Maryland testing a central piece of Trump's opioid response

Bernard Gyebi-Foster, executive director of Tuerk House, discusses a new federal regulation that the Trump administration is testing in Maryland and now hopes to expand nationwide that expands drug treatment capacity to help in the fight against opioid addiction. (Kim Hairston, Baltimore Sun video)

WASHINGTON — Bernard Gyebi-Foster had a problem this year that underscored, on a small scale, the challenge facing public health officials battling the opioid epidemic nationwide.

Gyebi-Foster, executive director of a drug treatment program in West Baltimore, had 44 beds at his center for detox patients. But in the midst of a crisis that’s killing more than two city residents a day — more than are dying in the city’s historic violence — he had funding for only two thirds of those recovery slots.


“That left 15 beds unoccupied,” said Gyebi-Foster, who runs Tuerk House, one of the city's best-known treatment facilities.

Now a federal initiative being tested in Maryland is showing some early signs of increasing treatment capacity by changing how care is paid for.


President Donald Trump, in declaring the opioid crisis a national health emergency last month, said his administration will expand that change to other states that request it.

Maryland, where overdose deaths are surging, is one of seven states that have been approved to allow large residential centers to bill Medicaid for substance abuse treatment — reversing a prohibition that dates to President Lyndon B. Johnson. Under the new structure, treatment centers receive reimbursement for each patient rather than a set grant.

“It allows us to see more patients, which we currently are doing,” Gyebi-Foster said.

Many drug treatment providers say it’s too early to declare the change a success. The federal money comes with new billing and staffing requirements that smaller treatment centers might struggle to meet. In expanding the initiative, the Trump administration said new states taking part must not increase federal Medicaid spending, which could prove difficult.

The change took effect in Maryland on July 1.

President Donald Trump’s administration on Thursday declared the opioid crisis a public health emergency, a move that could expand access to treatment in some parts of Maryland but that falls short of the large increase in federal spending some advocates sought.

Providers are optimistic about the approach, but say it can take months to submit claims to Medicaid and receive reimbursement. Several centers say they are considering an expansion, but few interviewed by The Baltimore Sun had increased capacity yet.

“It’s absolutely too soon to tell,” said Tracey Myers-Preston, a health care consultant for Maryland Addictions Directors Council, an association of treatment providers. “There’s great potential.”

Maryland officials have not yet submitted a report to the U.S. Department of Health and Human Services describing the state’s experiences with the program. The state health department will provide initial data about how the effort is going in May, a spokeswoman said.

The number of people who died in Maryland from drug- and alcohol-related overdoses through June was up nearly 20 percent over last year, state officials say.

Baltimore reported 694 overdose deaths last year, more than twice its 318 homicides. Another 393 died in the first half of 2017, up 29 percent compared to the same period last year.

Authorities say the increases are being driven by fentanyl and other powerful synthetic opioids that dealers are blending into heroin.

More than 2 million people in the United States need treatment for addiction involving prescription pain medication, according to the American Society of Addiction Medicine. Federal health officials have said less than half are receiving it.


Jacquelyn Covington began using drugs — including heroin — as a teenager. Now 55, she recently graduated from Tuerk House.

She says she believes it is more difficult for women to find residential treatment in Baltimore than it is for men.

“Most of the places that I called for women didn’t have any beds,” she said.

“The disease of addiction,” she said, “doesn’t discriminate.”

Covington said that she is now “feeling great” and is ready to get on with her life.

While Maryland and the rest of the U.S. struggle with an epidemic of opioid-related addiction, hospitals are working to reduce opioid use as the first line of defense in pain management.

When Johnson and Congress created Medicaid in 1965 to provide health coverage for millions of poor Americans, it prohibited the program from paying residential mental health and substance abuse centers with more than 16 beds. In part that was because lawmakers wanted to ensure Medicaid didn’t pay for treatment that had traditionally been a function of states.

But in the five decades since, the response to mental health treatment and substance abuse has changed dramatically.

Lawmakers have repeatedly proposed legislation to roll back the requirement, without success. The Congressional Budget Office has estimated that eliminating the prohibition for substance use and mental health could cost $40 billion to $60 billion over a decade.

Some states have applied to the federal government for waivers from the rules. Maryland applied in late 2015; the Woodlawn-based Centers for Medicare and Medicaid Services approved the request late last year.

California, Massachusetts, Virginia, West Virginia, New Jersey and Utah also have been granted waivers — some in recent weeks.

A commission Trump created on the opioid issue this year recommended eliminating the rule. That group, led by New Jersey Gov. Chris Christie, a Republican close to Trump, said the change would “immediately open treatment to thousands” of Americans.

The executive order that Trump signed last month did not mention the issue. But he said at the time that “a number of states have reached out to us asking for relief” and that “those approvals will come very, very fast.”

Christie is expected to testify at a hearing of the House Committee on Oversight and Government Reform in Baltimore next week. The hearing will focus on the city’s struggles with heroin; Baltimore Health Commissioner Dr. Leana Wen and Johns Hopkins Bloomberg School of Public Health associate professor Caleb Alexander are also scheduled to appear.

Rep. Elijah E. Cummings of Baltimore is the top Democrat on that committee.

A spokeswoman for the Maryland Department of Health said that 36 providers in the state are benefiting from the relaxed rules. Preliminary data show 1,606 Medicaid participants received substance use disorder treatment in July and August.

The state could not say how many of those patients might have received treatment under the previous rules, so it’s not clear if that number represents expanded coverage.

More than 2,300 beds are available at residential substance abuse treatment facilities throughout the state, according to the health department.

Baltimore City had 428 residential beds in the fiscal year that ended this fall, according to Adrienne Breidenstine, vice president with Behavioral Health System Baltimore. That organization spent $13 million in grants from the state health department to pay for those beds.

“We are seeing some capacity expand because there’s no longer a cap on residential beds,” Breidenstine said.

“There were other providers that were in a similar situation” to Tuerk House, she said.


Brittany Fowler, a spokeswoman for the state health department, said the waiver “erased a federal prohibition that had served as an impediment to treatment for many people.”

Dr. Marc Fishman is medical director of Maryland Treatment Centers, which operates four programs in the state. He said the new federal policy was long sought by providers.

“It’s a declaration of therapeutic optimism,” he said. “As providers, we are seeing the ability to provide care for more patients. There’s been this demand, but we’ve been unable to fill it.”

Advocates are watching to see which data the state is collecting to monitor progress. Without a clear measure of capacity, it will be hard to know what impact the waiver is having.

Clay Stamp, executive director of the state's Opioid Operational Command Center, said pinning down some of those numbers can be difficult, because individual patients have different needs and treatment facilities offer widely varying services.

“Demand is a moving target,” Stamp said.

“We know that we want to see the number of overdoses go down,” he said. “We want to see the number of fatalities go down.”

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