Obama’s Lousy Suboxone Offer

I was reading more about Obama’s executive order over at Dr. Burson’s blog.  I guess she is a ‘competitor’ in the blogging world, but I have to admit that her blog has a lot more detail about the issue than I do.  If you haven’t been there yet, check it out.  Keep coming back here too of course!

She wrote recently about the rules that would be required by the Feds, in order for them t o allow us the ‘right’ to treat people with buprenorphine.   I wrote to Dr. Burson after reading her post that she is providing the facts, and I can’t help but provide the emotion.  And after reading the baggage tied up with the ‘right’ to treat heroin addicts, I am.. ‘pissed’!  I realize that isn’t a word that doctors should use.  But honestly… I just don’t have another one!

Dr. Burson wrote that according to the current proposal, Doctors begging the Federal Government to treat another 100 addiction patients must 1. Use electronic medical records; 2. Accept insurance for the treatment; and 3. Require counseling of patients treated with buprenorphine products.  There were other requirements as well, but these were the three that I remember for irritating me the most.

Dr. Burson goes through her reactions to the requirements, and mine are mostly the same.  As a solo psychiatrist, I don’t see the value of electronic records.  Many of my patients don’t WANT their addiction treatment in a database. They know the stigma that they face already every time they go to the pharmacy.  Some of them work for employers who would discriminate against people once-addicted to opioids.  Some of them know they would be accused of ‘impairment’ for taking buprenorphine.  Those of us who prescribe buprenorphine know that they are not impaired– and that they’ve worked at jobs for years with no problems should speak volumes.  BUT IT WON’T.  We all know that ‘impairment’ can be in the eye of the beholder– and once someone thinks it is there, it IS there.  Once accused, how do you prove you’re not impaired?

I realize that at first glance, accepting insurance sounds like a good deal.  But now, I am able to see at most 2 patients per hour.  I have accepted insurance in the past, and that’s a completely different business.  Insurance companies reimburse psychiatrists at a rate that anticipates seeing 4-5 patients per hour.  Medicaid reimburses far below that, expecting doctors to make up the difference through commercially insured patients.  But that doesn’t work when treating addiction, where the large majority of patients are on Medicaid.  The only way it works is if the doctor works for a network where knee replacements and MRI scans subsidize addiction treatment, or where care is ‘mass produced’ by a team that minimizes the time doctors spend with patients.

I LIKE seeing two patients per hour.  The Obama team says if that is the case, I can’t see more than 100 patients, no matter how much my home town needs my services..  How ironic… if I spend less time per patient, I can have MORE patients.

I’ve written about the counseling issue before.  The requirement is a nod toward the huge counseling/rehab industry that has tried to block medication-assisted treatment at every turn.  Shouldn’t something as personal as counseling be decided by each individual patient?  Is there any other illness that requires counseling in order for patients to receive medication?  Of course diabetics would benefit from nutritional counseling– but would we consider withholding insulin without it?!

Who will decide, by the way, if the counseling is adequate?  Will the doctor stop your medication if you miss too many sessions?  What if you have nothing to talk about– so you still have to go? How many times? What type of ‘counseling’ counts?  Can a person get a massage and call it ‘counseling’?  If I get my ears candled, is that good enough? Group therapy?  Music therapy?  I saw recently that Madison WI has practices offering ‘float therapy’– is that OK? What about equine therapy?

I think you get my point.

As I mentioned in an earlier post, the TREAT Act would have increased the cap and allowed doctors to decide the best course of action for each patient.  The doctor remained in charge of patient care– sort of like ‘if you like your health insurance, you can keep it.‘  President Obama stepped in front of the TREAT Act to offer something different.  I can almost hear him saying with a Bronx accent… ‘how can you turn down dis’ deal?’

With all the heroin deaths, he’s putting forward ‘an offer you can’t refuse’.   No thanks…. I’ll stay at 100.