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    ADDICTION

    State Boosts Telehealth for Drug Therapy

    Baker’s order makes treatment for substance abuse more accessible

    By

    Gov. Charlie Baker signed an executive order on March 15 expanding access to telehealth services for the duration of the Covid-19 crisis. His action has the potential to make Medication Assisted Treatment (MAT) for substance abuse disorder far more accessible, according to several Cape-based addiction specialists.

    The governor’s order prevents private insurers from imposing telehealth restrictions more stringent than those outlined by MassHealth, the state’s health care safety net. This means that all insurers are now covering a wide range of telehealth services at in-person rates.

    Allie Andersen, chief clinical officer at Gosnold, the Falmouth treatment center, welcomed the new policy. “As far as paying for service,” she said, “they’re currently at the same rates as a face-to-face session, and I’m hoping that they will continue to do that. I think it’s a benefit to the patients.”

    Virtual options for behavioral health care, such as substance abuse treatment, teletherapy, and telepsychiatry, have been covered by MassHealth since the start of 2019. But before the pandemic, providers were required to use certain technologies, undergo telehealth-specific training, and “ensure the same rights to confidentiality and security as provided in face-to-face services.” Audio-only telephone conversations were not to be used in isolation.

    That changed in March of this year. MassHealth relaxed its requirements for providers, calling for confidentiality and security rights to be maintained “to the extent feasible.” Telehealth training and technology guidelines are waived, as is the rule about audio-only appointments.

    In addition, a federal rule that requires all new opioid treatment program patients to undergo a complete physical examination has been temporarily waived by the Substance Abuse and Mental Health Services Administration, except in the case of methadone programs, which are more strictly regulated.

    Though some insurance providers covered telemedicine services for behavioral health care prior to the Covid-19 crisis, strict regulations meant that the services gained little traction.

    MAT for opioid addiction, a form of outpatient rehab that uses prescription medications alongside counseling and behavioral therapies, may now be conducted exclusively remotely. Duffy Health Center in Hyannis; Gosnold in Falmouth and Cataumet; and Outer Cape Health Services in Provincetown, Wellfleet, and Harwich Port all provide forms of MAT using medications like buprenorphine and naltrexone (the combination of the two is the common therapeutic Suboxone), which reduce cravings for addictive opioids. Such programs usually require new patients to attend weekly appointments until the patient’s condition is stabilized, at which point meetings may become less frequent.

    Prior to the pandemic, Gosnold mainly prescribed Vivitrol, a monthly injection of the generic drug naltrexone, which can reduce opioid cravings for up to a month. Now, Andersen says, many patients have switched to an oral form of the medication in order to avoid going into a public place. Though in-office injections are still available, most patients have opted for fully remote treatment.

    Duffy Health provides services to people with substance use disorder throughout Barnstable County, as well as those facing housing instability, joblessness, lack of health insurance, and chronic disability. It typically provides MAT for about 330 patients Cape-wide, but that number has increased to 360 since mid-March, when telehealth restrictions were relaxed and in-person visits were severely limited.

    Daniel Rodrigues, the assistant director of substance abuse services at Duffy Health, said that the relaxing of federal regulations has made MAT for substance use disorder more accessible to many patients. “Telehealth restrictions have been a real barrier for the folks we’re serving,” he said.

    Rodrigues said that retention rates in particular have increased with the breakdown of transportation barriers. While Duffy is committed to providing same-day treatment to anyone seeking it because it can be “life or death,” he said, long commutes mean that weekly in-person appointments have proven difficult to maintain for patients outside the Upper and Mid Cape.

    At present, Duffy serves only six patients from the four Outer Cape towns. But Rodrigues said that broader usage of telemedicine services will increase Duffy’s geographic capacity and allow for greater accessibility to Outer Cape residents.

    Andersen hopes that telehealth will find a solid middle ground in a post-coronavirus world.

    “Patients can make their appointments from their homes, anywhere really,” she said. “We have patients who go out on their lunch break and do it from their cars. It’s allowed a lot more people access from a lot more locations.” While she views this increased accessibility positively, she is also looking forward to increased security standards after the pandemic.

    Could telemedicine increase Gosnold’s often waitlisted outpatient capacity in the future? “Absolutely,” Andersen said.

    The Mass. League of Community Health Centers reported that “telehealth — particularly telephonic — has quickly demonstrated its efficacy in eliminating patient barriers to treatment, including transportation, finding time for frequent visits, care-giving responsibilities, not having a job that offers flexible, paid time off, limited data plans, and ambivalence about coming into a clinic to engage in care.”

