The Terms of Reference for this study called for a review of the range of management, clinical and administrative practices existing in Australia in the delivery of methadone services and the funding mechanisms supporting those services. Recommendations were required as to how each of these dimensions of service delivery could be improved, and appropriate roles of the private and public sectors more clearly determined. The review did not extend to an evaluation of the underlying effectiveness of methadone maintenance as a treatment option for opioid dependence. This has been taken as a given. However, in order to provide a context for the study, the report provides a description of the principles of methadone maintenance therapy, its objectives and its effects across a range of health and social outcomes.
The study was undertaken by members of Coopers & Lybrand Health and Community Services Division in cooperation with the National Drug and Alcohol Research Centre (NDARC). It would not have been possible to complete the review without the assistance and support of a wide range of health professionals, administrators and clients from all States and Territories. Their contribution to the review is gratefully acknowledged.
Methadone treatment for opioid dependency dates back to 1969, and since that time has come to be endorsed as an effective method of treatment. It is now available in every State and Territory except for the Northern Territory, and is provided in a diversity of treatment settings involving both the public and private sectors.
A National Methadone Policy was adopted in 1993 which reflects a national position on the role of methadone, and provides core operational procedures to guide the provision of services. Despite agreement on these principles, there has been significant divergence between jurisdictions on the systems and structures by which services are delivered. This has led to a range of service settings and control mechanisms, and differing roles for the public and private sectors between States.
In assessing the potential demand for methadone services, a review of a number of published studies was undertaken. These studies suggest that the number of regular heroin users in Australia in 1993 was of the order of 60,000 persons, with up to twice as many again being irregular users. This represents an overall prevalence rate of 21 persons per 1,000 people aged between 15 and 44 years, up from 14.4 four years previously. However, the extent to which potential methadone clients are likely to enrol in methadone programs is uncertain, and will be determined as much by the availability of and access to programs, as it will by their attitudes to participation. Despite the fact that a greater proportion of regular heroin users now participate in methadone programs, the data suggest that demand has not been fully met even if a majority of heroin users are not interested in enrolling in methadone treatment.
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A comparison of methadone treatment services throughout Australia indicates that there are many areas of commonality between the States and Territories in regard to their philosophy of treatment. The principles of methadone maintenance treatment underpin all services, and reflect international experience in the use of maintenance therapy as an effective treatment for opioid dependence. The various State guidelines for treatment are similar in their content, and provide for comparable treatment regimens across State boundaries.
However, there are considerable differences across jurisdictions in Australia in regard to their history of methadone program development, and the mechanisms by which those services are provided. For example, the extent of centralised versus decentralised control, the different roles of the public and private sectors, and the extent to which methadone services are provided by larger specialist clinics compared to private practitioners as part of their general practice are evident in different degrees.
Thus, while the principles of methadone maintenance treatment are embodied in all programs throughout Australia, the means by which those services are delivered vary considerably. In combination, these factors demonstrate that the delivery of methadone programs on a national basis operates in a complex environment.
The general view expressed by the majority of persons consulted during this study is that the quality of services provided in methadone programs in Australia is of a very high standard. While some abuse of the payment system is apparent, there is no evidence to demonstrate that such abuse is widespread, nor that clients themselves are disadvantaged to a significant degree.
Growth in the total number of clients participating in methadone programs has been associated, particularly in the eastern States, with an expanded role for the private sector. For Australia as a whole, the number of clients participating in methadone programs increased from approximately 6,500 in 1989, to nearly 15,000 in 1994. Associated with this increase has been an increase in the number of clients treated in the private sector from 42% to 56% over the same period, virtually all of which has occurred in Victoria and New South Wales.
An evaluation of the clinical outcomes of methadone services in different clinical settings undertaken by NDARC compared the services provided in large public and private clinics in New South Wales. The study revealed significant differences in the methods and frequency of service delivery, the fees charged to clients for the dispensing of services, and the availability of takeaway doses. The role of medical practitioners was also found to differ significantly between the two sectors, particularly in regard to their counselling role. The study called into question the value of regular urinalysis for the detection of illicit drug usage, a finding which has been supported through discussions with a wide range of medical practitioners.
Despite systematic differences between the sectors in the treatment delivered, the outcomes achieved in the public and private clinics were very similar. Importantly, within both the public and private sectors, there were large differences in the quality and effectiveness of treatment delivered in different clinics.
Although clients in public clinics reported greater satisfaction with counselling services, there was no evidence that the greater emphasis on formal counselling contributed to less heroin use or greater psychological stability among clients of public clinics. Similarly, the considerable difference in takeaway availability did not seem to affect clinical outcomes, although there are clearly other disadvantages associated with their more ready availability in private clinics.
