TennCare's lack of coverage for methadone treatment slowing opioid addiction response, advocates say

Nathan Baker • Updated Aug 4, 2016 at 9:19 AM

Addiction treatment advocates complain TennCare’s lack of coverage of methadone clinic services for opioid addicted beneficiaries is slowing the state’s response to a public health epidemic and unequally impacting the well-being of low income residents.

In 2005, amid pressure from lawmakers and a drastic purge of TennCare rolls, Tennessee’s Medicaid program stopped covering methadone as a treatment for drug dependency for those 21 and older.

Under the program’s rules, the drug can be used to treat chronic pain, but it’s on the non-preferred list, meaning the patient must first meet a long list of prior authorization criteria, and then is subject to quantity limits.

In an emailed statement, TennCare spokesperson Sarah Tanksley said the decision to cease coverage was made because of “quality of care and delivery system concerns.” The change went into effect “with the support of the Tennessee General Assembly and with approval from (the Centers for Medicare & Medicaid Services),” she wrote.

When the policy was changed, Tanksley said TennCare members could not find adequate access to clinics because of the clinics’ refusal to contract with the program’s Behavioral Health Organizations, drawing safety concerns when patients sought treatment outside the network. Methadone also has a narrow therapeutic range and a higher risk of overdose than buprenorphine, a drug on TennCare’s preferred drug list for the treatment of opioid addiction.

The state program also covers drugs to reverse opioid overdose in an emergency situation and drugs to block the effects of opioids.

In 2004, state Sen. Rusty Crowe, R-Johnson City, and Rep. Jerome Cochran, R-Elizabethton, sponsored legislation seeking to prohibit methadone treatment providers from receiving reimbursement by the state’s health insurance option for low income residents.

“I have a big problem with us basically reimbursing people for drug habits,” Cochran said, before Gov. Phil Bredesen’s prescription drug limits to help turn around the insolvent state program were put in place. The legislation was not codified, but the next year, TennCare stopped paying for methadone clinic services to get or stay off drugs.

Joycelyn Woods, executive director of the National Alliance for Medication Assisted Recovery, a national group that advocates for the use of methadone and other prescriptions to treat addiction, said the stigma expressed by Cochran has negatively affected the availability of research-supported treatments and has been difficult to counteract.

“It has nothing to do with common sense, or helping people or public health,” she said. “The decision is made for political reasons, and it sounds like to me they’re saying, ‘if the care isn’t good, we’ll make sure you won’t get any care at all.’”

Ending TennCare’s reimbursements for methadone has limited the number of clinics in the state, forcing all patients in Northeast Tennessee, whether receiving state benefits or not, to drive hundreds of miles for treatment, Woods said.

In an application to the state Health Services and Development Agency for a certificate of need to operate a methadone treatment clinic in Gray, East Tennessee Healthcare Holdings Inc., a partnership between Mountain States Health Alliance and East Tennessee State University, lists the nearest clinics for most county residents being in Knoxville; Galax, Virginia; or Weaverville and Boone, both in North Carolina.

“We would be so delighted to see Tennessee cover treatments, we have been getting calls from Tennessee about methadone availability for 20 years, and I’ve been getting calls from Johnson City for 20 years,” she said. “It’s really awful to have to tell somebody that they’re going to have to pay about $400 per month for treatment, and then tell them they’re going to have to drive several hundred miles for it, too. I couldn’t do it.”

In the certificate of need application, the two regional institutions say they plan to investigate the ability to contract with TennCare for services, but they do not immediately plan to seek Medicaid and Medicare certification for the center, because of the lack of benefit coverage.

The new corporation excluded TennCare and Medicare members from its expected patient counts — 650 in the first year and 1,050 in the second — in the 200-page document, because of uncertainty regarding whether those patients would be covered.

Clinic managers expect to charge $13 per day per patient for treatment, including medication, counseling, social work and testing, leading to about $400 per month.

In states where opioid use and methadone treatment is more stigmatized, which tend to be in the Southeast, Woods said, it’s more difficult to respond to the public health issues caused by dependency.

“They tend to have the highest overdose rates, and they tend to react several years after the fact, after the epidemic starts,” she said. “If they had acted when they started to see changes in the overdose and use rates, they might have been able to do something, but it’s even harder when you don’t have the states cooperating.”

According to age adjusted Centers for Disease Control and Prevention data, Tennessee had the 11th highest drug overdose rate in 2014 and the 11th highest number of deaths, 1,269.

Email Nathan Baker at [email protected]. Follow him on Twitter at @jcpressbaker or on Facebook at facebook.com/jcpressbaker.

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