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?”