Adequate doses of methadone were associated with the lowest rate of heroin use. By comparison, low levels of non-opioid use, good levels of social functioning and high client rating of services were associated with clinics which had a more clinical and therapeutic approach to treatment and client relationships.
The study reinforced the need for the implementation of quality assurance mechanisms aimed at raising the standard of services provided in both sectors. A number of outcome measures are identified as being appropriate to the assessment of program effectiveness, including the proportion of clients retained in treatment at different intervals, continuing heroin use, the use of non-opioid drugs, and clients' psychological well-being.
While the involvement of general practice and community pharmacies is seen as an important mechanism for the expansion of methadone services, no study has been undertaken to date which compares the effectiveness of methadone treatment in these primary care settings. Given the increasing prevalence of these settings, this issue needs to be addressed. Such a study should seek to identify factors influencing these types of services, with a view to maximising their effectiveness.
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One of the major factors found to affect outcomes of methadone maintenance therapy is the experience and approach of those providing the services. Common to all practice settings is the need for service providers to be suitably qualified in the first instance, and to maintain those skills over time. While all jurisdictions offer training courses to medical practitioners, the courses vary in their content and duration, and participation is not universally compulsory. In this regard, there is considerable scope for greater standardisation of training. A similar situation exists in regard to dispenser training. In this case, however, work is being undertaken by the Pharmaceutical Society of Australia and the Pharmacy Guild of Australia to develop a national approach to training in the dispensing and administration of methadone.
When examining the respective roles of the public and private sectors in the provision of methadone services, the main trend today is to involve GPs and community pharmacies in methadone services as part of their wider practices. This approach seeks to use the existing service infrastructure of the private sector, rather than establish a new public infrastructure with its associated costs. In NSW large private methadone clinics have also been established.
The involvement of the private sector, particularly GPs, has the greatest potential to improve access to services by clients, particularly in more remote areas, and to reduce the stigma associated with attendance at specialist methadone clinics. The major difficulty with this approach has been and remains attracting medical practitioners and pharmacists to methadone programs, and the need to ensure that they are appropriately qualified and trained. There is a need to collect further information about the factors that influence participation in the provision of methadone services, and on client views about the services provided in different practice settings.
Given the current situation where there is a mix of private and public participation in various forms in the provision of methadone services, it is clear that there is no "one best way" for future services delivery. While some of the large private clinics in NSW have undoubtedly drawn considerable and apparently justified criticism in regard to the quality and costs of services they provide, they nevertheless meet a current demand for services. There is clearly a need to address the concerns raised about the activities of a number of these clinics.
At the same time, there is a need for the public sector to extend its current activities in the administration, regulation, quality control, coordination and monitoring of services. Support services for the private sector must also be established to encourage their participation and to ensure that client needs are appropriately addressed. These activities will be essential if service quality and continuity is to be improved and maintained.
We have outlined a preferred service delivery model which seeks to match the needs of different groups of clients with the services provided by suitably qualified and experienced practitioners. This approach does not restrict the public and private sectors to defined roles, although the tendency for more highly qualified practitioners in the field of alcohol and drug services to be located in the public sector may lead to a natural division of roles. The model seeks to provide greater access to methadone services for clients when they are stable, while providing the necessary safety net for them in times of need. At the same time, the needs of complex cases are catered for by practitioners most qualified to meet these needs. The referral system proposed in this model for complex cases is consistent with current medical practice across specialties.
A review of the comparative costs of methadone services between the public and private sectors and between different jurisdictions has been made difficult by the absence of reliable financial data. As a result, costs have been estimated based on the results of specific questionnaires to State health authorities and private medical practitioners, and by an examination of a sample of Medicare data. The uncertain reliability of these data sources suggests that the results should be interpreted with caution.
In the public sector, reasonable consistency was found in the direct costs per client treated. The exceptions to this were in Tasmania and Victoria, where relatively few public clients are treated, and concerns are held about the reliability of the costs reported. If these two States are excluded from the analysis, the average direct cost per client per annum of methadone treatment in the public sector is approximately $2,100, while the total cost (including program administration etc.) is $2,250 per client per annum. Given the basis on which public clinics are funded, these costs are expected to reduce with the number of clients treated, though not necessarily proportionally.
In the private sector, considerable variation has been found in the costs of treatment, depending on the intensity of treatment (which tends to be related to duration of treatment) and the nature of the service provider (i.e. whether it is a GP or a specialist). The nature of the funding system results in costs being directly proportional to the frequency of service delivery and the fee charged. Services provided by GPs were estimated to cost $737 in the first year of treatment, falling to $367 in subsequent years. For psychiatrists the equivalent costs were $2,189 and $1,267 respectively. These differences are reflective of considerable differences in treatment patterns between the two groups, and the higher fees charged by psychiatrists. There are no data available to indicate whether or not the clinical complexity of clients being treated by the two groups differs significantly, nor whether outcomes of treatment vary as a result of the differences in treatment approach. However, many of those consulted during the course of the study doubted that the differences in fees charged between these groups could be justified in terms of the nature of the services provided. The costs of services provided by psychiatrists are comparable to the costs incurred in the public sector.
