Troy R. Bennett | BDN
By Jackie Farwell, BDN Employees •
November 26, 2018 6:00 am
Rodney and Heather Auger used to get up every day understanding they’d want medicine to get via all 24 hours.
First they relied on ache drugs prescribed by docs, hers for a collection of well being points that started at age 16, his for a again damage from a piece accident.
When their docs abruptly stopped these prescriptions, the couple turned to heroin, they stated. They spent seven years on the streets, dwelling in garages and of their automotive, their days consumed by a determined seek for illicit medicine that would stave off the distress of withdrawal.
However right now, they’ve a tidy condo in Previous Orchard Seashore with an almost-view of the ocean. Now, they start every morning by taking buprenorphine, understanding the medicine will ease the cravings for opioids that dominated the higher a part of their seven-year marriage. The treatment doesn’t present a excessive.
“We’re pretty much starting our whole life over,” Heather stated. “Our marriage we’ve started over. We’ve only been married for seven years. We were always addicts together.”
As soon as every week, they attend a gaggle counseling session at a clinic in close by Biddeford referred to as Teams Recuperate Collectively. Additionally they should move a urine drug check to get their prescriptions crammed for the next week.
The Augers are a part of an rising strategy to treating opioid addiction in Maine, one that might by no means have gotten off the bottom with out the involvement of Teams Recuperate Collectively. The company, a for-profit chain of addiction treatment clinics, is increasing quickly in Maine and all through the nation, making use of a startup mentality to combatting the nation’s most urgent public well being disaster.
The company has managed to develop the place conventional suppliers have struggled to maintain up with the necessity, elevating bigger questions on who’s, or must be, chargeable for delivering care. Whereas some observers are involved about Maine more and more counting on a single, personal enterprise to look after weak sufferers, others merely see extra individuals getting nicely.
‘New model of addiction treatment’
Like almost all states, Maine lacks the capability to offer probably the most confirmed type of treatment for opioid addiction, often known as medication-assisted treatment. It combines drugs that scale back cravings and withdrawal signs, corresponding to Suboxone or methadone, with behavioral counseling.
Methadone treatment sometimes requires sufferers to go to a clinic day by day through the early morning hours, line as much as obtain their dose of the treatment, and attend counseling as soon as a month. With Suboxone, sufferers can get a prescription in quite a lot of settings, from physician’s workplaces to main care clinics, and fill them at a pharmacy.
Research have clearly demonstrated the effectiveness of each drugs in treating opioid use dysfunction. The counseling element, whether or not particular person or in group settings, hasn’t been studied sufficient to say definitively that it helps individuals get well, although many specialists consider it’s important.
Final yr, greater than 1,500 Maine residents acquired medication-assisted treatment. Specialists estimate the necessity far exceeds that.
Almost two years in the past, the LePage administration launched its “opioid health home” mannequin as an “innovative” response to the addiction disaster. Mary Mayhew, then commissioner of the Maine Division of Well being and Human Providers, expressed her confidence that “this model will help Mainers who need and want to get better.”
The program directs taxpayer cash to well being suppliers who meet sure requirements in offering addiction treatment. The “home” in its identify doesn’t discuss with a bricks-and-mortar area, however slightly to the idea that well being suppliers can turn into a house base for sufferers by coordinating with one another to offer higher care at a decrease value. The care is offered in outpatient settings, akin to clinics and physician’s workplaces, not in residential addiction treatment amenities.
Mayhew pitched the opioid well being residence mannequin as an effort to combine addiction treatment with main care, to deal with the “whole person” via not solely substance use counseling and drugs, but in addition further providers designed to deal with sufferers’ full vary of behavioral and bodily well being wants.
The $2 million program was geared towards sufferers who had no medical insurance and people coated by MaineCare, the state’s Medicaid program.
Although prompted by strain from legislative Democrats, the opioid well being house mannequin arguably represents the outgoing LePage administration’s clearest imaginative and prescient for a way Maine ought to meet the determined demand for addiction treatment.
