NDARC Technical Report No. 240
EXECUTIVE SUMMARY
The 2045 methadone patients selected in the study were representative of the overall methadone maintenance treatment (MMT) population in NSW. During the two-year study period they enrolled in 3252 programs, an average of 1.59 programs each, of which 81.2 per cent were managed by private practitioners and 73.9 per cent involved private sector dosing. These patients remained in treatment, on average, for 13.5 of the 24 months with 29.5 per cent of patients retained in treatment for the duration of the study period. Older MMT patients were found to spend significantly longer periods in MMT, while there was no difference between males and females or urban and rural residents with respect to the time spent in treatment.
Overall, these patients accessed health care services at 3 to 3.5 times the rate and cost of the general population of NSW, having averaged 41.5 services per annum at a cost of $1045. The additional services were comprised of doctor consultations and pathology services, with MMT patients using diagnostic procedures and investigations, therapeutic procedures, oral and maxillofacial services and diagnostic imaging services at a lower rate than the general population. This is noteworthy given that opioid dependent individuals would be expected to experience high levels of co-morbidity. For the 2045 MMT patients, women, those who lived in rural NSW and/or those who had spent longer in treatment, used more health care services, and cost more under the Commonwealth Medical Benefits Scheme (CMBS). In addition, being older led to an increase in the benefits paid under the CMBS for health care but not the number of services accessed, most likely attributable to the finding that psychiatrists treated more long-term patients than general practitioners.
For the 2640 programs provided by private practitioners, MMT on average involved 41.3 MMT services a year for which the Commonwealth Government expended $1024 per patient under the CMBS. MMT was comprised of 24.2 doctor consultations, 8.6 urine drug tests and 8.6 pathology collection items. While 4.5 doctor consultations, on average, were provided by an approved methadone prescriber other than the registered methadone doctor, it is likely that these services were for the purposes of providing MMT. The lower and upper boundaries for the cost of MMT might, therefore, be considered to be $888 and $1024, respectively. There was no difference in the length of methadone and non-methadone consultations provided by general practitioners but MMT psychiatric consultations were briefer than non-MMT psychiatric consultations, lasting for 15 minutes or less in 47.4 per cent of cases.
Looking at only those 1190 patients who had experienced both a non-treatment period and a treatment period under the care of a private practitioner, being in MMT resulted in a threefold increase in health care utilisation and costs. When in MMT patients accessed on average 69.1 services per annum at a cost of $1688 and when not in MMT patients accessed 21.8 services for which the Commonwealth Government paid $572 in benefits under the CMBS. The increase in health care use appears to be due solely to the provision of MMT as a health intervention since there was no difference in non-MMT service utilisation and costs between MMT and non-MMT periods. It is unknown however, what proportion of MMT services were spent in attending to general health care needs.
Being in MMT, while not reducing the number of non-MMT services did have an impact on the nature of those non-MMT services accessed. There was a decrease in doctor consultations that may have been the result of reduced “doctor-shopping” and/or better integration of health care services. On the other hand, there was an increase in pathology services, suggesting that a higher level of monitoring for illnesses relevant to the opioid dependent population may have occurred when patients were in MMT. The extent to which the finding that there was no difference in non-MMT utilization between treatment and non-treatment periods may have been the result of the restricted study period and, subsequently, the relatively brief time spent in treatment by these 1190 is unknown and requires further investigation. It could well be that over time being in MMT results in cost-offsets for non-MMT services.
As would be expected, the longer a patient remained in treatment the more MMT services they accessed and the greater the cost of MMT. Controlling for treatment length, the number of MMT services utilised could be predicted by knowing the patient’s place of residence and the type of dosing facility. Being an urban resident and attending a specialist facility, in particular a private clinic, led to an increase in the number of services accessed. MMT costs on the other hand, after controlling for the length of time in MMT, were determined by whether the patient lived in urban NSW, whether the registered doctor was a specialist and whether the dosing facility was a specialist clinic, all of which led to increased MMT costs. Unlike health care access in the general population, the composition and cost of MMT was unaffected by gender and age.
The number of MMT services provided, and consequently the cost of MMT, during stabilisation was greater than in subsequent months. After three months in treatment both the frequency and cost of MMT services were reduced by approximately 50 per cent.
In all dosing facilities the rate of MMT service access was higher in the first three months of MMT compared to subsequent months with privately operated clinics having been found to provide the most MMT services. Private clinics were also found to provide more services during the maintenance phase of treatment raising the question of whether the higher levels of servicing were appropriate and /or enhanced treatment outcomes. It may be that within the private clinic setting, methadone doctors provided counselling and case management services that in the other dose settings were provided by other health professionals. That there was no difference between the various dosing facilities with respect to non-MMT services either during stabilization or the maintenance phase suggests at least that there were no health care utilization offsets associated with the higher level of MMT service provision.
