Overview of the Office of Medicaid (MassHealth) Drug Testing Frequency

A brief look at MassHealth's spending and regulations related to drug tests.

Overview

Under Chapter 118E of the Massachusetts General Laws, the Executive Office of Health and Human Services, through the Division of Medical Assistance, administers the state’s Medicaid program, known as MassHealth. MassHealth provides access to healthcare services for approximately 1.9 million eligible low- and moderate-income children, families, seniors, and people with disabilities. In fiscal year 2016, MassHealth paid healthcare providers more than $14.8 billion, of which approximately 50% was funded by the Commonwealth. Medicaid expenditures represent approximately 39% of the Commonwealth’s total annual budget.

According to Section 401 of Title 130 of the Code of Massachusetts Regulations, MassHealth pays for drug tests provided to eligible MassHealth members. These drug tests must be ordered by providers who use the tests for diagnosis, treatment, or other medically necessary purposes. For the four-year period July 1, 2012 through June 30, 2016, MassHealth paid approximately $39,771,152 to laboratories for drug tests for 240,711 MassHealth members, as detailed below.

Year	Number of Drug Tests	Amount Paid	Members Served*
July–December 2012	372,858	$ 8,131,920	43,442
2013	657,927	11,609,908	98,976
2014	550,385	8,286,150	108,925
2015	464,849	7,414,465	92,278
January–June 2016	186,692	4,328,709	59,028
Total	2,232,711	$ 39,771,152

*    Some members are counted in more than one row of this column. The unduplicated total number of members served is 240,711.

Drug Testing as a Tool

The federal Substance Abuse and Mental Health Services Administration (SAMHSA) states in its Treatment Improvement Protocols 40, 43, and 47 and in its Technical Assistance Publication 32 that drug tests are a necessary tool to diagnose, assess, treat, and monitor patients’ health and progress in combating substance use disorders (SUDs). These guidelines emphasize that drug tests should be used in conjunction with related medical procedures because they are not medical services in themselves, but can help doctors optimize patient outcomes as part of medical treatment. Technical Assistance Publication 32 states,

Testing may provide unexpected information, but should never be the sole basis for diagnosis and treatment decisionmaking. Test results should be used to supplement the information obtained from a comprehensive patient interview, the physical examination, and consideration of the patient’s overall health. . . .

For the patients receiving medications, particularly opioids, with abuse potential, drug tests can be done during every visit, randomly, before providing prescription refills, or if the patient exhibits aberrant behavior. 

Appendix B of Treatment Improvement Protocol 47 states, “Routine specimen collection after admission [to an outpatient treatment program] should take place in conjunction with regular clinic visits.” It adds that during intensive outpatient treatment, programs may want to consider “requiring that all clients provide a specimen on every [treatment] visit.”

MassHealth’s own regulations in this area mirror SAMHSA’s guidelines: they require prescribers of drug tests to use the test results in treating patients.  

Urine testing is the most commonly used method of detecting drug use because it is regarded as the most accurate and least expensive method. The document also states that other testing methods, such as testing of saliva, sweat, hair, or blood, have shortcomings that make them largely impractical for monitoring drug use.

Drug testing is performed by clinical laboratories. Some are independent, freestanding laboratories; some are affiliated with hospitals, community health centers, and hospital-licensed health clinics; and others, such as SUD treatment centers or physicians’ offices, are owned by medical professionals.

Drug tests are typically used by SUD treatment professionals to (1) stabilize members on the proper dosages of methadone or buprenorphine (controlled substances used to treat opioid addiction) and (2) monitor members to determine whether they are abstaining from illicit drugs and not engaging in diversion.¹ In themselves, drug tests are not treatment; they are a necessary tool that healthcare professionals use when diagnosing and treating patients. Therefore, MassHealth regulations require that providers ordering drug tests do so in writing, indicating that the drug tests are for the purpose of diagnosing and treating MassHealth members.

Similarly, the Massachusetts Department of Public Health’s Bureau of Substance Abuse Services (BSAS) recently issued the document Practice Guidance: Drug Screening as a Treatment Tool, which discusses the use of drug screening as a treatment tool to improve prevention and treat SUDs.

Fequency of Drug Testing

As discussed above, drug tests are a tool that healthcare professionals use when diagnosing and treating MassHealth members. MassHealth has not created regulations or Provider Bulletins on the frequency of drug testing specifically for members suffering from SUDs. MassHealth currently allows members to receive one drug test daily.