    Dr. Matthew Libby at Outer Cape Health Services said that many patients enjoy the convenience of telehealth appointments, but some also miss the in-person experiences of counseling and group therapy. Throughout the pandemic, OCHS has had difficulty obtaining frequent drug screenings. A patient’s internet and cellular connectivity can also pose problems. OCHS currently serves around 200 patients in its Office-Based Addiction Treatment (OBAT) program, a number that has remained stable since before the pandemic.

    OCHS expects telehealth will remain “an important part of how we deliver care in the future,” said Libby.

    Last week the Mass. Senate unanimously passed the Patients First Act, which requires all insurance providers to cover telehealth services “in any case where the same in-person service would be covered” at the same reimbursement rates for at least the next two years.

    “While Covid-19 has stressed healthcare in a myriad of ways, the transition to telemedicine and the expanded practice of providers during the emergency have proven to be extraordinary tools that keep patients healthy, especially in geographically isolated regions like the Cape & Islands,” said Sen. Julian Cyr (D-Truro) in a June 26 press release.

    Olivia Weeks’s summer fellowship with the Independent is supported by the Harvard Alumni Association and the Harvard Club of Cape Cod.

    PANDEMIC

    Health Center Funds Dwindle as Patients Stay Home

    OCHS puts losses at $1 million per month

    By

    PROVINCETOWN — No clinical services to patients have been canceled since Outer Cape Health Services last week furloughed or laid off nearly half its staff because of lost revenue caused by the coronavirus pandemic.

    Federally qualified health centers like OCHS are the “canaries in the coal mine” of the economic crisis caused by COVID-19, according to the Mass. League of Community Health Centers. Though it was not clear whether any other such centers in Massachusetts had announced staff reductions as of Monday, Atrius Health, the largest independent health care organization in the state, also made temporary cuts affecting about half its workforce on March 23.

    In a conference call on Monday, Dr. Andrew Jorgensen, medical director of OCHS, said no clinicians have been furloughed or laid off. But many support staff at all three clinics, in Provincetown, Wellfleet, and Harwich, will be out of work, mostly temporarily, for an estimated four to six weeks, said CEO Pat Nadle.

    “Today has truly been one of the hardest days in my entire career,” Nadle stated on March 25. “Making decisions that impact even one staff member’s life is very difficult.”

    OCHS has furloughed about 70 of its 200 employees. They can return to their jobs when patient visits and revenues return to normal. In the meantime they can apply for unemployment benefits and health insurance through MassHealth, Nadle said. Others, including members of the management team, will work reduced hours, she said. There will be a small number of permanent layoffs — “enough to count on one hand,” she said.

    Gynecology, behavioral health, radiology, and other services will continue for now, Nadle said. Dentistry and ophthalmology were suspended about two weeks ago at the recommendation of the governor, Nadle said.

    Cape Cod Healthcare, which operates both Cape hospitals, had avoided staff reductions as of the Independent’s deadline. But in reaction to the lost revenue from canceled elective surgery, CEO Mike Lauf announced he would give up his salary for April ($78,000 according to the Cape Cod Times). The trustees of Cape Cod Healthcare said they would match that amount in a donation to the company’s foundation.

    At Outer Cape Health, the reduction in patient visits is expected to create losses of $1 million a month, according to Nadle’s announcement.

    The League of Community Health Centers announced on March 20 that clinics like OCHS (which get federal funding to serve poor and rural areas) are expected to see revenue drop by 50 to 70 percent during the pandemic.

    Ironically, health care is taking a hit because, as people isolate, they postpone seeing their doctors. Community health clinic revenue comes mostly from patient visits. For hospitals, the top revenue streams are from elective surgery and cardiovascular surgery, followed by cardiology, neurosurgery, orthopedic surgery, and gastroenterology.

    In order to adapt to the losses, OCHS is applying for grants, and should benefit from the recent federal stimulus bill, though Nadle said the amount of help was still not known.

    Aside from the aid package, the government is beginning to help shift the immediate revenue picture. The federal government did recently allow Medicare to begin paying for telemedicine appointments. Private and state-funded insurance companies were ordered by Gov. Charlie Baker to reimburse immediately for telemedicine, Jorgensen said. But that did not happen quickly on the federal level.

    Telemedicine, which now accounts for about 80 percent of appointments, could help stop the spread of the virus, and saves on personal protective equipment, which continues to be in short supply.

