Is a large cut to methadone-providing doctors justified or putting patients at risk?

Doctors who solely provide methadone therapy to treat addiction to narcotics say they’re facing reductions of around 25% to their income, as a result of cuts to the fees for urine tests announced this month by the Ministry of Health.

Some addictions doctors and public health experts across the province are sounding alarm that this cut could mean reductions in methadone clinics’ hours and the services these clinics are providing. Some say methadone-providing clinics will close as a result.

“I’m hearing from a lot of doctors who provide methadone right now. There’s a lot of panic,” says Michael Parkinson,who provides coordination support for municipal drug strategies in his role with the Waterloo Region Crime Prevention Council.

Philip Berger, who provides methadone as part of a family practice at St. Michael’s Hospital, is not sure the panic is warranted, however. “These fees have been a huge financial windfall for physicians who spend their entire careers giving out methadone,” he says. Berger says the fee cut is “not unreasonable” and argues that “doctors always threaten to cut services when fees change.”

Methadone is a synthetic opioid provided to people addicted to heroin or prescription opioids like OxyContin. A maintained dose of methadone doesn’t produce a high and doesn’t cause withdrawal, so those on the drug can function in their day-to-day lives with less of an urge to seek out illicit drugs. It doesn’t work for everyone, however. Those who successfully stop using illicit opioids often take methadone steadily for a year or more, sometimes for life. One multi-site Canadian study found 50% of patients are able to stick to a methadone maintenance program.

“If methadone services aren’t available, what will people do? There’s a large cohort of people who will seek opioids at a street level,” says Parkinson. The costs of a spike in street-level drug use would far outweigh the costs of methadone treatment, Parkinson states. One Toronto-based study estimated the economic costs of untreated opioid addiction – including health care, crime and law enforcement costs – is $44,000 per person per year, not including social assistance costs. The cost of providing methadone maintenance treatment in Canada is estimated to be $6,000 per patient. “Financially, it’s a no-brainer,” says Parkinson.

Fee cuts target screening tests for illict drugs

In cuts to the fees paid to Ontario doctors announced this month by the Ministry of Health, the fee the government pays doctors for a “drugs of abuse screen” was cut in half from $29 to $15 for the first five urine tests per patient per month, and from $15 to $7.50 for the sixth to ninth urine tests. The fee changes to the codes G040 and G043 will become effective October 1.

Methadone-providing doctors are affected by this fee change because they frequently perform the test in their clinics. Urine tests are necessary to detect the presence of other drugs in a patient’s bloodstream and thus avoid an overdose. The College of Physicians and Surgeons of Ontario recommends urine screening anywhere from once a week to two times a week, depending on how long the patient has been in treatment and how long the patient has avoided illicit drugs.

A doctor who provides methadone on a full-time basis may have around 150 patients, according to several sources we interviewed. If that doctor provides an average of four urine tests per month for each patient – as per the College guidelines – the doctor will lose $100,800 per year. Because other fee codes that methadone providers bill for are relatively lower than the urine test, the cuts could represent about 25% of the current incomes of doctors who provide methadone full time, according to two methadone providers who spoke on the condition of anonymity. Family doctors who provide methadone for 25 patients as part of their family practice and do four urine tests per month for each patient will lose $16,800 per year.

There are currently 474 providers who care for 42,000 patients (as of July 2015), according to numbers sent by the College of Physicians and Surgeons of Ontario. This number includes doctors who are providing methadone treatment full-time, one or two days a week, or an hour or two total per week as part of a family practice.

Jeff Daiter is the co-CEO of Canadian Addiction Treatment Centres (CATC), which operates dozens of clinics in Ontario and provides methadone or Suboxone (a less-used methadone alternative) to 12,000 patients. In a statement he sent to Premier Kathleen Wynne, Health Minister Eric Hoskins and Deputy Health Minister Bob Bell – and forwarded to Healthy Debate – he wrote “as a result of the fee reduction, many of our clinics won’t be able to stay open as these changes place them firmly into a significant financial loss.” (When asked, a company representative said they don’t yet know exactly how many clinics could close.)

Despite the threats that clinics will have to close, it’s no question doctors who provide methadone full time have done well financially – with sources that didn’t want to be named saying it’s possible to gross more than half a million (before the fee cuts). That’s higher than the average doctor’s gross income of $350,000.

Mel Kahan, medical director of the Substance Use Service at Women’s College Hospital in Toronto, thinks the fee cut is justified. Even after the fee cuts, methadone therapy will be better compensated than primary care, he explains.

