Fifteen years ago, with an EMT colleague and an armed police officer, I arrived as a novice 25-year-old paramedic to a grungy college apartment in my hometown of Ithaca, New York to find a woman my age, clothed but drenched, draped out of a stand-up shower with blue lips, pinpoint pupils and no respiratory effort.
Her panicked boyfriend cradled her dripping head and told us, “I don’t know what happened; we didn’t take anything!” For fear of arrest he delayed, even as I breathed for her through a mask, finally telling us that she had just sucked fentanyl from patches and overdosed.
Naloxone revived her immediately. After a spate of projectile vomiting in the back of the ambulance, her vital signs completely normalized and a look of resigned shame set into her face.
I don’t know what happened after we dropped her at the ER but, like others in her chain of care, I had no responsibility to find out.
“I didn’t know that every person on chronic narcotics should be sent home with Narcan,” Dr. Justine Waldman, who was likely the receiving ER physician that day, now reminds me. “And I didn’t know that every time I or my staff added shame to a person she became less likely to ever return for help.”
After practicing medicine for years, I’m now back in Ithaca. I’m a mother, a family physician and the associate medical director at REACH: a low-threshold, harm reduction primary care clinic with embedded medication-assisted treatment (MAT) for opioid use disorder. Justine is the medical director. Under her brave leadership and mentoring, we opened our doors in February in response to the growing opioid crisis sweeping through Upstate New York.
Patients from no fewer than 17 counties have come to us for MAT in the six months since we opened. There is simply no help where they live.
Rural populations like ours are especially vulnerable to opioid use disorders. Small clinics in small communities are less likely to have sufficient staff to support a treatment program, less likely to have buprenorphine-waivered providers, and less likely to have nearby specialists to consult.
Rural communities have fewer social support systems for patients, such as housing, public education and job opportunities. They may also lack accessible peer meetings, affordable healthy food, and reliable public transportation.
There are an estimated 2.1 million Americans with opioid use disorder. Overdose is the leading cause of death in our country for everyone under the age of 50. Last year there were an estimated 72,000 overdose deaths in the US, a 10 percent increase from 2016.
In our state of New York, the increase in overdose deaths has been much faster than the national average. But there is a profound urban-rural split: Between 2010 and 2015 New York City saw a 45 percent increase; the rest of the state saw 84 percent.
At our Ithaca clinic, this disproportionate distribution of opioid use to rural areas is reflected by the alarming fact that patients from no fewer than 17 counties have come to us for MAT in the six months since we opened. This initially surprised us greatly. But they are coming because there is simply no help where they live.
Justine reminds us that we are working within the very medical system which taught all of us words like “abstinence” and “addict,” and that we shouldn’t enable “these people” by giving them a warm blanket. Those on whose shoulders we stood told us that all “addicts” lie and manipulate, not separating their humanity from behaviors driven by substance use disorders and many other factors.
We had both become cogs in the machine of stigma and unnecessary death which still masquerades as modern American medicine.
Justine and I are two of the lucky ones. Having entered medicine to improve our societies, and wrestled throughout our training with the reality of inequitably distributed care, we were ready for our veils to be lifted. As we grew increasingly aware of the prejudice faced by people who use drugs, we also realized how little we truly knew about opioid use disorder.
For instance, we didn’t know, earlier in our careers, the extent to which it could become long-term, or involve repeated relapses—or that people with opioid use disorder have a 10-fold higher mortality rate than the general population. We didn’t know that medications like methadone and buprenorphine were powerfully associated with improved outcomes for these patients.
Neither did we know that access to these lifesaving drugs—especially in rural America—is abysmal, and far more restricted by law than is our ability to prescribe opioids themselves. We didn’t know that providers can only prescribe buprenorphine to 30 patients concurrently in their first year after taking a special training. We didn’t know that access to treatment is often reliant on weekly urine testing and mandatory counseling—even though these further-stigmatizing measures have never been shown to save lives.
This is systematized stigma, and it must change now.
What we did know, years ago, is that we were being paid to see patients as fast as possible with as many procedures as we could justify. We also knew, from both the primary care and emergency department perspectives, that the medical system didn’t care how many times each patient visited the ER for the same, untreated problem. That’s because the insurance system doled out money based on fee-for-service—not value.
To both of us, this felt less like healing and more like retail. Though we were good-hearted and educated women, we had both become cogs in the machine of stigma and unnecessary death which still masquerades as modern American medicine.
The Value-Based Payment Model
Now we see a different path forward, a way to change healthcare while reducing human and fiscal costs to society, by offering what all people want and deserve: dignity, respect, compassion, and equal access to smart providers who care.
Under the increasingly central Value-Based Payment approach to health care reimbursement, government and other agencies who pay for care hold providers accountable for and reward them for the quality of care provided, not just its cost. Quality measures include, among other examples: how well blood pressure and sugar are controlled, whether patients get recommended vaccinations, and whether cancer screenings are up-to-date.
What, then, are the barriers to the Value-Based Payment model?
Let’s say Medicaid pays our clinic $100 for a 45-year-old patient’s visit to control her hypertension, counsel her about opioid use disorder, and refill her Suboxone. And let’s say she sees us for six such visits in a year, for a total reimbursement of $600 paid to our non-profit clinic.
Even if that work prevents Medicaid’s having to pay for a $4,000 ER visit or a $90,000 ICU admission after overdose, we can’t use that saved money to sustain our preventive treatment.
The reimbursements paid under the current Fee For Service system (eg. $100 for one visit) do not provide enough money to run a clinic. Many practices therefore either accept no Medicaid patients, or cap their number of Medicaid patients to ensure they still get paid enough to keep the doors open.
Currently we at REACH rely on grant support, primarily Medicaid reform pilot allocations. We will not be able to reliably afford our low-cost care until Value-Based Payment is implemented, or Medicare is expanded to include all Americans.
We have to make this epidemic about health equity. Those of us who went into health care to help people, not shame them into the shadows, must be willing to take the risk of offering the care that is needed, even though it is not yet financially viable.
The current crisis is our chance to change the system, and get it right this time. It’s our chance to stand up and say “The treatment system, not our patients, is the problem.” And when we force this system to change, we will improve treatment not only for opioid use disorder, but also for diabetes, for depression, for Hepatitis C—heck, even for a pesky case of adolescent acne!
This opioid crisis, in all its tragedy, can drive systemic overhaul. If we let it. If we make it.
This piece was written with collaboration and contributions from Dr. Justine Waldman.