Rodney and Heather Auger used to wake up each day knowing they’d need drugs to get through all 24 hours.
First they relied on pain medications prescribed by doctors, hers for a series of health issues that began at age 16, his for a back injury from a work accident.
When their doctors abruptly stopped those prescriptions, the couple turned to heroin, they said. They spent seven years on the streets, living in garages and in their car, their days consumed by a desperate search for illicit drugs that would stave off the misery of withdrawal.
But today, they have a tidy apartment in Old Orchard Beach with an almost-view of the ocean. Now, they begin each morning by taking buprenorphine, knowing the medication will ease the cravings for opioids that dominated the better part of their seven-year marriage. The medication does not provide a high.
“We’re pretty much starting our whole life over,” Heather said. “Our marriage we’ve started over. We’ve only been married for seven years. We were always addicts together.”
Once a week, they attend a group counseling session at a clinic in nearby Biddeford called Groups Recover Together. They also must pass a urine drug test to get their prescriptions filled for the following week.
The Augers are part of an emerging approach to treating opioid addiction in Maine, one that may never have gotten off the ground without the involvement of Groups Recover Together. The company, a for-profit chain of addiction treatment clinics, is expanding rapidly in Maine and throughout the country, applying a startup mentality to combatting the nation’s most pressing public health crisis.
The company has managed to grow where traditional providers have struggled to keep up with the need, raising larger questions about who is, or should be, responsible for delivering care. While some observers are concerned about Maine increasingly relying on a single, private business to care for vulnerable patients, others simply see more people getting well.
‘New model of addiction treatment’
Like nearly all states, Maine lacks the capacity to provide the most proven form of treatment for opioid addiction, known as medication-assisted treatment. It combines medications that reduce cravings and withdrawal symptoms, such as Suboxone or methadone, with behavioral counseling.
Methadone treatment typically requires patients to visit a clinic every day during the early morning hours, line up to receive their dose of the medication, and attend counseling once a month. With Suboxone, patients can get a prescription in a variety of settings, from doctor’s offices to primary care clinics, and fill them at a pharmacy.
Studies have clearly demonstrated the effectiveness of both medications in treating opioid use disorder. The counseling component, whether individual or in group settings, hasn’t been studied enough to say definitively that it helps people recover, though many experts believe it’s essential.
Last year, more than 1,500 Maine residents received medication-assisted treatment. Experts estimate the need far exceeds that.
Nearly two years ago, the LePage administration launched its “opioid health home” model as an “innovative” response to the addiction crisis. Mary Mayhew, then commissioner of the Maine Department of Health and Human Services, expressed her confidence that “this model will help Mainers who need and want to get better.”
The program directs taxpayer money to health providers who meet certain standards in providing addiction treatment. The “home” in its name does not refer to a bricks-and-mortar space, but rather to the concept that health providers can become a home base for patients by coordinating with each other to give better care at a lower cost. The care is provided in outpatient settings, such as clinics and doctor’s offices, not in residential addiction treatment facilities.
Mayhew pitched the opioid health home model as an effort to integrate addiction treatment with primary care, to treat the “whole person” through not only substance use counseling and medication, but also additional services designed to address patients’ full range of behavioral and physical health needs.
The $2 million program was geared toward patients who had no health insurance and those covered by MaineCare, the state’s Medicaid program.
Though prompted by pressure from legislative Democrats, the opioid health home model arguably represents the outgoing LePage administration’s clearest vision for how Maine should meet the desperate demand for addiction treatment.
The program got off to a lethargic start in 2017, with Maine’s health providers complaining that the rules were burdensome, requiring them to link patients with a deep bench of hard-to-find staff with expertise in addiction, including a nurse care manager, licensed drug and alcohol counselor, and peer recovery coach.
Much has changed. In the last year, the program has grown exponentially — largely attributable to the involvement of Groups Recover Together.
The company, founded in New Hampshire and funded by venture capital, has thrived against the backdrop of Maine’s otherwise mostly local and nonprofit substance use treatment network. Promising a “fundamentally new model of addiction treatment,” Groups Recover Together is growing, targeting rural areas while dodging the economic and regulatory roadblocks encountered by other providers.
‘Just a question of who’s profiting’
Groups Recover Together prescribes buprenorphine and provides weekly counseling in nine Maine communities: Biddeford, Portland, Lewiston, Augusta, Rockland, Ellsworth, Calais, Machias, and Farmington. By early next year, it plans to open locations in Bangor, Houlton, Waterville, and Belfast, and by next summer it anticipates adding Newport and Rumford.
Groups Recover Together now operates 60 clinics in eight states including Maine and as far west as California. The company has committed to seeing patients within a week, with no wait lists.
The Biddeford clinic where the Augers receive treatment was among the first locations Groups Recover Together opened in Maine in 2016. The company served about 800 people in the state before signing the opioid health home contract with DHHS in April.