The cost of MMT was always determined, regardless of what phase of MMT the patient was in by whether the patient lived in urban NSW or whether the registered doctor was a specialist. Under either of those conditions the cost of MMT was greater.
There was little in the current study, other than gender and, for the maintenance phase in treatment, length of time in treatment, that influenced the number or cost of non-MMT services accessed. As with the general population, women used more services at a greater cost than men. While the patient’s clinical presentation would be expected to be a significant predictor of non-MMT service access, it may also be that non-MMT services during treatment periods were determined by the individual practices of the registered methadone doctor. Given that non-MMT service access during MMT involved less doctor consultations and a greater number of pathology services as compared to non-MMT periods (section 3.3), it could be that the level and cost of non-MMT services was to some extent dependent on whether the methadone doctor was in the habit of undertaking a battery of routine health investigations.
The findings suggest that a ‘capitation’ fee approach to funding methadone services (using for example $700 per annum per patient) would be inadequate, on average, to cover the methadone services currently being provided by private doctors. Such a fee, with CPI adjustments, however, would be sufficient to cover the expenses presently incurred by general practitioners, but there is ample evidence to suggest that general practitioners are generally dissatisfied with the rebate provisions under the CMBS. More specifically, general practitioners are not particularly willing to become involved in the Methadone Program. Recent studies (Lintzeris, Koutroulis, Odgers, Ezard, Lanagan, Muhleisen & Stowe, 1996; Abouyanni, Stevens, Harris, Wickes, Ramakrishna, Ta & Knowlden, 2000) have indicated that those who are willing to become involved in the Methadone Program believe that the structure of the CMBS provides disincentives for spending adequate time with patients and does not provide adequate financial compensation for the administrative requirements of the program and the demanding nature of the patients.
There was no difference in the number of MMT services provided by general practitioners and specialist but there was a significant difference in the cost of MMT. At an average cost of $1226 per patient per annum there is no question that a ‘capitation’ fee of $700 would not have been sufficient to compensate specialists for the services provided in 1997 and 1998. A ‘capitation’ fee set too low would therefore, in all likelihood, result in either the resignation of specialists from the Methadone Program or a reduction in the number of services they provide to patients, both of which would be unsatisfactory outcomes in those jurisdictions where specialists provide MMT. However, given that there appears to be no difference in the time spent with patients between general practitioners and specialists, and the fact that psychiatrists tended to provide services to longer term methadone patients, there is little to suggest that specialist prescribers treated those MMT patients with more complex co-morbid conditions. As such, the Commonwealth Government’s concern about the additional funds expended on specialists may well be justified. It would seem appropriate that the role of specialists in the provision of MMT ought to be reviewed and the system reconfigured such that, where appropriate, methadone patients with significant mental health problems are treated by psychiatrists.
Given, that under the ‘capitation’ model put forward, methadone patients would have continued to access the CMBS for their general health care needs, it is questionable whether a ‘capitation’ fee approach would have resulted in reduced expenditure on MMT. There are many inherent incentives and opportunities contained within a ‘capitation’ model that removes methadone treatment from the CMBS and artificially separates it from general health care. Cost-shifting between the two types of services may have occurred, resulting in an increase in the real cost for MMT. Alternatively, the potential to under-service could have compromised treatment outcomes.
The fundamental goal of the methadone treatment system in Australia should be the provision of cost-effective, quality services that improve health and social outcomes for patients. At present the State Government, the Commonwealth Government and methadone patients contribute to the funding of MMT, with patients generally incurring the highest treatment cost. The focus should not be simply on who pays what but rather on what services should be provided to which patients, for what outcome and at what price. While the Commonwealth has decided not to proceed with a ‘capitation’ approach for MMT, the current study provides a reference point from which service providers can begin to build a model of MMT which identifies appropriate levels of service provision to meet the differing needs of patients and which looks more holistically at the total health care needs of these patients. In so doing, the model of MMT service delivery should address the current discrepancies in levels of care between the various dosing facilities and the differences in treatment costs found between specialists and general practitioners.
Citation: Ward, P. and Mattick, R. (2005) Health care utilisation and costs under the Commonwealth Medicare Benefit Scheme by methadone maintenance treatment patients in NSW. Sydney: National Drug and Alcohol Research Centre.