[Paul25]

I've read some interesting accounts of encounters with Methadone patients. Most of them are construction workers who get their meds for pain. I understand that here they mix it with Orange juice and I'm told they have to show the on duty Pharmacist that they have indeed ingested their prescribed dosage. I'll add a link to a couple stories on the negative side as well.
I've personally worked in retail for 15 years and if people are rude it's simply in their nature whether they're medicated or not.

Paul - Here's a story for you

MDs profit from methadone scheme
Posted: 03-04-2006 08:47 AM
From Toronto Star - Mar 4 - 2006



OPP health fraud squad raided addiction clinic offices; owners are going to court to get search warrant quashed
Mar. 4, 2006. 07:32 AM
KEVIN DONOVAN AND JESSICA LEEDER
STAFF REPORTERS


Doctors at a large chain of methadone clinics are billing OHIP for expensive, excessive tests that are rarely used for patient care, a Star investigation shows. The Ontario Addiction Treatment Centres are running these tests through an unlicensed lab and many of its doctors are being paid for patients they don't see.

One-third of the province's 13,600 methadone patients are at risk and it's costing the health-care system millions of dollars.

The Ontario Addiction Treatment Centres are exploiting for profit the provincial program designed to help drug addicts, say patients and medical experts.

Multiple investigations into the clinics have dragged on for three years, including probes by the Ontario Health Insurance Plan and the Ontario Provincial Police into allegedly fraudulent billing habits. Four months ago, detectives raided the clinics and seized paper records and computer hard drives. The College of Physicians and Surgeons of Ontario recently reviewed three patient cases and cautioned an OATC founder and two others for failing to use test results to improve patient well-being, among other issues.

Drs. Jeff Daiter and Michael Varenbut are the founders of OATC, which has 23 province-wide clinics and 4,000 patients. Both have refused interviews. Through their lawyers, the pair say they have "acted honestly and professionally in delivering necessary medical services to the public."
The Star found that, at one point in December 2004, several months' worth of OATC tests - thousands of bottles of urine - sat, mouldy, waiting to be analyzed. Urine testing is critical to the treatment of methadone patients, who are battling addictions to heroin and opiate-based painkillers. They rely on the clinics to provide them with a high level of care, along with daily doses of the potent liquid drug. A synthetic, government-sanctioned narcotic, methadone keeps opiate addicts from going into withdrawal and blocks them from getting high.

Patients must abide by rules set by clinic founders. The rules require many patients to attend clinics every day, give urine samples twice a week, and purchase medication from the pharmacist of their doctor's choice.

Those rules have allowed OATC to become an addiction treatment empire over the past decade.

The centres include clinics in Brampton, Mississauga, North York, Woodbridge, Newmarket, Hamilton, Kitchener and Barrie, and are staffed by 50 doctors. Daiter and Varenbut run the clinics, along with the series of enterprises they set up a few years after leaving medical school: a medical software company, a rapid detoxification centre, a sleep disorder centre and a private laboratory. One of their companies is named Asklepios Medical Inc., for the Greek god of medicine.

Daiter, 42, and Varenbut, 37, have prominent positions in numerous professional medical groups, including the Ontario Medical Association and the Canadian Society of Addiction Medicine. Several years ago, Ontario's health ministry appointed them investigators for the now-defunct Medical Review Committee, which reviewed claims submitted by physicians. They also ran a website offering advice to Ontario doctors being audited by investigators.

Methadone treatment has become big business in Ontario.

"Seeing the patients and prescribing the methadone isn't that lucrative. What I think is lucrative is the tests that you might do along with it - urine testing and blood testing," said Dr. Graeme Cunningham, former head of the College of Physicians and Surgeons' methadone committee and director of Homewood Health Centre in Guelph, a mental health and addictions treatment facility.

A Star analysis of patient billing records and interviews with people who have worked at the clinics reveal OATC testing revenue began to increase in 2000 when Daiter and Varenbut started processing and billing urine tests, instead of sending the samples to a government-regulated laboratory.

Most OATC patients represent between $5,000 and $10,000 in annual revenue each, depending on the number of tests ordered and the number of assessments done by the doctors. With 4,000 total patients, potential revenue is in the tens of millions each year.

Most of that money is ultimately paid to OATC by taxpayers through the Ontario Health Insurance Plan.

Ontario's methadone industry has grown since government made the treatment more widely available in 1996. Since then, the number of patients on methadone has ballooned from about 475 to 13,599 in 2005. Ontario Addiction Treatment Centres treats one-third of the market.

To get on the methadone program, patients with opiate addictions must sign on with a licensed methadone-prescribing doctor. After initial urine and blood tests to determine addiction levels and overall health, the patient settles into a treatment program tailored to his or her individual needs.

Ontario's Methadone Maintenance Treatment Guidelines, set by the College of Physicians and Surgeons of Ontario, the Ontario College of Pharmacists and the Centre for Addiction and Mental Health, mandate that patients be monitored and tested regularly. The rules require new patients to visit a doctor or pharmacist daily to pick up their medication and submit regular urine tests (twice a week at first, once every one or two weeks once the patient is stable).

