division then paid for transportation to and from methadone clinics for people who had that benefit. It was expensive because there are not many clinics—people might have to travel 100 to 200 miles daily. A new clinic opened in Brattleboro and we took 11 patients who were being transported to the then closest clinic in Greenfield. Analysis of the costs showed that paying the rate for the 11 transported patients at the Brattleboro clinic—about $5,200 annually—would save approximately $151,000. That might not sound like much, but Vermont is a small state and that was for only 11 people. We worked with a clinic in Brattleboro to make slots available for patients we called "The Travelers." In only a year and half, we were able to double the amount of methadone slots available in Vermont. The Medicaid division also is saving money, despite the fact that it paid all clinic fees, because it did not have to pay for patient transportation.
Are there waiting lists in Vermont for MAT?
Todd Mandell
We still have some waiting lists, especially in highly populated areas and we receive many calls each week asking for buprenorphine. Although we have the highest number of waivered physicians per capita, they actually do not treat the allowed number of patients; most doctors treat fewer than 20.
Peter Lee
It also depends on where you are. In Burlington, our largest city, we have only one clinic that treats approximately 220 people and has a waiting period of up to six months. The waiting list is a bit skewed because it may include patients who are on buprenorphine but prefer to be on methadone. Being on the waiting list doesn't mean patients are not receiving service. In Brattleboro or Newport, the waiting lists are only a week or two. It is a problem; we need more methadone slots in Vermont.
The rate of opiate users in Vermont has grown steadily in recent years, eclipsing other drugs. What do you think is the reason for this and how has it affected your treatment system?
Todd Mandell
I think it's important to remember that, in general, people get narcotics from their families', friends' and neighbors' medicine chests. It's there and available, which we are trying to address. We're trying to have doctors do a better job of prescribing and to address proper disposal of unused medications. Most callers right now who ask for treatment for opiate dependence focus on prescription drug abuse rather than on heroin.
How big of a problem is diversion?
Todd Mandell
We hear reports of diversion of buprenorphine. We're responding to diversion in the larger sense by saying we have to better address our prescription drug abuse problem rather than say buprenorphine is not a good thing. It's a very good thing, and it's a good treatment option. However, we have to ensure that our prescription drug abuse problem is being addressed. We also have an ongoing workgroup to deal with the issue. It's not nearly as much of a problem as the full agonist narcotics such as oxycontin—that's much, much higher.
Do you have any lessons for other states that want to expand their MAT services?
Todd Mandell
I think one reason our hub has been successful is that each patient receives a full assessment. A determination is made whether the patient is a candidate for methadone and if it is available in the area. We work directly with the physicians from the hub. The MAT coordinator works directly with primary care doctors to determine the success of patient treatment. If it is not going well, the coordinator will send the patient back to the hub. Our flexibility in the relationship of the treatment center with primary care doctors is outstanding. Previously, when physicians referred patients for substance abuse treatment, they often would never hear of them again and the physician would not be included as part of a team. The doctors have had an exceptional working relationship with the hub. They want to know what's happening. That's important to remember for any state that's trying to expand its services. Yes, recruit the physicians, but also provide them the support for managing opiate dependent patients.
Peter Lee
Our most successful venture has been partnering with other agencies such as the Medicaid division and helping them see that, by providing MAT, they're going to realize fairly immediate reductions in other health cost areas. The amount spent on buprenorphine patients for other health care services such as emergency room care and doctor's visits is greatly reduced, and the cost offset can be recognized in the first year.
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