CEO Cooper Zelnick said the company’s model rewards it for helping people get better, rather than for simply rendering services that are profitable for it to deliver. Through its contract with DHHS for the opioid health homes, the company is paid one rate for a bundle of valuable services it provides to uninsured residents, he said. That’s in contrast to the “fee for service” payments more typical in health care, in which providers get paid every time they deliver a service, such as a urine drug screen, regardless of whether that service helps patients get better, he said.
“By keeping people in treatment and helping them actually recover and ultimately get off medication and be successful and healthy, we’re massively lowering the cost to the health care system,” he said. “When we make money, we are participating in the value that’s created.”
The company claims retention rates well above the national average. While no government source reports retention rates, Groups Recover Together compares its rates to those of outpatient Suboxone providers who report their outcomes to one private insurer.
“If people do not come to Groups, get better, and then leave Groups healthier, we don’t make money over the long term,” Zelnick added.
As for its for-profit status, “All health care is for profit, it’s just a question of who’s profiting,” he said.
But some question whether Groups Recover Together’s domination of the opioid health home program is best for Maine, worrying that the company will naturally respond to market demands as it serves a particularly vulnerable population.
“There are a number of communities where there have been some nonprofits that have stepped up to the plate, integrated [medication-assisted treatment] into their system, not looked necessarily to the state to bankroll that … and then there’s suddenly a Groups office a block over,” said Eric Haram, a Portland-based consultant who helps states and others improve their response to substance use disorders.
“If you’re in charge of the safety net, there needs to be some strategy around equitable access. There’s not much use to having five programs in one town, when the next 15 don’t have one. That’s not necessarily a strategy for public health, that’s market share gamesmanship.”
250 people on the first day
After a year, DHHS reported that opioid health homes were serving “almost 50” MaineCare recipients and just five uninsured people. That was a far cry from the 400 Mainers Mayhew originally envisioned.
Then, 18 months into the program, Groups Recover Together got on board. On its first day in the program, it enrolled more than 250 people, according to Zelnick. It’s since more than doubled that figure, serving 600 people a week through the program, he said.
Overall, Maine’s opioid health homes had served roughly 750 people by the end of September, nearly double Mayhew’s projections, according to DHHS.
Of those, Groups Recover Together accounted for more than 80 percent of billing for MaineCare members and nearly half of billing for uninsured members.
Groups Recover Together’s contract with the state to provide opioid health home services to uninsured residents is valued at $864,000. The company gets paid $1,000 per uninsured individual each month, and both the treatment and medication are free to these patients.
For people with MaineCare coverage, the state pays Groups Recover Together $496 per member each month, and individuals use their coverage to purchase the medication. They may have to pay a small co-pay at the pharmacy.
“The goal is not lifetime medication maintenance; it’s to use the medication as a tool, which will allow you to meaningfully engage in the therapy to get the skills and tools that are needed,” said Heather Prebish, Northeast clinical director for Groups Recover Together. “Then when you’re ready, in consultation with your care team, begin to taper off. We’ve had that experience for hundreds of our members across the different locations where we provide treatment.”
While the program has taken off, it’s still just one piece of Maine’s overall substance use treatment network. Hundreds of people receive treatment through arrangements outside the program.
‘I’m a little more humble’
Outside of its state contract, Groups Recover Together’s finances are private. Zelnick said it’s funded by three venture capital partners, two in New York and one in Boston. The company as a whole is not yet profitable, but most of of its locations in Maine are yielding profits, he said.
The company’s roots are in Claremont, New Hampshire, where a former Dartmouth medical school student teamed up with a local doctor in 2014 to open the first clinic, serving the uninsured before the enactment of the Affordable Care Act and expansion of Medicaid. The model aimed to remove two hurdles that uninsured people seeking treatment often face: cost and distance.
The company opened clinics in mostly small towns, serving rural areas desperate for treatment options, and offered a straightforward program. For $65 a week, members got a prescription for Suboxone, which they paid for and filled at a local pharmacy, and weekly group therapy.
By opening clinics outside of expensive metro areas, Groups Recover Together kept its real estate costs down. The clinic in Biddeford, where the Augers receive treatment, is located on the second floor of a brick building downtown, above a coffee shop and bookstore. Just a few hundred square feet, it houses a reception desk, a couple of offices, and a group therapy room with modern but spare furnishings.
Groups Recover Together requires minimal staffing on site — with just one full-time counselor and one office coordinator. In Maine, because of the opioid health home contract, the company also has clinical supervisors, counselors, peer recovery coaches, nurse care managers and patient navigators who float between offices. The doctors who prescribe Suboxone work on an hourly basis, sometimes seeing patients through telehealth video screens.
Because Groups Recover Together doesn’t dispense medication, it also avoids the associated costs that methadone clinics must pay, such as stepped up security.