If the patient responds to treatment, doctor visits become less frequent; doses of medication can be dispensed a week at a time, in take-home doses called "carries"; urine tests can be submitted bi-monthly.

All methadone patients must submit to urine tests so doctors can ensure they're taking their medication (not diverting it to sell on the street) and not abusing it (by using it with heroin or other drugs).

However, doctors have discretion to decide the number of visits and tests for each patient, meaning doctor billings to OHIP for methadone-related testing can range broadly.

Methadone experts say this is the most problematic element of Ontario's methadone program.

"The concern about methadone maintenance in general is that it has become a business," said a former employee of OATC who asked not to be named. "It's because the way physicians for methadone get paid is through pee samples."

(Clinic employees - doctors, nurses and receptionists - are typically required to sign a confidentiality agreement that bars them from publicly discussing OATC business.)

OATC's rules require most patients to give two scheduled urine samples per week, regardless of their stability or length of time on the program. They run a barrage of tests on each sample, which dramatically raises the amount billed OHIP.

Jay, a current OATC patient in northern Ontario and full-time hospital employee, has been using methadone for more than 10 years. When his long-time doctor went into business with OATC in mid-2004, his entire treatment plan was abruptly changed to correspond with OATC rules.

Carry privileges that previously allowed Jay to pick up a week's worth of doses were suddenly revoked due to clinic rules; he was no longer able to make a specific appointment to see his own doctor. Instead of giving random urine samples as he'd been doing for years at his doctor's old clinic, Jay was forced to leave work to give samples twice a week at the clinic, even though he says he was clean.

When Jay questioned clinic staffers about the changes, he never got a satisfying answer.

"There has to be a reason they're urine sampling so much," he said.

OHIP officials and methadone expert Cunningham say doctors must be able to justify why the tests they have ordered are "medically necessary."

"In urine tests with methadone patients, you are mainly looking for the drug level: cocaine, heroin, other drugs. And you're looking to see if the urine has been passed (by the patient himself)," Cunningham said.

The Star found that OATC runs those drug tests and a separate series of tests for the levels of alcohol, potassium, sodium, chloride, pH and creatinine.

Testing twice per week for any of those is "an absolute waste of time" unless a patient has an unusual kidney disease. "Even urine alcohol I would challenge as being helpful," Cunningham said.

In Ontario, government-regulated labs run most tests on patients. But Daiter and Varenbut have taken advantage of a rule that allows doctors to bill OHIP if they run a handful of simple tests themselves in their own office. The rule was originally intended to allow quicker test results for doctors in remote parts of the province.

OATC orders a plethora of extra tests which maximizes their billings and increases weekly OHIP tallies from the typical $35 to about $124 per patient. Included in those tests, which are performed on most patients, are expensive measures that OATC says allows doctors to "fingerprint" the urine to make sure it is a patient's own sample. OATC doctors insist on running these tests even though clinic staffers carefully monitor each patient while they urinate.

Daiter and Varenbut defend their testing habits by arguing that the tests maximize patient care.

Neither doctor would agree to an interview, despite four months of attempts by the Star. Through their lawyers, Daiter and Varenbut say they are "honourable, conscientious doctors." Many other OATC doctors have refused comment.

Their lawyers sent the Star several medical journal articles (some dating back years and including a one-page editorial by Daiter) advocating for more testing. In a letter to provincial officials last year, Varenbut argued: "Ongoing, regular urine screening is one of the strongest tools that we use to introduce movement along the addiction recovery continuum in our patients at different stages of recovery."

OATC, in a recent newsletter, told patients that frequent urine testing is key to good patient care. "Twice weekly samples is the only way to absolutely establish the truth to any claim that no drugs have been consumed since most drugs will still be present in the urine for up to 48-72 hours." The newsletter also states that the extra tests are performed to ensure that the sample has not been tampered with.

"We strongly feel that testing in this fashion is essential to reduce the harm to all our patients and those in the community," says the unsigned article on the first page of the newsletter.

Last February, an expert for the College of Physicians and Surgeons of Ontario, following up on complaints about patient care, looked into the care provided three patients by Daiter and two other OATC physicians.

In a written report dated last August, the expert found urine tests the doctors performed were of little or no use: "... there does not appear to be any evidence of the clinical use of these results." Daiter's patient care, the report said, fell "below the standard of care for a competent practitioner in this field of practice."

It is critical that methadone doctors have quick access to test results. For example, if a test shows a patient is "dirty," meaning they're using heroin, painkillers or other drugs that could interact with their medications, their normal dose of methadone could be fatal.

The expert also found "many examples of toxicology data being overlooked, ignored or misinterpreted," and severe delays in results. "When results are not available until days and sometimes weeks after the time of collection ... it becomes difficult to use them in a supportive, patient-centred fashion."

While the three doctors were issued a "caution" by the College, the hearing panel chose not to move the case to a full disciplinary hearing because "the College would have little chance of success were it to prosecute the OATC physicians" based on the allegations brought forward by a complainant.

