Heaven Godley, 39, chats with receptionist Angela Mason. Opioid treatment centers like Reach Health Services in Baltimore are providing counseling in addition to medication. (Courtesy of ©The Pew Charitable Trusts)

To Heaven Godley, a recovering heroin addict, the methadone treatment center he visits every day feels like home. “It’s my refuge,” said the 39-year-old Baltimore native.

Godley’s treatment plan at Reach Health Services, one of 20 opioid treatment centers in Baltimore that provide methadone and other addiction medications, is intensive. He talks to his behavioral health counselor several times a week, sees a psychologist to help manage his anger and gets regular medical checkups at an on-site clinic. The combination of medication and monthly or weekly counseling or group classes has been shown to be effective at keeping most patients away from heroin and other drugs for six months to a year.

But, like Godley, a small percentage of patients need counseling that is more intensive, said Reach’s medical director, Yngvild Olsen.

A growing consensus among medical researchers that patients who receive a combination of addiction medication and counseling that is tailored to their needs fare better than those who receive little or no counseling is leading to a change in policy in Maryland.

The state’s Medicaid agency is shifting its payment policies to encourage as much counseling as needed. But some clinic operators say the new pricing plan will jeopardize their businesses because they contend many addicts refuse counseling and there is little they can do to change their minds.

Baltimore has been hit hard by the opioid epidemic, with at least 20,000 of the city’s 620,000 residents actively using heroin and far more abusing prescription painkillers. About 10,000 others are receiving treatment at free-standing or hospital-based treatment centers such as Reach, according to Behavioral Health System Baltimore, a nonprofit that distributes funds to these centers.

In March, rather than paying the same flat rate for all patients, Maryland’s Medicaid agency will begin to pay providers for as much counseling and related medical services as are needed for certain patients, while lowering the flat per-person weekly reimbursement rate for patients who receive only minimal counseling.

The new fee structure is similar to those developed in New York and California. New Jersey is moving in the same direction.

“The evidence is clear,” said Leana Wen, Baltimore’s health commissioner. “Addiction is a disease, treatment exists and recovery is possible. Medications, including methadone and buprenorphine, combined with counseling, are proven to lead to better outcomes than treating opioid addiction with medication alone. Counseling allows those in recovery to develop the tools and coping skills they need to prevent relapse.”

And, Olsen said, the additional Medicaid money should inspire treatment centers to work harder at getting patients who need extra counseling to agree to it.

But some in Baltimore’s opioid treatment field worry that the new payment plan will make it difficult for them to remain open.

The Rev. Milton Williams, founder of the Turning Point Clinic, which dispenses daily methadone doses to more than 2,800 patients in East Baltimore, said most people who come to his treatment center don’t want counseling. It’s better, he said, to give people with a heroin addiction methadone on its own — to keep them from suffering withdrawal symptoms and committing crimes to pay for illicit drugs — than to force them into counseling.

“Addicts don’t want to sit for counseling. They want their dose and leave,” Williams said. He predicted Maryland’s new regulations will drive away patients because clinics are likely to pressure them to get more counseling.

Williams cautioned that clinics that are unable to talk more patients into counseling and to develop more-sophisticated billing systems to get paid for it will go out of business because of the reduced flat rate. “If they don’t figure out how to get more people into counseling, they could lose 25 percent of their revenue,” he said.

Individualized treatment

Medicaid programs in 34 states cover methadone treatment, and most of them pay a flat daily, weekly or monthly fee for a basic, federally required set of services, including dispensing addiction medication daily, routinely screening patients’ urine to determine whether they’re using illicit drugs and checking in with patients weekly to see whether they need additional help staying sober.

For patients such as Godley who need extra time in counseling or group classes, Medicaid does not pay a higher rate. That means Reach has “had to eat some of the costs,” Olsen said.

Maryland’s new rules are designed to give treatment centers a financial incentive to customize treatment plans to patients’ individual needs, according to Shannon McMahon, the state’s deputy secretary for health-care financing.

The more counseling a patient needs, the more money Medicaid will pay. Group counseling will be reimbursed at $29 per session, for example, while intensive individual counseling will be reimbursed at $125 per session. For patients who need only minimal counseling, Medicaid will pay a flat rate of $63 per week instead of the current $81.60.

When New York started charging separately for medication and counseling in 2009, “there was a lot of trepidation about it,” said Allegra Schorr, owner of an opioid treatment center based in Manhattan and president of the Coalition of Medication-Assisted Treatment Providers and Advocates.

New York’s transition from a flat monthly rate to separate billing for counseling and other services was phased in over four years to give treatment centers time to develop billing systems and add new services, Schorr said. In the end, it resulted in higher overall revenue for most treatment centers and a more robust set of counseling and medical services for clients, she said.

Contrary to initial concerns, New York’s pricing scheme did not stunt the growth of opioid treatment centers, Schorr said. Three new centers opened in 2015, bringing the statewide total to 101, and five new centers are scheduled to open in the next year, she said.

Fear and misinformation

Growing up in a city plagued by drugs and crime, Godley said he had been using and selling heroin for a decade before he realized he was addicted. His brother used, his uncles used, practically everyone he knew used drugs and alcohol. They also went to prison a lot.

“Kids in Baltimore grow up with addiction as the norm for them. It’s a way of life,” said Kathleen Westcoat, chief executive of Behavioral Health System Baltimore.

Almost a year ago, Godley heard about Reach from friends. He was admitted the day he walked in. He said he is still amazed at what he learned there. He carries around a diagram from the National Institutes of Health that shows how drugs affect the brain. “Now I know I have a disease and I need to change a lot of my behaviors,” he said. “I’m learning to think things through instead of just acting on my emotions.”

Godley relapsed and started using heroin again a few months after he began treatment last year. But after Reach counselors contacted him by phone and encouraged him to come back, he returned to treatment. Since then he has quit cocaine, alcohol and even cigarettes.

Recently, his counselor helped him land a job with the Baltimore health department, showing people how to use naloxone to rescue someone who has overdosed on heroin or prescription painkillers.

Despite the progress he has made, Godley is sometimes ambivalent about quitting drugs, and he’s not sure how much longer he’ll keep coming to Reach, Olsen said. “I keep reminding him that addiction treatment is a marathon, not a sprint.”

Stateline