Painkillers are an expensive addiction, but for many users trying to quit, treatment isn’t much cheaper.
Insurance can defray much of the cost of counseling and medication to help with cravings. The Affordable Care Act, passed in 2010, made treatment for substance use disorder an essential health benefit, requiring that insurance companies cover it without yearly or lifetime limits, even for people with pre-existing conditions.
But when doctors don’t accept insurance or Medicaid, their patients find themselves in a familiar predicament — they’re stuck with an expensive draw on their money that they could have used for rent, food and a car, all essential items in maintaining a productive, and sober, life.
Patients who don’t have insurance or who use public assistance are the most vulnerable treatment population, said Tom Britton, president of Gateway Rehab, a drug rehabilitation center with locations in Southern Illinois, including Caseyville.
Gateway treated about 36,000 people in six states during the last fiscal year, Britton said, but because of what the company pays doctors, it’s common for them to maintain their own practices.
Dr. Rakesh Chandra, a licensed psychiatrist in Carbondale, started treating opioid use about three years ago after the Gateway center there called to say it wanted to work with him, he said. When he saw how big the problem was, he took an eight-hour training course and became certified to treat with buprenorphine, which helps manage opioid cravings.
“These are very fragile people who have gone through a lot,” he said.
Britton couldn’t determine how many people Chandra treated at Gateway, but Chandra knew there was more work to do, so he founded Rassik Complete Care in August 2015.
There, he treats the rest of his patients with opioid use disorder, which are capped by law at 275. Unlike Gateway, however, Rassik doesn’t accept insurance or Medicaid. Everyone must pay cash.
Patients, profits or both?
Because there aren’t many doctors who treat opioid use disorder in Illinois, Chandra is supplying a much-needed service for a neglected population. However, some of Chandra’s colleagues disagree with his business model and say it puts profits ahead of patients.
By accepting only cash, Chandra avoids lower rates set by insurance companies and the often slow pace of Medicaid reimbursement. But for the people who can’t afford treatment without third-party payers, it means they have to go somewhere else.
Despite this, Rassik is thriving.
“Spots fill up quickly,” Chandra said, and over the years he’s had to say “no” to a lot of people who wanted treatment because his clinic was at capacity.
After he was approved to treat addiction with buprenorphine products, which include Suboxone and Subutex, Chandra quickly reached the first-year limit of 30 patients, he said. In his second year of treatment, he applied to treat 100 patients, but those spots also filled up, so in his third year, he applied for the legal maximum, 275.
Dr. Jeff Ripperda, who treats opioid use disorder in nearby Murphysboro, said several of his patients transferred from Chandra because his treatment is too expensive. According to them, Chandra schedules a $250 appointment every two weeks, and that mandatory counseling and medication cost extra.
“I’ve not had a single patient who told me of a positive experience with this type of arrangement,” Ripperda said in an email. “It reeks of profits before patients. I see the arrangement as just another barrier to treatment.”
Chandra would not say how much treatment at Rassik costs, but he considered it reasonable.
“It’s a free enterprise system,” he said. “This is our model.”
At Ripperda’s practice, out-of-pocket fees are much lower, in part, because he spaces out appointments more, depending on how well patients are doing, and because he works at Shawnee Health Service, a federally qualified health center that works with medically underserved communities and accepts private insurance and Medicaid.
According to Rachel Rector, Shawnee’s revenue cycle director, patients with opioid use disorder who have private insurance pay $30 out-of-pocket for an office visit and another $30 for medication. On average, the most they pay out-of-pocket a year is $300, although some patients reach $500 and $700.
At the same time, Medicaid patients typically pay less than $5 out-of-pocket for appointments and less than $5 for medication, and their yearly out-of-pocket expenses mostly stay below $150 for all expenses, including appointments, medication and counseling.
“I don’t have a yacht or a vacation home in the south of France, but I am certainly making a comfortable living with my clinic’s business model,” Ripperda said in an email.
Although Rassik refuses third-party payers, the clinic states on its website that it is “happy to provide a receipt and help you fill your insurance claim forms.”
For small practices like Rassik, working with insurance companies can be hard because they have less leverage to get good reimbursement rates, Rector said. But, it can be even harder for patients, who often can’t navigate the paperwork and are reimbursed less than what they would have been had their medical providers accepted insurance.
“I’ve heard of a few clinics doing that for state employees because the state is so behind on paying its bills,” Ripperda said, referencing Illinois’ two-year budget stalemate, “but I haven’t really heard of it in any other circumstance.”
A legislative opening?
Rassik likely is not the only cash-only addiction clinic in Illinois, but rather it is part of a trend.
“Sometimes called direct pay … this sort of business model was once seen as the perquisite of rich folks and medical tourists from foreign lands,” Time magazine wrote this year. “But nowadays many of the people seeking cash-based care are middle-class Americans with high-deductible insurance plans.”
The Time story focused on a $19,000 knee replacement; however, opioid use disorder can require lifelong treatment with medication, according to the Substance Abuse and Mental Health Services Administration, or SAMHSA. A patient going to Chandra’s clinic would spend that amount on appointments alone in a little more than three years.
So far, the number of addiction treatment providers who don’t accept insurance is small enough that it hasn’t attracted the attention of the Illinois General Assembly.
