Faced with Medicaid's low payments and bureaucratic red tape, some Maryland doctors are reluctant to prescribe buprenorphine for heroin addicts, even though the drug has been promoted as a potential magic bullet in the war against addiction, according to a survey set for release today.
The survey, commissioned by the Center for a Healthy Maryland Inc., found that doctors were not always sufficiently reimbursed for their time and services and that there were other "hassles," including medication preauthorization, a process that in some cases can take 48 hours, and varying and confusing protocols among Medicaid providers.
The report comes as state officials are deciding how to spend an extra $3 million earmarked for buprenorphine treatment in the budget year that starts July 1.
Medicaid is a state-run program that uses federal and state money to pay medical bills for the poor and disabled. In Maryland, the program is run through seven managed-care organizations that contract with a network of health care providers.
Buprenorphine advocates want Medicaid officials to quickly fix the red tape and payment problems so the $3 million can be used to help uninsured addicts and others who want treatment but do not qualify for Medicaid.
"One of the biggest barriers to prescribing buprenorphine is dealing with the insurance companies," said Dr. Christopher Welsh, a psychiatrist and assistant professor at the University of Maryland School of Medicine in Baltimore. Welsh uses the drug to treat patients at the university's hospital. Some come from hundreds of miles away to get a prescription, only to have their treatment thwarted by red tape.
"A few hours later, you'll get a call, and the patient will tell you that the pharmacy said the prescription wasn't authorized," said Welsh, who participated in the survey.
He added that a physician who intervenes to help the patient is often "passed from voice mail to voice mail" by the health care provider, and the experience "can be very time- and labor-intensive."
Of the 17 doctors from across the state who participated in the survey, some said they have been so frustrated by the system that they have paid for the drug themselves.
Only 25 percent of those surveyed said they were willing to prescribe buprenorphine for a variety of reasons. Some of the reasons given for not prescribing the drug included negative attitudes about drug addiction and a lack of experience regarding care of addicted patients. Some managed-care organizations don't view drug addiction as a long-term disease, according to doctors.
"It is a disorganized and chaotic system according to physicians," said Dr. Robert Schwartz, director of drug addiction treatment programs at the Open Society Institute - Baltimore, which provided grant money to pay for the survey.
As a result of the study, doctors and representatives of managed-care organizations have agreed to work together to improve addiction treatment opportunities for residents, including those in rural parts of the state where few doctors have the necessary certification to prescribe buprenorphine. State officials, who only recently received the survey, have also said they will cooperate.
"We have a real chance here to work together to deal with the concerns doctors have and the barriers they have told us about," said Dr. Meena R. Abraham, executive director of the Center for a Healthy Maryland, an affiliate of the Maryland State Medical Society.
Susan Tucker, executive director of the Office of Health Services for the Maryland Medicaid Program, said she plans to discuss the survey's findings tonight at a forum scheduled by the medical society. She said some doctors are hampered by federal rules regulating the use of buprenorphine and a lack of education about drug treatment.
"It is clear that it is more than insurance," said Tucker. "Some doctors don't feel comfortable providing counseling for patients; some don't feel they have the background."
The pill form of buprenorphine was approved by the Federal Drug Administration for use in the treatment of opioid addictions in 2002. Before that, it was used in a liquid form in the operating room to help with pain. Doctors must go through a certification program to prescribe the drug and initially are allowed to give it to only 30 patients. After a year, they can treat up to 100 patients.
Recently, Baltimore health officials have advocated the use of buprenorphine, which helps relieve withdrawal symptoms, as an alternative to methadone, a synthetic opiate that is addictive and requires close supervision.
Doctors must take a short class to receive a certificate to prescribe buprenorphine, and the city has launched a program recently to help cover the costs of such coursework. Ninety-one doctors have signed up for the training, and nearly 50 have completed it, according to Dr. Joshua M. Sharfstein, the city health commissioner.
Sharfstein said that he has not heard complaints from doctors who work with the city to treat drug addicts, in large part because the city runs interference between physicians and managed-care organizations. Sharfstein said it also helps that most buprenorphine patients start off in buprenorphine-oriented treatment programs. By the time they phase out to care with a private doctor, their treatment has been approved by Medicaid providers.
"We are not expecting doctors to go out on their own," said Sharfstein, who added, however, that the system should work for every doctor, not just those dealing with patients in the public health sector. "It is not an either/or situation. It needs to work for everyone."