The exemption that allows doctors to bill OHIP for doing tests states that doctors can only bill OHIP if they perform the test on their own patient in their own office.

OATC lab work is not done in the doctors' offices. Instead, thousands of bottles of urine collected each week at the clinics are shipped in black toolboxes - by courier and, in some cases, a vehicle driven by Varenbut's father, Boris - to an unlicensed testing area in the back of the Woodbridge OATC clinic.

There, a nurse or technician employed by the doctors loads 50 test tubes filled with urine into an automatic urine analyzer each hour; the clinic owns two analyzers. The machines process batches of the tests and download results into medical records software - created by a computer company owned by Daiter and Varenbut - used to link clinics and partner pharmacies.

The OATC's lab is not subject to the rigid quality control standards of the Ministry of Health. It's not licensed by the ministry, nor is it ever inspected by ministry experts.

A ministry spokesman said yesterday officials have "information that a physician is performing laboratory testing at the location." He said the ministry is "reviewing the situation" to ensure the doctor is complying with provincial lab regulations, and would not say whether the ministry is looking into other doctors who use the lab.

At OATC, the network's 50 doctors take turns reading test results, which are sent to them by email on a rotating basis. The doctors bill OHIP for reading these tests even though, often, they've never met the patients.

At the OATC lab, processing sometime lags and that can be critical to patient care. An employee who recently worked at the Woodbridge clinic said urine was left so long it turned mouldy. Staffing issues and the constant expansion of the clinics caused urine sample boxes to pile up in the hallways. "Oh God, it was everywhere," said the employee.

In late 2002, an OHIP analyst noticed a dramatic increase in billings for urine tests by OATC clinics. The analyst found that the pattern began in 2000. It is unclear if the analyst knew the tests were being done in an unlicensed lab.

The provincial Health Insurance Act prohibits doctors from allowing their billing code (each doctor in Ontario has a unique billing code) to be submitted for work they did not do; it also stipulates that payments for services go only to the doctor who billed for the work.

Letters were exchanged between senior OHIP officials and the founders. OHIP told the founders to stop, but the billing practices have continued.

In an interview, a senior health ministry official explained the situation to the Star. "You should not be billing for patients you have not seen because you are not doing any clinical management of the patient," said the official, who requested anonymity.

"The notion that you can be in Toronto and direct the care of patients in Sudbury, North Bay or Ottawa is, frankly, ludicrous."

The Star has reviewed OHIP billing records with several patients. An analysis shows OATC doctors are frequently billing the province for testing patients they never actually treat.

"I looked at the list of doctors and in most cases said, 'Who the heck are these people?'" said a former Oak Ridges OATC patient who was treated there from 1998 to 2003. "There are doctors on my billing list that I have never seen and never heard of in my life."

Another patient from Owen Sound who was treated until 2004 pointed out he did not know five of the doctors who billed for treating him.

Joe was an OATC patient between 1999 and 2002. His OHIP records show that a host of doctors in Kitchener, Barrie, Thornhill, Mississauga, North York and Midhurst treated him.

The problem is he never met any of those doctors. He had never seen their names until he read them on his billing records. In fact, he has never gone to those cities for any sort of medical treatment.

After OHIP raised questions, OATC argued it should be allowed to bill for the tests. OHIP was poised to further investigate and halt the excessive testing when auditing of doctors' OHIP billings, until then done by the province's Medical Review Committee, was abruptly suspended by the health minister in 2004.

The suspension was prompted by a decision to review and overhaul the province's auditing system, following the death of a Welland family doctor, who committed suicide after being audited by the committee.

While the review, conducted by former Supreme Court of Canada justice Peter Cory, was underway, a temporary provincial law was enacted to suspend all OHIP billing audits. Cory's recommendations to construct a new, more accountable Physician Audit Board were delivered to the health minister more than a year ago. All auditing remains suspended.

Meanwhile, OHIP turned to the Ontario Provincial Police, which has a squad charged with investigating allegations of OHIP fraud. They've probed the scheme for two years.

Last November, detectives raided three OATC offices, seizing records, files, laptops and personal computer hard drives. Crown Attorney Paul Tait requested Justice of the Peace Julius Dogbe to seal the three search warrants issued in the raid. Tait then asked provincial court Justice Richard Blouin to alter the sealing order so documents could be released to Daiter, Varenbut and other targets.

A team of lawyers working for the doctors has opposed an application by the Star to have the documents released. A ban prevents publication of details regarding those proceedings, which are ongoing.

The OATC lawyers are going to court next month in a bid to have the warrant quashed, which would effectively end the police investigation.

In an email to the Star, Brian Heller, a Toronto lawyer representing at least one of the doctors, said printing any information "would unfairly denigrate and harm" one of his physician clients who has "acted honestly and professionally in every aspect of her practice."

Jessica Leeder can be reached at jleeder @ thestar.ca

Kevin Donovan can be reached at kdonovan @ thestar.ca