Additionally, the fact that methadone providers’ income has been so weighted on the urine test fee has incentivized doctors to do more urine tests, which can unnecessarily take up patients’ time and “generate cynicism” in patients, says Kahan.

Berger agrees that some methadone providers are providing less than optimal care and seeing excessive numbers of patients. Other methadone providers, he says, “are doing it ethically,” offering quality services to patients for the right reasons.

Michael Toth, president of the Ontario Medical Association, admits that it is possible some methadone providers are being overcompensated though he said he’s not aware of the issue. He stresses, however, that if the government had consulted with the province’s doctors before making this change, negotiations would have allowed for remuneration changes that wouldn’t threaten patient care.

On Wednesday, Healthy Debate asked the Ministry of Health about the cuts have been made, and whether the Ministry is concerned about how the cuts will affect access to methadone therapy. Last evening, a Ministry spokesperson said the government would not be able to send a response in time to meet our deadline.

Methadone clinics in small communities may be under threat

Wiplove Lamba, a psychiatrist who provides methadone to a handful of patients at St. Michael’s Hospital, says the problem with the cut is that it affects everyone – including those providing high quality methadone maintenance therapy to small numbers of patients in remote, rural or suburban communities. “Some of the smaller clinics may no longer be viable,” says Lamba. (Clinic owners’ incomes are based on a share of doctors’ fees.) “That means some people from small towns could have to travel an hour to a larger centre.” (Many patients on methadone need to see their provider at least once a week.)

One methadone clinic owner who didn’t wish to be named explains many methadone-providing clinic operators run clinics in high-demand areas that can be highly profitable as well as in low-demand areas that are only marginally profitable – this allows clinic operators to provide greater access to patients while also providing more work opportunities for their staff. But the fee cut, said the source, will mean the smaller clinics will start losing money, and this will necessitate closures.

The cut also affects those family doctors who provide methadone maintenance therapy to few patients as part of their larger general practice. “In the context of a primary care practice, doctors are not in [methadone treatment] for financial gain,” says Berger. A family doctor who provides methadone maintenance therapy may do so for about 25 patients, Berger says.

Berger explains that the fee cut could be unfair to the family doctors providing methadone treatment. Already, methadone prescribing requires special training and additional regulation, including “punctilious audits” by the College, says Berger – which explains why few family doctors provide the service.

Berger and Kahan point out the bigger problem with methadone treatment – that it’s not typically provided by family doctors, who are more accessible to patients and can provide more comprehensive care – isn’t being addressed. “Methadone treatment needs to be integrated into primary care, it needs to be accessible by all patients,” says Kahan. “And if you want to incentivize methadone providing doctors, why don’t you incentivize them in different ways, rather than providing urine drug screens? Why don’t they get incentivized to provide primary care or mental health counseling or to deal with other addictions besides opiates?”

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  1. James Collins

    The idea that funding cuts will somehow result in better outcomes is absurd. If you wish to make structural changes to programs, introduce different regulation, fine. To simply run a chainsaw through the funding formula and then expect that things will adjust accordingly to the standard you prefer, well we saw that before in Ontario, Mike Harris and his Common Sense Revolution destroyed countless lives with this methodology.

    The idea we need to “deincentivize” bad behavior by cutting doctors fees is a Trojan Horse for defunding opioid substitution programs and drug treatment in general.%featured% If there needs to be oversight of how many urine tests are being done, then that should happen; simply yanking the funding hurts everyone, corrupt and honest alike.%featured%

    • Sue

      James Collins are you a doctor? What do you know about the Methadone Maintenance Treatment and how clinics are run?? How on earth does URINE test fee cutbacks (the amount of money a doctor receives for a pee test) have any negative impact on clients— for clients, they likely will not have to continually revolve their lives around providing video taped urine tests, in clinics where their METHADONE prescription is held hostage until they have done so. This practice does not occur ANYWHERE ELSE or for any other prescription medication. IS it ethical for it to be done for methadone clients, simply so doctors can earn money for each pee that a client leaves?? Now THAT is absurd!! These “cutbacks” SHOULD happen! Doctors should not be given an “incentive” to dispense methadone. It should be dispensed judicially and empathetically to those that need it, just as every other medication is dispensed!!