The program acquired off to a torpid begin in 2017, with Maine’s well being suppliers complaining that the principles have been burdensome, requiring them to hyperlink sufferers with a deep bench of hard-to-find employees with experience in addiction, together with a nurse care supervisor, licensed drug and alcohol counselor, and peer restoration coach.
A lot has modified. Within the final yr, this system has grown exponentially — largely attributable to the involvement of Teams Recuperate Collectively.
The company, based in New Hampshire and funded by enterprise capital, has thrived towards the backdrop of Maine’s in any other case principally native and nonprofit substance use treatment community. Promising a “fundamentally new model of addiction treatment,” Teams Recuperate Collectively is rising, concentrating on rural areas whereas dodging the financial and regulatory roadblocks encountered by different suppliers.
‘Just a question of who’s profiting’
Teams Get well Collectively prescribes buprenorphine and offers weekly counseling in 9 Maine communities: Biddeford, Portland, Lewiston, Augusta, Rockland, Ellsworth, Calais, Machias, and Farmington. By early subsequent yr, it plans to open places in Bangor, Houlton, Waterville, and Belfast, and by subsequent summer time it anticipates including Newport and Rumford.
Teams Get well Collectively now operates 60 clinics in eight states together with Maine and as far west as California. The company has dedicated to seeing sufferers inside every week, with no wait lists.
The Biddeford clinic the place the Augers obtain treatment was among the many first places Teams Get well Collectively opened in Maine in 2016. The company served about 800 individuals within the state earlier than signing the opioid well being residence contract with DHHS in April.
Troy R. Bennett | BDN
CEO Cooper Zelnick stated the company’s mannequin rewards it for serving to individuals get higher, somewhat than for merely rendering providers that are worthwhile for it to ship. Via its contract with DHHS for the opioid well being houses, the company is paid one fee for a bundle of useful providers it offers to uninsured residents, he stated. That’s in distinction to the “fee for service” funds extra typical in well being care, through which suppliers receives a commission each time they ship a service, resembling a urine drug display, no matter whether or not that service helps sufferers get higher, he stated.
“By keeping people in treatment and helping them actually recover and ultimately get off medication and be successful and healthy, we’re massively lowering the cost to the health care system,” he stated. “When we make money, we are participating in the value that’s created.”
The company claims retention charges properly above the nationwide common. Whereas no authorities supply stories retention charges, Teams Recuperate Collectively compares its charges to these of outpatient Suboxone suppliers who report their outcomes to at least one personal insurer.
“If people do not come to Groups, get better, and then leave Groups healthier, we don’t make money over the long term,” Zelnick added.
As for its for-profit standing, “All health care is for profit, it’s just a question of who’s profiting,” he stated.
However some query whether or not Teams Get well Collectively’s domination of the opioid well being residence program is greatest for Maine, worrying that the company will naturally reply to market calls for because it serves a very weak inhabitants.
“There are a number of communities where there have been some nonprofits that have stepped up to the plate, integrated [medication-assisted treatment] into their system, not looked necessarily to the state to bankroll that … and then there’s suddenly a Groups office a block over,” stated Eric Haram, a Portland-based marketing consultant who helps states and others enhance their response to substance use issues.
“If you’re in charge of the safety net, there needs to be some strategy around equitable access. There’s not much use to having five programs in one town, when the next 15 don’t have one. That’s not necessarily a strategy for public health, that’s market share gamesmanship.”
250 individuals on the primary day
After a yr, DHHS reported that opioid well being houses have been serving “almost 50” MaineCare recipients and simply 5 uninsured individuals. That was a far cry from the 400 Mainers Mayhew initially envisioned.
Then, 18 months into this system, Teams Recuperate Collectively acquired on board. On its first day in this system, it enrolled greater than 250 individuals, in response to Zelnick. It’s since greater than doubled that determine, serving 600 individuals every week via this system, he stated.
General, Maine’s opioid well being houses had served roughly 750 individuals by the top of September, almost double Mayhew’s projections, based on DHHS.
Of these, Teams Get well Collectively accounted for greater than 80 % of billing for MaineCare members and almost half of billing for uninsured members.