The no-frills approach set Groups Recover Together apart from other health providers, including publicly funded facilities paying more overhead for staff and space in areas often far from where their patients live. There are also many reasons health providers avoid prescribing Suboxone, including the hassle of getting a special certification, lacking staff to provide counseling to accompany the medication, not being equipped to do pill counts and urine screens and the stigma surrounding addiction.
Groups Recover Together, on the other hand, supports its local staff as a centralized organization, Zelnick said. It staffs a 24-hour crisis line and an intake line for when patients first sign up, and it’s not paying doctors to maintain full-time office hours, which some critics say means patients don’t get enough face time with their physician.
“It allows them to be very nimble and expand very rapidly and work with a very high volume of patients very quickly,” Haram said. “Those are important qualities of a program; access is important. But this is medical work; you do need the medical professional to have their eyes on the patient.”
The fee-for-service model most providers have operated under also means that “the people who provide really good care typically are not able to make money,” Zelnick said. For nonprofit providers with no access to venture capital funding like Groups Recover Together enjoys, it’s a difficult endeavor.
“They’re expanding access better than the rest of the medical delivery system, which is largely nonprofit. There’s a reason for that,” said Noah Nesin, vice president of medical affairs at Penobscot Community Health Care. The opioid health home rules are “challenging for an organization like ours, which has lots of other work … besides just treating opioid use disorder. We feel strongly that the real answer for society … is that opioid use disorder be treated in primary care settings just like any other chronic disease.”
PCHC will treat 600 people this year for opioid use disorder, he said. It has an opioid health home designation for its Hope House clinic in Bangor, treating about 15 patients through the program.
Now, Groups Recover Together is broadening its model nationally and evolving. In Biddeford, it offers a more intensive outpatient program with members receiving counseling three times a week instead of one. And it’s increasingly shifting to serving the “huge number of folks with commercial insurance and Medicaid who can’t get high-quality access to treatment,” Zelnick said.
While many of the changes resulted from beginning to work with insurers, some are a result of Groups Recover Together’s participation in the opioid health home program, Zelnick said.
“The clinical outcomes in Maine are better than anywhere else for us,” he said, and “this is the way we feel the world is moving.”
Groups Recover Together offers the opioid health home services at all of its locations in Maine, but also serves patients with other forms of insurance and continues to offer the $65-a-week rate.
“The for-profit model, of which probably people have traditionally been pretty critical, may be serving a really important purpose,” said Nesin of PCHC. “And at least for the people who can get the cash together to buy the prescription, may be saving their lives. I’m a little more humble about judging anybody’s model these days.”
‘I was 1,578’
The state’s health officer, Christopher Pezzullo, sees so much promise in the opioid health home program that, if it were up to him, “I would want all the patients in Maine to be served by OHHs, because I feel like that’s the most comprehensive approach to substance use disorder.”
But Haram said Maine should have pursued greater funding for the program, drawing down only $2 million where neighboring New Hampshire got $46 million to address the opioid crisis.
“It’s a pittance of an amount of financial support, with one strategy, and it took over a year to begin to deploy it, and it required the special relationship … with Groups so say, ‘Ok, now we have it. That whole dynamic is, I think, pretty problematic.”
Haram is also concerned that Maine’s reliance on Groups Recover Together puts the state in a difficult position. West Virginia, for example, contracted with one for-profit methadone program that later wreaked havoc across the addiction treatment service system, blocking development of other options, he said.
Groups Recover Together also recently added opioid health home slots for prisoners being released from the state prison in Warren. As soon as those individuals walk out of the gates, they are transported to a Groups office, complete an intake process and get enrolled in the program. Groups Recover Together then helps them fill out MaineCare applications and get connected to housing and employment resources, Zelnick said.
In addition to Groups Recover Together, 10 other health providers participate in the opioid health home program. The state expects more will sign up following changes that will introduce a tiered payment structure, ranging from services for patients just starting on treatment to those who are stabilized and receiving care longer term.
The program is also due for another influx of funding as a result of legislation passed earlier this year that set aside $6.6 million for addiction treatment.
For the Augers, their treatment at Groups Recover Together has become a way of life.
“They don’t make you feel like you’re a drug addict. They make you feel like you’re somebody that wants to get help,” Heather said.
Groups Recover Together’s approach is worlds away from her previous experience in treatment, said Heather, who was raised by her grandparents because her mother struggled with addiction. At the methadone clinic she visited years ago, she was literally a number, one she remembers precisely to this day.
“I was 1,578,” she said. “They don’t even say your name. My mom was number four.”
The Augers are now looking forward to their first “normal” Christmas.
“We were always sick for those holidays,” Heather said, trailing off.
“Making up lies and excuses why we couldn’t go,” Rodney said, finishing her sentence. “We don’t have to do that anymore.”
Maine Focus is a journalism and community engagement initiative at the Bangor Daily News. Questions? Write to firstname.lastname@example.org.