      • Tristan Tsuji

        There is a growing cadre of ethical GP and family practice doctors who want to dispense in an ethical and clinically appropriate setting just like ANY other narcotic, part of the whole cycle of dependence and abuse stems from the judgement and prejudice built in to the methadone program. (References: 10+ years on program)

  2. Ann Silversides

    Interesting story. I am curious to know how many full-time methadone prescribing/dispensing doctors there are in Ontario and what proportion of the total number of methadone patients they treat.%featured% The painkiller/opioid crisis has no doubt led to a significant increase in people now on methadone and, I assume, to the number of doctors who practice exclusively as “methadone doctors”.%featured%

  3. Sos101

    I lost my job on Wednesday as a result of these cuts. I had only been back at work for 4 weeks following my parental leave so I don’t qualify for EI. Thanks, government.

    • Lisa

      I’m sorry, the work you do, is so important.

    • Sue

      You’ve lost your job as a methadone providing physician due to URINE test fee cuts?? Please explain, as this seems to be the most absurd claim yet. Do you not work for, or run a family practice?

    • Leeanne

      So sorry for your loss. ITS SO unfair,, they should allow you EI or some sort of benefit.

  4. Ashlee

    I was hired about three weeks ago with a promising amount of hours even for a part time position. I was excited to gain a part time job in my field as an SSW at a small rural methadone clinic. After the cuts take effect, I will have nine hours per pay cheque. Thanks government, for getting my hopes up and ripping them down, now, my job is basically non existant. 🙂

    • Sue

      How is your Social Service Work position affected by URINE fee cutbacks?? This makes absolutely no sense?? You mean because you won’t have to go in so often to work to put a testing strip in people’s pee samples? Is that really what you went to school to do?

      • Leeann

        I hate how condescending some people can be on here. Gee Sue if you don’t agree with what someone field its OK. But no need to be rude or ignorant its not necessary

    • Angela

      Ashley I feel for you I am in the same boat ! Sue – I feel sorry for you – please get educated

  5. Lisa

    The real question I’d… why this was all so secretive. People suffering from any addiction are a vulnerable population, and this will cost our system far more than it saves.%featured% I guess it’s an easy sell to balance the budget on the backs of a problem that nobody has much sympathy for, and to lump those doctors in with it… But this is very wrong. This will not help patients, and now, just attending clinics will keep patients from gainful employment. Most employers aren’t all that happy about their workers missing time every day.%featured%

  6. Jason Scott

    I am not quite sure how I feel about this. Methadone sounds like a great thing because it is able to help drug addicts that are trying to quit stay clean. Now at the same time this doesn’t change the fact that usually they can get hooked on the Methadone and be on it for a long time. If it is helping people in the long run, I don’t think it can be super bad for you.

  7. Judy

    The practice of urine dips happens in primary care for patients on a narcotic and to confirm they are taking their medication. The same practice is used with the methadone program. The challenge is that the operational costs of running a methadone clinic is set by the income. If a Physician can bill for the urine dips, telemedicine sessions then that is their only source of income. The operated their clinics by hiring staff and setting up a clinic location. When the income stream is drastically reduced than the operational costs of staff, location is compromised. This is simple business management. We are faced with this situation in our rural island with 3 small clinics being operated by two physicians. Our total number of people in the programs are 24, 16, 100 respectfully in each of the communities. The staffing costs and the physicians serves are being cut due to the low number of patients and the overhead attached to each clinic.

  8. Nurse Jojo

    I don’t think people understand this is not about just urine test cuts , the doctors , nurses . councillors and staff income are provided with these said ” urine test money” it is part of there salary which is a good percentage. This money goes to the doctor which pays for the clinic , heating , electricity washrooms , methadone , suboxone ect. and also pays the nurses , secretary’s and staff providing the clients treatment . Looking at the big picture it doesn’t matter what you label the cut its part of the whole clinics income and what keeps it open . It means smaller clinics will shut down . clinics will have to cut staff and business hours, which means more people traveling farther to a overcrowded clinic with crappy hours and huge waiting time because of lack of staff . A lot of people dont realize these people have jobs they have to attend to most of them will be late or having to change there hours , children and babies to look after . and a here’s something to think about there are people who have never abused drugs at the ciinics ! There are many people who have lost doctors , retired family doctors Ect. whatever the reason may be i personally know a few that need pain management that rely on methadone clinics because they are on a painkiller/narcotic prescribed by a previous doctor because of a car accident, work incident, fibromyalgia for example.