Teams Get well Collectively’s contract with the state to offer opioid well being residence providers to uninsured residents is valued at $864,000. The company will get paid $1,000 per uninsured particular person every month, and each the treatment and drugs are free to those sufferers.
For individuals with MaineCare protection, the state pays Teams Get well Collectively $496 per member every month, and people use their protection to buy the medicine. They could should pay a small co-pay on the pharmacy.
“The goal is not lifetime medication maintenance; it’s to use the medication as a tool, which will allow you to meaningfully engage in the therapy to get the skills and tools that are needed,” stated Heather Prebish, Northeast medical director for Teams Get well Collectively. “Then when you’re ready, in consultation with your care team, begin to taper off. We’ve had that experience for hundreds of our members across the different locations where we provide treatment.”
Whereas this system has taken off, it’s nonetheless only one piece of Maine’s general substance use treatment community. Tons of of individuals obtain treatment by means of preparations outdoors this system.
‘I’m somewhat extra humble’
Outdoors of its state contract, Teams Recuperate Collectively’s funds are personal. Zelnick stated it’s funded by three enterprise capital companions, two in New York and one in Boston. The company as an entire isn’t but worthwhile, however most of of its places in Maine are yielding income, he stated.
The company’s roots are in Claremont, New Hampshire, the place a former Dartmouth medical faculty scholar teamed up with an area physician in 2014 to open the primary clinic, serving the uninsured earlier than the enactment of the Reasonably priced Care Act and enlargement of Medicaid. The mannequin aimed to take away two hurdles that uninsured individuals looking for treatment typically face: value and distance.
The company opened clinics in principally small cities, serving rural areas determined for treatment choices, and provided an easy program. For $65 every week, members acquired a prescription for Suboxone, which they paid for and crammed at an area pharmacy, and weekly group remedy.
By opening clinics outdoors of pricy metro areas, Teams Get well Collectively stored its actual property prices down. The clinic in Biddeford, the place the Augers obtain treatment, is situated on the second flooring of a brick constructing downtown, above a espresso store and bookstore. Just some hundred sq. ft, it homes a reception desk, a few workplaces, and a gaggle remedy room with trendy however spare furnishings.
Teams Get well Collectively requires minimal staffing on website — with only one full-time counselor and one workplace coordinator. In Maine, due to the opioid well being residence contract, the company additionally has medical supervisors, counselors, peer restoration coaches, nurse care managers and affected person navigators who float between workplaces. The docs who prescribe Suboxone work on an hourly foundation, typically seeing sufferers by means of telehealth video screens.
As a result of Teams Recuperate Collectively doesn’t dispense treatment, it additionally avoids the related prices that methadone clinics should pay, comparable to stepped up safety.
The no-frills strategy set Teams Get well Collectively aside from different well being suppliers, together with publicly funded amenities paying extra overhead for workers and area in areas typically removed from the place their sufferers reside. There are additionally many causes well being suppliers keep away from prescribing Suboxone, together with the effort of getting a particular certification, missing employees to offer counseling to accompany the treatment, not being outfitted to do capsule counts and urine screens and the stigma surrounding addiction.
Troy Bennett | BDN
Teams Recuperate Collectively, however, helps its native employees as a centralized group, Zelnick stated. It staffs a 24-hour disaster line and an consumption line for when sufferers first enroll, and it’s not paying docs to take care of full-time workplace hours, which some critics say means sufferers don’t get sufficient face time with their doctor.
“It allows them to be very nimble and expand very rapidly and work with a very high volume of patients very quickly,” Haram stated. “Those are important qualities of a program; access is important. But this is medical work; you do need the medical professional to have their eyes on the patient.”
The fee-for-service mannequin most suppliers have operated underneath additionally means that “the people who provide really good care typically are not able to make money,” Zelnick stated. For nonprofit suppliers with no entry to enterprise capital funding like Teams Recuperate Collectively enjoys, it’s a troublesome endeavor.