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However, the costs quoted for the private sector exclude the cost of dispensing methadone, as this is usually met by the client. Costs in the public sector generally include the dispensing costs of public clinics. When taken into account, this difference in reporting largely negates the difference in the quoted costs for the two sectors, and would make the services provided by psychiatrists in the private sector more costly than those in the public sector.
Charges to clients for dispensing of methadone vary considerably both within and between jurisdictions, and there is a need for greater standardisation of these charges at an affordable level. The issue of whether or not there should be government subsidisation of costs incurred by pharmacists in dispensing methadone should be considered in the context of its cost-effectiveness and its effect on attracting more community pharmacists to the program.
An analysis of the respective contributions by the State and Commonwealth governments for the provision of methadone services has indicated that, in total, they are currently of a like order of magnitude of approximately $15.2 to $15.3 million. It should be noted, however, that the expenditure by States may include funds provided by the Commonwealth under National Drug Strategy (NDS) funding ($4.9 million) for the provision of methadone services. Given the trend for greater private sector involvement in methadone services, it is likely that a continuation of the current funding arrangements will result in the Commonwealth bearing a greater proportion of the total costs.
On the issue of accountability, we have considered four dimensions - financial accountability, clinical accountability, accountability to clients and program accountability. In regard to financial accountability, the failure in both the public and private sectors to separately identify costs associated with methadone treatment from the costs of other services is a major barrier to full financial accountability. In the public sector, this requires a resolution on the part of the respective health authorities as to the level of financial reporting they wish to adopt.
In the private sector, the issue is more complex. One of the fundamental impediments to proper financial accountability under the current administrative and funding arrangements in the private sector is the fact that the responsibility for approval and regulation of methadone prescribers and clients rests with State health authorities, while the funding of these services rests with the Commonwealth. While the States have administrative procedures in place ostensibly to monitor activities in the private sector, these vary between States, and indeed are limited in the information they provide. Consequently, little information is available in State health authorities on activities (and hence costs) in the private sector. Conversely, while the Commonwealth has these data available through the Health Insurance Commission (HIC) data base, it is unable to identify those activities specific to methadone programs, their clients and practitioners. As long as this dichotomy between the regulators of services and the funder of services exists, then financial accountability in the private sector cannot be achieved.
Several options have been considered to address this issue. On balance, the option which provides the most reliable method of improved financial accountability in the private sector which is not contingent on the collection of additional data is the separate identification of methadone services on the Commonwealth Medicare Benefits Schedule (CMBS) or whatever other payment mechanism is used to fund services in the private sector. However, any decision to do so should also consider the acceptability of this approach to the medical profession, and consumer concerns about privacy and confidentiality.
Clinical accountability refers to the quantity and quality of services provided, the extent to which they conform to guidelines for service provision, and the outcomes achieved. Information on each of these issues is difficult to obtain, and has highlighted the need to improve such data sources. Information provided by a sample of medical practitioners in New South Wales has illustrated the considerable variation that exists between professionals both within and between specialties which is unlikely to be explained solely by differences in client complexity. This serves to highlight the need for the establishment of a national data collection of basic performance indicators of methadone services. At the same time, there is a need to establish a regular program of clinical review of services to identify and promulgate models of best practice.
In regard to the issue of accountability to clients, information provided during the course of the review highlighted the differences in clinical practices, and in the relationship between service providers and their clients. Many of the concerns expressed about these issues could be addressed through the inclusion of clients' rights as part of the recommended quality assurance and accreditation procedures, and access to a fast and effective appeals mechanism.
Program accountability is currently being examined by the National Methadone Committee, with the development of a set of national indicators and a minimum data set under active consideration. We support these initiatives, and recommend that work in this area continue.
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Discussion of the relative advantages and disadvantages of four funding mechanisms has highlighted the fact that there is no single funding mechanism which addresses and solves all the problems associated with the provision of methadone services and their remuneration. Notwithstanding this fact, the choice of payment system may act as a major influence on practitioner behaviour, and provide an incentive (or disincentive) for promoting models of best practice.
The existing fee for service arrangements embodied in the current Medicare system, coupled with the fact that these services are not separately identifiable from other medical services in the CMBS encourage over-servicing. However there have been no widespread reports of this occurring, and most complaints about these issues have been restricted to a relatively small number of practitioners.
