It’s obvious that preventing painkiller abuse and reducing addiction would save lives. But it would also save a lot of money, even help balance the state budget.
MaineCare, the Medicaid health insurance program for low-income children and adults, is in the center of Maine’s prescription drug abuse epidemic. The state paid about $473 million of the program’s $2.5 billion budget last year.
State officials say they don’t know how much pain-pill abuse costs MaineCare each year. But there are three obvious ways that drug abuse is a significant drain.
• First of all, some recovering addicts say they have routinely used Maine-Care to buy pills they didn’t need, at least not for pain. “Diverted” pills are used to get high and feed addictions, and some are sold for a sizable profit to other addicts. A MaineCare patient pays a $3 co-pay for a supply of oxycodone, for example, but the same 90 pills can be sold for $2,700 or more.
“We don’t know how much diversion there is,” said Scott Fitts, director of the fraud, investigations and recovery unit at the Department of Health and Human Services.
In 2010, more than 77,000 MaineCare patients – 31 percent of those in the program – had at least one prescription for an opiate pain drug, according to data provided by DHHS. MaineCare paid about $7 million for the drugs last year. If 5 percent of the pills were diverted for abuse, that cost the state $385,000.
• On the other end of the problem, MaineCare pays for treatments to help addicts get sober, from daily methadone doses to intensive outpatient counseling to residential programs that last months.
Treatment is the only way out of the spiral of opiate addiction, doctors say. But it isn’t cheap.
MaineCare payments for all substance abuse treatment totaled more than $100 million in the fiscal year that ended last June, according to figures provided by DHHS. Prescription pain relievers account for about one-third of the admissions for substance abuse treatment in Maine, second only to alcohol, according to the Office of Substance Abuse.
• The biggest cost to MaineCare, however, is health care services related to abuse and addiction, from emergency department visits for withdrawal and overdoses, to treatments for hepatitis C and collapsed veins to the care provided to pregnant addicts and their babies.
It’s not known how much abuse-related health care is costing MaineCare each year. However, every dollar spent on treating someone for substance abuse saves as much as $5 in health care costs that won’t be needed, according to Maine’s Office of Substance Abuse Services.
MaineCare case managers have added restrictions to try to reduce abuse and control the costs, but it’s unclear how effective they have been.
In January 2010, for example, MaineCare began requiring doctors to get special authorization before prescribing more than a three-month supply of any narcotic. Doctors routinely seek and get the authorization, and more than 17,600 patients had more than a 120-day prescription in 2010.
MaineCare also places special restrictions on some patients, often after receiving a complaint that the person is diverting drugs. One restriction, known as a lock-in, confines patients to one doctor and one pharmacy.
But only five patients in the entire state are in the full lock-in now. The use of lock-in programs has been limited in part because of an old data management system that has just been replaced, officials said.
About 800 MaineCare patients have to get authorization before filling any opiate prescription.
MaineCare managers are now trying to improve policies that may inadvertently contribute to the problem. Like other insurance carriers, MaineCare pays for medications to treat pain, but doesn’t cover alternative pain treatments such as acupuncture or physical therapy. Maine-Care Medical Director Kevin Flanigan told a legislative study committee last month he is exploring ways to encourage other effective, and cost-effective, pain treatments, which could reduce the use of opiates.
Staff Writer John Richardson can be contacted at 791-6324 or at: