Elimination of Methadone Benefits in the Oregon Health Plan: Patient Impacts

1. October 7, 2004 AHSR Conference Philidelpha PA 1 Elimination of Methadone Benefits in the Oregon Health Plan: Patient Impacts Bret E. Fuller, Ph.D. Traci Rieckmann, Ph.D. Dennis McCarty, Ph.D. Oregon Health & Science University

2. October 7, 2004 AHSR Conference Philidelpha PA 2 Acknowledgements Sponsors: Oregon Practice Improvement Collaborative (CSAT) 1-UDI � TI12904 � 01 (Edmundson) Robert Wood Johnson Foundation RWJ 048301 (Fuller) National Institute on Drug Abuse (1 RO3 DA017710-01, Fuller) Big Help: CODA, Inc., Roz Ringor-Carty, Sandy Kennard, Kristen Carlson R01 DA14688 (McCarty)

3. October 7, 2004 AHSR Conference Philidelpha PA 3 Changes in the Oregon Health Plan (OHP) Benefits eliminated for outpatient drug treatment (OHP-Standard recipients). OHP covered 60% of methadone patients OHP Standard recipient choices Detoxification and termination Pay out of pocket

4. October 7, 2004 AHSR Conference Philidelpha PA 4 Background Methadone Maintenance Treatment (MMT) is an effective, evidence-based therapy (National Census Development Panel, 1998). Effects of MMT (Kreek, 1991; McGlothlin & Anglin, 1981; Strain et al., 1994). Decreased opioid use, mortality, HIV risk, criminality Increased retention in care

5. October 7, 2004 AHSR Conference Philidelpha PA 5 Background Termination of MMT leads to Return to illicit use of opioids Increased legal, occupational and social problems (Rosenbaum et al., 1996; Anglin et al, 1989; Alexandre et al., 2002)

6. October 7, 2004 AHSR Conference Philidelpha PA 6 Opportunity for Policy Analysis A prospective assessment of MMT patients following the loss of benefits Characterize those patients who lost benefits Assess long-term outcomes

7. October 7, 2004 AHSR Conference Philidelpha PA 7 Study Design A naturalistic, prospective, time-series design including four waves of data collection: Wave 1: Baseline � before loss of benefits (2/03-3/03) Wave 2: One-month post reduction (4/03) Wave 3: Three-month follow-up (6/03) Wave 4: One year follow-up (2/04-3/04)

8. October 7, 2004 AHSR Conference Philidelpha PA 8 Method Participants: OHP-Standard Involuntary Detox (OHP-ID) lost benefits for methadone and were were given 30 days to taper off methadone. OHP-Standard Self Pay (OHP-SP) patients lost methadone benefits who were able to pay for at least four weeks of methadone out of pocket. OHP-Plus (OHP-Plus) did not have benefits cut.

9. October 7, 2004 AHSR Conference Philidelpha PA 9 Procedures Randomly selected clients were contacted through the dosing window. If interested, research staff scheduled an appointment or initiated the consent process and assessment at that time. Interview included obtaining detailed contact information and the completion of three assessments.

10. October 7, 2004 AHSR Conference Philidelpha PA 10 Procedures Participants were given a $20 dollar gift card for each visit, with a $20 bonus for attending all four sessions. A second chart review was done at one year to assess treatment characteristics, methadone dosing and treatment progress. Clients were re-consented for the June interviews due to changes in the consent form and federal implementation of HIPAA regulations. Clients were re-consented for the June interviews due to changes in the consent form and federal implementation of HIPAA regulations.

11. October 7, 2004 AHSR Conference Philidelpha PA 11 Instrumentation Addiction Severity Index-Lite (McLellan, et al., 1980; 1992). One-year Questionnaire: Assessed injection drug use, use of heroin and reuse of needles with a one-year timeline follow back. Clinical Record Review: Assessed dosing levels of methadone prior to funding cuts, as well after change in service coverage. This has been one of the most widely used instruments in the addictions field and has been shown to be highly reliable and valid in many scientific investigations. The follow-up version asks questions only the items that are variable. This instrument has been used in many studies and in state governments to assess substance-abusing clients and its reliability and validity are well established (McLellan et al. 1985) with extensive research and testing in drug and alcohol abusing populations. Modifications also continue to be made to improve the usability of this instrument across populations and assessment periods (Carise et al. 2001). This has been one of the most widely used instruments in the addictions field and has been shown to be highly reliable and valid in many scientific investigations. The follow-up version asks questions only the items that are variable. This instrument has been used in many studies and in state governments to assess substance-abusing clients and its reliability and validity are well established (McLellan et al. 1985) with extensive research and testing in drug and alcohol abusing populations. Modifications also continue to be made to improve the usability of this instrument across populations and assessment periods (Carise et al. 2001).

12. October 7, 2004 AHSR Conference Philidelpha PA 12 Methadone use by Medicaid Categories

13. October 7, 2004 AHSR Conference Philidelpha PA 13 ASI: Medical Problems

14. October 7, 2004 AHSR Conference Philidelpha PA 14 ASI: Employment Problems Self-paying clients reported more employment problems than the other two groups. A significant increase in employment problems was observed over the year. Self-paying clients reported more employment problems than the other two groups. A significant increase in employment problems was observed over the year.

15. October 7, 2004 AHSR Conference Philidelpha PA 15 Percent not working in past 30 days

16. October 7, 2004 AHSR Conference Philidelpha PA 16 Monthly Income

17. October 7, 2004 AHSR Conference Philidelpha PA 17 Percent homeless over the year following benefit cuts

18. October 7, 2004 AHSR Conference Philidelpha PA 18 ASI: Drug Problems

19. October 7, 2004 AHSR Conference Philidelpha PA 19 Drug-Related Risk Behaviors

20. October 7, 2004 AHSR Conference Philidelpha PA 20 ASI: Legal Problems

21. October 7, 2004 AHSR Conference Philidelpha PA 21 ASI: Family

22. October 7, 2004 AHSR Conference Philidelpha PA 22 ASI: Psychiatric Problems

23. October 7, 2004 AHSR Conference Philidelpha PA 23 Discussion This naturalistic study provides relevant and timely information about the impact of benefits reduction for individuals receiving methadone, an evidence-based practice. The results above are instructive in that they show that benefit cuts inordinately affected those who are poorer and have fewer resources at their disposal.

24. October 7, 2004 AHSR Conference Philidelpha PA 24 Discussion The project suggests that those patients who were able to maintain care did substantially better. The patients who were unable to pay out of pocket showed significant elevations on the medical, legal, drug and psychiatric problems scores for at least three of the four waves. The results also indicated that those who were forced to detox returned to using heroin during their detox and afterwards.

25. October 7, 2004 AHSR Conference Philidelpha PA 25 Appendices Mean Tables For ASI Scores

26. October 7, 2004 AHSR Conference Philidelpha PA 26 ASI: Medical Problems

27. October 7, 2004 AHSR Conference Philidelpha PA 27 ASI: Employment Problems

28. October 7, 2004 AHSR Conference Philidelpha PA 28 Employment

29. October 7, 2004 AHSR Conference Philidelpha PA 29 Income

30. October 7, 2004 AHSR Conference Philidelpha PA 30 ASI: Drug Problems

31. October 7, 2004 AHSR Conference Philidelpha PA 31 Drug-Related Risk Behaviors

32. October 7, 2004 AHSR Conference Philidelpha PA 32 ASI: Legal Problems

33. October 7, 2004 AHSR Conference Philidelpha PA 33 ASI: Family

34. October 7, 2004 AHSR Conference Philidelpha PA 34 ASI: Psychiatric Problems