“I cannot comment on the business practices of a particular doctor,” wrote Rep. Lou Lang, D-Skokie, in an email. Lang led the push for the 2015 Heroin Crisis Act, which went on to strengthen some laws to help the opioid crisis.
“However,” he wrote, “it is my view that medical people who will not serve patients in need do a disservice to the profession. I understand that the state is slow (to) pay. Nevertheless, patients who are addicted need help. I can only hope patients are finding the access they need.”
Legislative insurance committees also aren’t aware of the issue.
“(This) is the first time it’s come to me,” said Rep. Laura Fine, D-Glenview, who chairs the House’s Insurance Committee. “(But) just because I haven’t heard of it doesn’t mean it’s not going on.”
Sen. John Mulroe, D-Chicago, who heads the Insurance Committee in the Senate, also said he hadn’t heard of cash-only substance use treatment.
“(It) should be something the medical profession should be concerned about,” he said.
Sen. Bill Haine, D-Alton, the former chair of the Insurance Committee, said it would be difficult to legislate how doctors get paid.
“You’re opening up a Pandora’s box of controversy with that,” he said.
Haine recommended speaking with the Illinois State Medical Society to find out what it recommends doctors do.
The ISMS declined to comment.
The Illinois Psychiatric Society also doesn’t have a hard position on cash-only addiction treatment clinics. At an Oct. 23 meeting of the group’s Addictions Committee, some members thought that some clinics price addiction treatment too high and bordered on profiteering, but in the psychiatric world, cash-only practices are common, said Dr. Chris Stewart, the committee chair.
“That’s almost not even an issue, really,” he said.
The business model stems to the 1980s, when insurance companies put limits on mental health treatment by covering a limited number of therapy sessions, Stewart said. Even though the Affordable Care Act later abolished those limits, other issues still discourage psychiatrists from accepting insurance and Medicaid.
One includes funding: National politics are making insurance markets more unstable, so medical professionals don’t want to change their funding models if they’re about to change again.
Another reason includes the ways insurance companies sometimes manage reimbursement by requiring reviews and prior authorizations, varying reimbursement rates and even purposefully putting administrative staff on hold while they discuss reimbursements over the phone.
“There needs to be more access to treatment,” Stewart said, but lots of psychiatrists are resisting it. “The only way you change this is you get someone who sees a lot of Medicaid patients ... and they start treating with Suboxone.”
Although Chandra said he does not accept Medicaid, records from the Healthcare and Family Services Division show that he was reimbursed by the program as recently as fiscal year 2017.
He performed a psychiatric evaluation, gave a shot and later had a short bedside visit at a nursing facility. He was paid $655.38.
Doctors missing in action
It is difficult to estimate the number of people who have opioid use disorder, but it is easy to see that the number of doctors who treat it is not enough.
Extensive surveys by SAMHSA show that only 11.7 percent of Illinoisans aged 12 and older with illicit drug dependence or abuse — about 29,000 people out of a total population of 248,000 — received treatment on average from 2010 through 2014. However, this estimate takes all drugs into account, including cannabis, hallucinogens, cocaine, heroin and other substances. More detailed results from SAMHSA don’t separate heroin from prescription painkillers.
Doctors often have waiting lists of people seeking addiction treatment. As of mid-September, there are just 909 medical professionals in Illinois who treat opioid use with buprenorphine, according to SAMHSA data.
Of those, only 569 Illinois medical professionals have made their contact information searchable on SAMHSA’s treatment locator website. Together, they account for 37,005 available treatment spots in the state. The other unlisted 340 doctors make up the remaining 14,155 spots. But the real number of treated patients is likely lower — just because doctors are allowed to treat a certain number of people, it doesn’t mean they do.
By comparison, tens of thousands of other doctors fail to seek certification to treat with buprenorphine.
There are approximately 44,000 physicians and surgeons with a controlled substance license, according to the Illinois Department of Financial and Professional Regulation. It is unlikely that surgeons would commonly treat opioid use disorder, but the department does not separate the two categories. Still, if just 10,000 doctors treated 30 people for opioid use disorder, it would more than cover the number of Illinoisans who depend on or abuse all illicit drugs.
Recognizing the lack of access to medication treatment, Congress in 2016 expanded buprenorphine prescribing privileges to nurse practitioners and physician’s assistants, of which there are approximately 10,600 in Illinois with a controlled substance license. If all of them took addiction treatment training, they could prescribe to 30 patients apiece, increasing the number of patient spots by another 300,000 — eclipsing the 248,000 people with all illicit drug dependence or abuse a second time.
Chandra, who said he used to hear patients called “druggies” and “junkies,” is familiar with the medical community’s aversion to treat with buprenorphine, and he estimated that today only 10 percent of patients who need addiction medicine receive it.
“(It’s) the tip of the iceberg,” he said.
For some users, it’s the high cost of treatment that makes them relapse, Ripperda said.
“Several patients have told me that their heroin habit cost them less than Dr. Chandra’s program,” he wrote in an email. “For an addict, the choice between expensive recovery and cheaper addiction will frequently lead to a relapse.”
While Chandra treats more people for opioid use than most doctors in the state, even he acknowledges that his treatment may be out of reach.
“Some of them don’t come to us because they can’t afford it,” he said.