    • Scott

      I’m one of those people that goes to a methadone clinic for pain management. I was on OxyContin for years due to a car accident that gave me a herniated disc in my neck but I gained such a high tolerance for it that I couldn’t go to a higher dose due to the negative effects it has on your liver and kidneys. Methadone has been a godsend for me, I’m on a pretty low dose and it WORKS all day, don’t have to worry about it until the next day and it’s a LOT cheaper. I don’t mind peeing in a cup for them because I haven’t done drugs since I was in my early 20s, but this is just something that shouldn’t be considered to be cut until it’s the absolute LAST option. There are so many people I’ve met that methadone has completely saved them from hitting absolute rock-bottom and they are now completely functioning, tax-paying members of society. %featured%The clinic I go to (CATC) has reduced their hours from 8-5 to 8-2, and they’ve closed down 8 clinics so far in their network. So the cuts are pretty obvious already.%featured%

      • Mandy

        I’m also on methadone for pain so I know exactly where you are coming from. I use to have a family doctor to prescribed it to me but I ended up moving away to another city and now I need to go to a clinic.

  9. Rob C

    The full-time MMT doctors get pain too much. Everyone knows it especially with telemedicine. They need to write better notes and make less. The money can then go to new programs like IVF and home care

  10. michael

    The availability of good medical care tends to vary inversely with the need for it in the population served.

    -Julian Tudor Hart, The Inverse Care Law, The Lancet, 1971

    After 15 years of prescribing billions of dollars of opioids- a substance of known dependency- to Ontarians, the impacts are a deadly mess in most Ontario communities. Opioid dependency (>50,000 persons) and death (one opioid-related overdose every 14 hours) should come as no surprise. Clearly there are no adults in charge, inside and out of government.

    %featured%How darkly ironic that methadone is so heavily regulated and restricted yet (high-dose) opioids can be Rx’d by any physician. %featured% Tis scandalous that naloxone continues to be withheld from at-risk patients by governments, professional colleges and practitioners, especially considering the wide availability of epinephrine to treat anaphylaxis (92 deaths in 25 years vs opioid-related deaths of 4,984 in 13 years). It is easier to get pharm-grade heroin (opioids) than the lifesaving antidote naloxone or the addiction treatment medicine methadone.

    Irrespective of any reforms to medical billing, cutting or curtailing methadone services will aggravate an already desperate situation, especially for those on the margins. And if one is working through an addiction, you’re on the margins and know too well that Canadians are still a long way from universal and equitable health care.

  11. Keith Phillips MD

    I am a methadone prescriber in BC, for the past 11 years. We are paid 15$ or so for a urine screening test. It costs us 11 $ for the cup.

    Whats wrong with this picture?

    Lets compare the two provincial fee structures for methadone prescribers. There must be some other issues here, that needs clarification.

    • David

      Dr. Phillips,

      I would like to ask you a few questions regarding the cost of the urine test kits. I might be able to help bring that cost lower.

  12. Angela

    I have had to find work elsewhere because of these cutbacks. I was back from parental leave for 4 days to find out my hours would be cut significantly so that now I cannot support my family. Thanks government – not to mention the ones that truly matter – the clients! The hours of operation at our clinic have been cut so significantly that clients are less likely to come for treatment anymore. If clients are trying to work it is hard to make it into the clinic before noon- hurts all of us as these clients will be back on the street using and in the end costs us all more money .. And the lives of the clients are jeopardized . Wtg government

  13. T.Keeler

    To suggest that the urine screen cut backs are going to present a financial hardship to the vast majority of methadone prescribing physicians or clinics is a complete and utter fallacy. Yes, there may be some significant fallout for smaller, rural clinics who do not have the volume of patients that most inner city clinics have, but the clinics I have attended in the past years of my Suboxone treatment seem to be doing just fine. The physicians and pharmacists who have “commoditized” addiction treatment may lose a little off their bottom lines but the “services” that they offer, if you can even call them that are unlikely to be affected. Most of the clinics I have attended as a patient (I am currently being treated with Suboxone after becoming heavily addicted to Oxycontin for a debilitating back injury, the premise is that the Suboxone assists with the addiction and “off label” for pain management….but the reality is that I am NOW dependent on the Suboxone….better or worse??) offer urine screen as the ONLY service…other than the dispensation of the medication (which they can NOW do by computer meaning the Physicians do not even have to SHOW UP at the office!!!). I have yet to be offered ANY counselling or bio/psycho/social assessments as MANDATED by the Guidelines for Methadone Maintenance Therapy, in fact the clinics I have attended and the ones I have APPLIED to as an Addiction Counsellor have no counselling staff to speak of. The system is NOT set up to assist people in “getting off” of opiates but rather to get them “on” to methadone….and KEEP THEM THERE! I challenge ANY clinic that is operating in Ontario to show their statistics on the number of clients that they have transitioned OFF of the treatment. This has become a literal “cash cow” for not only physicians and pharmacists but also for the investors who have ponied up huge amounts of cash in partnerships with P & P’s to open and operate these clinics in ALL communities in the anticipation of ongoing profits. The treatment of addiction has become, like all other areas of medicine, a commodity to be profited from, unfortunately the VICTIMS are the addicts themselves NOT the medical professionals who profit from their misery!!