“They’re expanding access better than the rest of the medical delivery system, which is largely nonprofit. There’s a reason for that,” stated Noah Nesin, vice chairman of medical affairs at Penobscot Group Well being Care. The opioid well being house guidelines are “challenging for an organization like ours, which has lots of other work … besides just treating opioid use disorder. We feel strongly that the real answer for society … is that opioid use disorder be treated in primary care settings just like any other chronic disease.”
PCHC will deal with 600 individuals this yr for opioid use dysfunction, he stated. It has an opioid well being residence designation for its Hope Home clinic in Bangor, treating about 15 sufferers via this system.
Now, Teams Get well Collectively is broadening its mannequin nationally and evolving. In Biddeford, it presents a extra intensive outpatient program with members receiving counseling 3 times every week as an alternative of 1. And it’s more and more shifting to serving the “huge number of folks with commercial insurance and Medicaid who can’t get high-quality access to treatment,” Zelnick stated.
Whereas most of the modifications resulted from starting to work with insurers, some are a results of Teams Get well Collectively’s participation within the opioid well being house program, Zelnick stated.
“The clinical outcomes in Maine are better than anywhere else for us,” he stated, and “this is the way we feel the world is moving.”
Teams Get well Collectively provides the opioid well being residence providers in any respect of its places in Maine, but in addition serves sufferers with different types of insurance coverage and continues to supply the $65-a-week fee.
“The for-profit model, of which probably people have traditionally been pretty critical, may be serving a really important purpose,” stated Nesin of PCHC. “And at least for the people who can get the cash together to buy the prescription, may be saving their lives. I’m a little more humble about judging anybody’s model these days.”
‘I was 1,578’
The state’s well being officer, Christopher Pezzullo, sees a lot promise within the opioid well being house program that, if it have been as much as him, “I would want all the patients in Maine to be served by OHHs, because I feel like that’s the most comprehensive approach to substance use disorder.”
However Haram stated Maine ought to have pursued larger funding for this system, drawing down solely $2 million the place neighboring New Hampshire obtained $46 million to deal with the opioid disaster.
“It’s a pittance of an amount of financial support, with one strategy, and it took over a year to begin to deploy it, and it required the special relationship … with Groups so say, ‘Ok, now we have it. That whole dynamic is, I think, pretty problematic.”
Haram can also be involved that Maine’s reliance on Teams Get well Collectively places the state in a troublesome place. West Virginia, for instance, contracted with one for-profit methadone program that later wreaked havoc throughout the addiction treatment service system, blocking improvement of different choices, he stated.
Teams Get well Collectively additionally just lately added opioid well being residence slots for prisoners being launched from the state jail in Warren. As quickly as these people stroll out of the gates, they’re transported to a Teams workplace, full an consumption course of and get enrolled in this system. Teams Recuperate Collectively then helps them fill out MaineCare purposes and get related to housing and employment assets, Zelnick stated.
Along with Teams Get well Collectively, 10 different well being suppliers take part within the opioid well being residence program. The state expects extra will enroll following modifications that will introduce a tiered cost construction, starting from providers for sufferers simply beginning on treatment to those that are stabilized and receiving care long run.
The program can also be due for an additional inflow of funding because of laws handed earlier this yr that put aside $6.6 million for addiction treatment.
For the Augers, their treatment at Teams Recuperate Collectively has turn into a lifestyle.
“They don’t make you feel like you’re a drug addict. They make you feel like you’re somebody that wants to get help,” Heather stated.
Teams Recuperate Collectively’s strategy is worlds away from her earlier expertise in treatment, stated Heather, who was raised by her grandparents as a result of her mom struggled with addiction. On the methadone clinic she visited years in the past, she was actually a quantity, one she remembers exactly to today.
“I was 1,578,” she stated. “They don’t even say your name. My mom was number four.”
The Augers at the moment are wanting ahead to their first “normal” Christmas.
“We were always sick for those holidays,” Heather stated, trailing off.
“Making up lies and excuses why we couldn’t go,” Rodney stated, ending her sentence. “We don’t have to do that anymore.”
Maine Focus is a journalism and group engagement initiative on the Bangor Daily News. Questions? Write to [email protected]