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Early this week, Maria Paige was fighting to save her patient’s life. Paige is an addiction specialist at the community health nonprofit Mary’s Center, and she was taking care of someone with severe heroin addiction. “He was in really bad shape,” she says, and he was scheduled to go into inpatient treatment. First, he just needed to pick up his Suboxone, a medication that helps people combat heroin addiction.
But there was a problem. When he went to pick up his Suboxone, DC Medicaid denied the prescription, saying he wasn’t due for more medicine yet. So he tried again the next day, and he got a second denial. Paige hasn’t heard from him since. “I’m not sure if he made it,” she says.
This was the result of a sudden, seismic change in DC Medicaid’s procedures surrounding addiction treatment. On Nov. 1, due to a system error, DC Medicaid began accidentally prohibiting patients from picking up their Suboxone even one day before their last round of medicine runs out. In addition to this restriction, there appears to be another major glitch in the system. “If a patient picked up a one week prescription last Tuesday, they … won’t allow patients to pick up until the subsequent Wednesday,” says David Sternberg, clinical services manager at the harm reduction nonprofit HIPS. “The following week, they cannot pick up until Thursday. This means that patients are out of medication for a day each time they need to pick up a new prescription.”
Treatment providers have been faced with confusion and conflicting information as they’ve tried to navigate this change. Multiple health care providers tell City Paper that they heard—from DC Medicaid officials—that this was part of a new zero tolerance policy stopping patients from picking prescriptions up early. However, Dorinda White, a spokesperson for the Department of Health Care Finance (which operates DC Medicaid), says the change was a programming error, not an intentional shift in policy. “The District does not have a zero tolerance policy prohibiting early refill of suboxone,” White says. When implementing an unrelated policy change meant to make these medications more accessible, “an error was made in the system that precluded early fill/refill of buprenorphine [Suboxone is a mix of buprenorphine and naloxone]. We are working to correct the error and expect it to be resolved by 11/12/19.”
Paige says that every day now, she has patients scheduled to pick up their Suboxone who are told they must wait one or more days before they can get their meds. Yesterday alone, Mary’s Center had five patients denied their routine medicine. “These little things really make a big dent in their recovery,” she emphasizes. People may spend years dealing with addiction before they’re ready to take the leap into recovery, and if they can’t get care when they need it, addiction can quickly regain its hold. “That’s the window,” Paige says. “The little window when they’re ready. When they want to go … When these things happen, we have patients that are relapsing or dying.”
“We live or die by these regulations that D.C. Medicaid sends out,” Sternberg says. “One day without their medication can result in a fatal overdose.” Going a day or two without Suboxone, “folks are going to experience withdrawal,” he explains. “That’s flu-like symptoms. Diarrhea. Vomiting. Withdrawal is considered a medical emergency, and can result in death.” In order to end the pain of withdrawal, people may buy heroin and relapse, and since people’s tolerance for heroin can decrease if they’ve not been using for a while, the risk for overdose becomes especially high. In the past, Sternberg says, “we’ve had patients die of an overdose while they’re waiting for their prescription.”
Before the change went into effect, patients were allowed to pick up their meds up to 72 hours ahead of time, says Dr. Dan Smith, who leads the addiction treatment programs at Mary’s Center. He thinks that was “a good policy” because patients might lose some of their meds or have them stolen from them, and because people dealing with poverty and addiction can’t always find transportation the exact day they’re scheduled to pick something up. Furthermore, that leeway helps soften the blow of occasional medicine shortages. “Two weeks ago, all except like two pharmacies in D.C. were without generic Suboxone,” he explains. “Imagine that happening if you didn’t have that [72 hour] grace period.”
One pharmacist City Paper spoke to says they’ve already had about a dozen Suboxone patients get their prescriptions denied because of the change. (The pharmacist asked to remain anonymous because they work for a chain drugstore and didn’t have time to get their employer’s permission to speak.) This pharmacist believes that by not giving these patients leeway, the Department of Health Care Finance is over-correcting in order to minimize the chance people will sell their addiction treatment meds on the black market. “Everyone is afraid of getting in trouble. So a lot of insurance companies are making Suboxone harder to get,” they say. “I think the fear is definitely causing a decrease in the quality of care.”
The impact on patients is compounded by the fact that DC Medicaid didn’t tell everyone about the changes. No one City Paper interviewed knew about what happened until their patients suddenly stopped getting their meds. “We come in one day, business as usual,” another pharmacist recounts. “Then bam! Patients start getting denied. We start calling around, asking other pharmacies what’s happening. Doctors start calling us. Eventually, someone figures out there’s a new policy.”
(DHCF says that this is because they themselves didn’t know about the error until patients started getting denied. Several providers expressed frustration, however, that they didn’t receive communications from DC Medicaid even after the error was identified.)
“There’s no communication. Why couldn’t someone have just emailed us?” Sternberg asks. “‘Hey, these are the changes that are coming on November 1.’ Being able to give feedback would be lovely. But just a heads up would’ve helped us prepare for this.”
And the new requirements have been rigidly enforced. Paige says she’s called DC Medicaid asking for a little leeway, saying, “These clients need their medications today. They can’t wait.” The agency reportedly told her, “Ah, well, there’s nothing we can do.”
Sternberg thinks the damage will deepen day by day, as more patients have their prescriptions run out and now have to abstain from medication—especially patients with severe addiction, who are at the greatest risk. “Starting tomorrow, and into the weekend and beyond, if it doesn’t change, it will be more and more of a problem,” he says. “It’s already hard enough to get good outcomes. There’s so much work that goes into coordinating care for highly acute, homeless people.”
“You have the Bowser administration saying that they’re on top of the opioid crisis. But these are the nitty-gritty details that determine if it works. These little changes … will result in more deaths,” he emphasizes. “The clock is ticking.”
Update: On Nov. 14 and 15, City Paper received further details from Dr. Pamela Riley, DHCF’s medical director. Riley says that due to internal miscommunications, providers may have been told this was a deliberate change, and that nothing could be done for patients getting denied their meds. “This change may have been misunderstood as intentional and miscommunicated as such by DC Medicaid representatives,” she says, “using the technical term ‘zero tolerance’ referring to the fact that the system had now imposed a zero-day ‘tolerance’ or grace period for early refills.” “It in no way signals that we’re changing our stance,” she adds. “We’re very committed to patients getting their medicine, and we don’t want this to happen. This is very much a priority for us.” The error has reportedly been fixed. City Paper has updated the post to reflect these additional details about the technical error.