    • Nadia

      in an ideal world, there would be a comprehensive program addressing addiction. in this world, in this province, the government refuses to pay for that counseling. so it falls to the clinic owner — the physicians who run the clinics to pay for that counseling. how do you expect that to happen when physician fees are being cut recklessly? where do you expect the money to come from? will you pay $100-200 per hour of counseling? T Keeler, Sue — all the trolls on this site — pay attention: these urine drug tests are mandated by the government as a key component of good care for opioid addiction. the fee for this “key component” has just been cut; what does that tell you about our government’s priorities?
      the reason many of these clinics are closing is because they DON’T MAKE ENOUGH OF A PROFIT TO TOLERATE a 25% drop in one set of fees. how does that make the docs who run these clinics money-hungry???

  14. michael

    At least one clinic in Toronto is closing, plus the addiction clinics on Manitoulin, in Iroquois Falls, Cochrane, and Espinola. There is no plan to mitigate the negative impacts which are certain to occur and could include overdose deaths, street-sourcing opioids, loss of employment etc.

  15. Ryan

    It is incredible how easy it is to cut mental health services in this province. Is the fear that physicians providing this service are making too much money? It must be, because this service has been shown to provide overall cost savings. God forbid a psychiatrist or a family physician finds a way to make more money than the “average”. %featured%If we are concerned about cost cutting in this province, and concerned about physician wages, why do we not look at the cash cow specialties that are radiology, cardiology, dermatology, and opthamology. These physicians regularly bill over $750,000 per year. In addition, there are many examples of these physicians billing over one million dollars per year. We as citizens of this province are not willing to scrutinize and make cuts to these services, and would rather slash services to mental health patients. The reason is simple, mental health is under-served, under-recognized, and stigmatized.%featured%

  16. chris frise

    hi my name is chris ive been on and off methadone for years. i started useing pills as i worked in auto industry ford mo company, its ruined my life, how can the canadian goverment allow this drug to be so easily accessible. doctors take an oath to help humans get better not sit at a desk to give you drugs even tho your piss may be dirty. i have been thinking of doing a documentary as the journey of me coming off begining to end study how it affects people,interview addicts interview ex meth doctors interview the families. i know some one who took a percocet lied said he was useing for years he had a script the same day only to sell it and when he got carries and ratted out still gets it. I thought it was for hard core heroin addicts ive never seen heroin. i w love to get people to do that as part of documentary. im currently on 25 mil because im trying to get off the only problem there is only 4 medical detoxes in all canada and wait list is huge. im heading to a half way house for 4 months to transform my life. in canada my belief you should be put into a goverment run detox rehab for 6 months at the least b4 EVEN BEING CONSIDERED TO BE PUT ON DEVIL JUICE. i HAVE A GREAT STORY AND W LOVE SOMEONE TO COME ON BOARD. LETS GET THIS OUT TO THE PUBLIC film festivals i can film ysel cheply daily but i want it to be done right. not for profit if it makes money to open the first opiate recovery home in canada that is run right anyone wants to contact me

    • Sara

      I would love to chat w you more! I’ve been on the methadone maintenance program for 11yrs!

  17. Krystal

    Can a clinic secretary hold your script until you pay your clinic fees?

  18. Chelsie Brouillette

    If you take money from methadone clinics you’re going to end up spending it on policing, courts, jails etc. because addicts will go back to crime to support their habit.

  19. Robert Liveric

    My Methadone Dr. takes a two week vacation every two to three months. She talks to her patients for two minutes at a time. Sometimes it could be up to ten to fifteen minutes.

    I could have five patients ahead of me, I leave to buy a coffee across the street and come back to see that she’s already seen six patients. My name on the list crossed out with pen.

    Easiest Dr. job in the world! She does not have to diagnose, examine, view naked bodies, refer, put her finger in anuses or remember anything.
    She talks about Leonard Cohen and the weather. She believes Methadone is not an addiction, but a physical dependency. No! Air, water and food are physical dependencies. Methadone is an opioid.
    Maybe that belief system of her’s lets her sleep better at night. Whichever country she happens to be in at any particular time.
    Twenty one years and counting.

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