The following table shows the frequency with which drug tests are ordered by healthcare professionals who treat patients for SUDs, according to treatment guidelines and protocols for SUD treatment published by the Centers for Medicare & Medicaid Services and SAMHSA.

Treatment Phase	Duration	Frequency of Drug Testing
Induction	0–30 days of abstinence	1–3 times weekly
Stabilization	31–90 days of abstinence	1–3 times weekly
Maintenance	91 or more days of abstinence	1–3 times monthly

Drug Detection Times

Another factor to consider when determining the frequency of drug tests is drug detection times. Substances ingested by the human body are eliminated over time. The length of time that a substance remains in a person’s body and can be detected through drug testing is called detection time or elimination rate. Detection times offer scientific benchmarks that can be used to determine how frequently a patient should be drug tested.

The detection time for many drugs is between two and four days. Considering detection times, testing more frequently than every third or fourth day may not be medically necessary, according to Appendix B of SAMHSA’s Treatment Improvement Protocol 47:

Under ideal conditions . . . [urine] collection should occur not less than once a week or more frequently than every 3 days in the first weeks of treatment. It is important that the scheduled frequency of urine collection match the usual detection window for the primary drug. Too long an interval between urine tests can lead to unreliable results because most of the target drug and its metabolites will have been excreted. On the other hand, if the interval between tests is too short, a single incidence of drug use may be detected twice in separate urine samples. 

Since drug tests, which are a tool, are valid for a short period given their detection times, it is essential that healthcare providers use the results in a timely manner when treating their patients via evaluation and management, counseling, or therapy. Healthcare providers should monitor drug test results on a timely basis when treating patients. If drug test results are not reviewed in a timely manner—for example, within four days—the patient’s condition may change and the drug test results may not be useful in making treatment program decisions, monitoring illicit substance use, adjusting medication dosage, and deciding whether a patient is responsible enough to receive take-home medication.

Sober Homes and Limits on Residential Monitoring

Sober Homes

“Sober home” is a general term used to describe a shared living environment that promotes sober, safe, and healthy living to encourage its residents to recover from alcohol use, drug use, and related issues. Some sober homes are not very structured; others have very specific rules, such as curfews and mandatory in-house meetings, and encourage residents to seek treatment from medical professionals to address their drug and alcohol use.

MassHealth members can live in one of three types of sober home to assist in their recovery from SUDs:

• Privately owned sober homes that are not certified by the state. These residences do not provide SUD treatment to residents, because they are not operated by SUD treatment professionals.
• Privately owned sober homes that are certified by the state and must adhere to the requirements of a state-approved vendor, the Massachusetts Alliance for Sober Housing. State agency employees who wish to refer individuals under their care to sober homes must choose homes that are state certified. These residences do not provide SUD treatment to residents because they are not operated by SUD treatment professionals.
• Recovery homes that are licensed by BSAS as either short-term or long-term residential facilities, some of which may provide varying levels of SUD treatment. These facilities are licensed and managed by BSAS.

Drug Tests for Residential Monitoring

Many sober homes require residents to be drug tested two to three times per week. This type of testing is referred to as residential monitoring, since the sober home requires it in order to ensure that a resident is not abusing alcohol or drugs. The testing is not correlated with a member’s specific SUD treatment. Although this type of testing may be a policy of sober homes, current MassHealth regulations do not cover drug tests for “purposes of civil, criminal, administrative, or social service agency investigations, proceedings, or monitoring activities” or “residential monitoring purposes.” Rather, sober homes are responsible for covering the costs of such tests as part of their operating budgets.

   

Since our last audit report (No. 2012-1374-3C), we have found that MassHealth has taken several initiatives to limit drug test costs, including reducing rates paid for drug tests; limiting the number of drug classes paid for per drug test; and strengthening documentation requirements for drug test authorizations, including requirements for order forms and standing orders. However, these initiatives did not address the issue of high-frequency drug testing, nor did they prevent the improper use of drug testing for residential monitoring. The current statuses of both of these issues are discussed in this report.

1.    Diversion is the use of a controlled substance in an unlawful manner, such as selling suboxone (a narcotic) to people for whom it is not prescribed.

Date published:	July 27, 2018