     

    PANDEMIC

    OCHS Faces Fiscal Strain in Virus Crisis

    Hours reduced, and closing one clinic may be necessary

    By

    WELLFLEET — Outer Cape Health Services must reduce its hours and possibly close one of its three clinics at least temporarily because of the financial pressure imposed on the organization by the coronavirus, its directors report.

    In a conference call with reporters on Monday, medical director Andrew Jorgensen said the volume of patients has gone down as people self-isolate, “so to be financially responsible we’ll do a reduction in hours.”

    Though a new schedule was not final by the Independent’s deadline, the three OCHS clinics in Provincetown, Wellfleet, and Harwich will have phased opening and closing times so that in combination they will be open 8 a.m. to 5 p.m., Jorgensen said. Updates will be made available on outercape.org.

    On Tuesday, Executive Director Pat Nadle appealed to donors in an email that began, “In what has been a matter of days, nothing is as it has been before.” Her message was dire: “We are facing an immediate threat to our ability to provide health center care to residents of the Outer and Lower Cape who depend upon us as their only health care resource.”

    Nadle’s memo cited compounding threats to federally qualified health centers like OCHS, including new expenses, supply shortages, and a lack of support from the federal government.

    “As we are local residents like you, we find the idea of closed health care assets horrifying,” the email continues. “And yet, without your help, our hands are tied. The funds are simply not available to serve our community as we have for decades.”

    According to the email, 17,000 patients could be facing closed pharmacies, limited access to local providers, and reduced access to supportive social services.

    No one from OCHS would comment on the donor appeal email by the Independent’s deadline on Tuesday.

    OCHS clinics are still treating people for common ailments, but there are some COVID-19- related changes. They are doing more telemedicine, in which clinicians provide treatment by phone. This includes psychotherapy — for which there is great demand, especially in this time of anxiety and isolation, said Marta “Dikke” Hansen, director of behavioral health at OCHS.

    Those who need to come to a clinic are met at the entrance by a staff member who will ask about COVID-19 symptoms and take their temperature. Those with symptoms will be sent back to their cars to await a phone call or visit from a nurse. OCHS is trying to limit exposure because if the clinic is contaminated it would have to close for 24 hours, Jorgensen explained.

    “We are determined to keep our health centers open during the epidemic,” he said.

    Tests of Limited Value Now

    A shortage of coronavirus test kits and equipment at hospitals and health centers continues.

    OCHS had tested 50 people by Monday, mostly at the Wellfleet clinic where the organization now directs those approved for “drive-by” testing. Two residents of Provincetown tested positive at the Wellfleet clinic, said Jorgensen.

    On top of the usual screening questions for COVID-19 symptoms, OCHS doctors are making strategic choices, conducting tests only in certain cases, because the tests are in short supply.

    The lack of tests is not a major concern at this stage in the pandemic, according to Dr. Michael Shear, a Boston-area emergency room doctor — it is too late for them to be much help.

    “Easy access to testing might have helped us in trying to contain the virus,” he told the Independent. “But now, with COVID-19 already widespread, the question becomes what to do with the test results.

    “At this point, anyone with symptoms of respiratory illness (cough, sore throat, fever) should stay home and self-isolate,” Shear continued. “They will most likely be fine and will feel better if they just treat the symptoms. Having a test, whether the results are positive or negative, won’t change that advice. The tests are really most useful in helping hospitals decide which of their patients are most in need of stricter isolation.”

    In order to preserve scarce protective equipment, OCHS is scheduling COVID-19 tests back to back in Wellfleet as much as possible. That way, gowns and N95 masks do not have to be changed each time a patient is tested from a vehicle, Jorgensen said.

    One bright spot in the bleak days since the pandemic began is that Christy Shilling, a molecular scientist with a home in Provincetown, on Monday donated about 200 N95 masks to OCHS. She was not in town, but asked her friend James Frederick to get the masks from her home and bring them to the clinic, Frederick said Tuesday.

    Nadle called the donation “a miracle.”

    Worst Is Yet to Come

    Questions about the medical capacity of this rural area continue.

    Cape Cod Healthcare, which owns both hospitals in Barnstable County, has 60 ventilators at Cape Cod Hospital and another 20 at Falmouth Hospital, said spokesman Pat Kane. The two hospitals combined have 34 I.C.U. beds, according to the watchdog Leapfrog Group.

    Staying home and socially isolated to avoid infection is the best way each citizen can help, though Sean O’Brien, the county’s emergency preparedness coordinator, stated on Monday that the worst is yet to come.

    “If I had to say one thing, it’s that we’re just at the start of this,” he said.

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