Of the options considered, the fee for service approach caters best for the significant variation that exists between individual clients and their clinical needs, and remunerates practitioners according to the quantum of services they provide. It is also the most commonly accepted form of payment for medical services, and is supported by medical practitioners, which is essential if they are to be retained and attracted to providing methadone services. Despite these advantages, this approach does not encourage or facilitate the adoption of best practice methods.
If the fee for service model is to be continued, we consider that, as a minimum step, medical services relating to methadone treatment should be separately identified within the CMBS. Such an approach is likely to lead to greater clinical and financial accountability, without significant change to the current payment mechanism. At the same time, we consider that the differential fees charges for methadone consultations between GPs and specialists (including psychiatrists) are not justified by the nature of the methadone services provided in the large majority of cases, and that a common set of fees should be determined.
A client management payment model reduces the incentives for over-servicing, and as such may be seen to promote models of best practice. This model may be structured to provide financial incentives for medical practitioners to retain clients in methadone programs for longer periods. On the other hand, it may also promote under-servicing, leading to concerns about the quality of services provided under this model. The client management payment model also has equal application in both the public and private sectors. The model works best for stable clients, but does not cater well for variations in clients' clinical needs unless differential payments are made. In the absence of differential payments, more complex cases may be referred to the public sector or be excluded from treatment altogether. In order to reduce the potential for abuse, and to cater adequately for the different needs of complex and stable cases, the client management payment model must work in concert with the service delivery model. In particular, the role of the general practitioner in assessing the needs of individual clients, and in acting as the referral agent for complex cases to "specialist" practitioners is pivotal to its success.
The final option considered of removing methadone treatment from the CMBS and substituting it with direct grants to the States effectively transfers the payment responsibility from the Commonwealth to the States, who may adopt any of the funding models described. This approach provides for greater flexibility and control by the States over the mix of public and private services they choose to employ in their jurisdiction. It also brings the regulatory and funding roles closer together, which may be used to monitor and improve the quality of services provided. On the other hand, this approach will lead to a duplication in the infrastructure required to administer methadone services, leading to higher total costs of administration. The potential for double-billing by medical practitioners to the States and the Commonwealth may also increase total costs of service provision under this option. In addition, the capacity of the States to negotiate alternative payment structures to the existing fee for service arrangements with medical practitioners may be limited.
A variation to this option would see a transfer of the purchasing role to the Commonwealth. While this variation has some attractive features, it would entail significant changes to the legislative and administrative framework to be effected. It also calls into question the capacity of the Commonwealth to plan and administer methadone services at the local level. However, as the central purchaser of services provided in the private sector, the Commonwealth is in a much stronger position to negotiate alternative payment structures.
The ultimate choice of funding system will be determined by the priorities of the various parties, and the weight they apply to the various criteria. Discussions with the Steering Committee have indicated that the criteria of promoting best practice, administrative simplicity and reducing the potential for abuse and fraud are of particular importance. At the same time, the choice of funding system should also be considered in the context of its capacity to support the preferred service delivery model. Of the alternative payment systems considered, the choice essentially narrows to a continuation of the current fee for service system, with methadone services identified separately within the CMBS, or a client management payment system funded by the Commonwealth through Health Program Grants. While the former is likely to be more acceptable to medical practitioners, the latter is more conducive to the promotion of best practice models of care. Each may be regarded to offer similar features in regard to their administrative simplicity and potential for abuse.
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Accordingly, we have recommended that a client management payment system, with differential payments for services provided to complex and stable cases, is most likely to meet the major criteria identified by the Steering Committee. However, there are a number of issues of principle and practicality in regard to both the service delivery and payment models which need to be addressed before such a system may be introduced. These include:
- Developing and agreeing on the different training and experience requirements of medical practitioners to treat stable and complex cases;
- Developing agreed clinical criteria for the identification and referral of complex cases to specialist providers;
- Establishing mechanisms for the treatment of complex cases in remote areas or where access to specialist services is limited;
- Determining an appropriate differential fee structure for complex and stable cases, having regard to differences in service intensity both between the two groups and over time, and the qualifications and experience of service providers treating the different client groups;
- Identifying and agreeing the mechanism for payments to pharmacists for the dispensing and administering of methadone;
- Assessing the acceptability of the payment system to medical practitioners, and the potential impact on the capacity of the system to meet current and anticipated demand for services;
- Minimising the administrative complexity for medical practitioners to apply for Health Program Grants for methadone services;
- Establishing a payment mechanism by the Commonwealth for methadone services which minimises the potential for duplication of payment between practitioners, while also providing for client mobility between practitioners; and
- Assessing the overall applicability of the proposed model in those states, particularly New South Wales, where the proposed approach represents a significant change to the existing service delivery models and structures currently in place in the private sector.
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