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Insurance Companies Continue to Play Doctor, Deny Neccessary Treatments for Drug Addiction

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at September 26, 2016

The Cincinnati (OH) office of USA Today published a story consistent with our posting last week about the failure and refusal of insurance companies to follow federal law which mandates insurance coverage for drug and alcohol abuse treatment.

In their article “When insurers deny treatment for drug addiction,” Terry DeMio & Jayne O’Donnell report the following:

During a nationwide epidemic in which one American dies every 19 minutes from opioid or heroin overdose, addiction doctors say insurance barriers to medication that can save lives are instead putting them at risk for death.

Most of the states that have the highest levels of opioid consumption are below average when it comes to public funding of one of the most effective medication treatments for addiction, known as buprenorphine, according to a report released last week by IMS Institute for Healthcare Informatics and the Advocates for Opioid Recovery.

Six years after the passage of the Affordable Care Act, no state covers all of the substance use disorder treatments required by the law without harmful treatment limitations, a report out this summer by the National Center on Addiction and Substance Abuse found.

“Your healthcare depends on where you live,” said for U.S. Representative Patrick Kennedy, whose group, “Advocates for Opioid Recovery” is funded in part by the pharmaceutical industry. “Justice depends on geography.”

Those with opioid addictions “lose their jobs very quickly and lose their families pretty quickly,” which is “almost like pushing them into Medicaid,” Kennedy said.

Once on Medicaid, Kennedy said, patients’ addiction has to be “treated like every other illness.” Imposing more prior authorizations or coverage caps may violate the “parity” law Kennedy sponsored back in 2008 that requires insurers to cover behavioral health as they do physical health issues.

The barriers doctors cite are traditional with insurance coverage, but with heroin addiction, doctors say, patients need their medication promptly and without interruption.

Some insurers want patients to try a particular medication first and fail at it before they’ll cover the one their doctors’ order. That’s allowed, but insurers can only do it if they require the same “fail first” policies for traditional medical coverage. Other insurance companies require prior authorization or re-authorization from the insurer, which shouldn’t take more than hours, but can often take days if there are problems with the paperwork.

Doctors argue they alone should make treatment decisions for their heroin-addicted patients. It was over-prescribing of pain medicine that led to many of the addictions being treated, though, so insurers and other experts worried about high drug costs say the oversight is needed.

No state in the country covers all of the substance use disorder treatment offerings required by the Affordable Care Act without harmful treatment limitations, says the National Center on Addiction and Substance Abuse in New York City. The center released a report this summer that analyzed the states’ 2017 Essential Health Benefits’ benchmark plans for addiction coverage. The analysis included all kinds of addiction treatment, but the authors said thin coverage of heroin and opioid addiction treatment options is wrong.

There’s currently no federal penalty for plans that don’t meet the ACA, although state officials are supposed to send them back to insurers for revisions, said Becky Vaughn, vice president of addictions at the National Council for Behavioral Health. The center believes every plan should cover all FDA-approved medications, although they are only required to cover the ones that a benchmark plan in each state includes as “essential health benefits.”

Some states are taking action on their own, though. New York Attorney General Eric Schneiderman successfully sued to force insurers to make sure their plans meet the law, and other states have contacted Schneiderman’s office.

In March, President Barack Obama announced the launch of the Mental Health and Substance Use Disorder Parity Task Force to increase awareness and understanding of parity provisions in the laws, to make it clear what it takes to comply and possibly to expose plans and insurers that don’t.

A key problem is that some insurers – like some people – still think of addiction as a choice, rather than a disease, says Louisville psychiatrist Dr. Kelly Clark, who is also board certified in addiction medicine.

“Health plan personnel are very committed to improving health of members, but there is a level of ignorance about the chronic disease of addiction,” said Clark, chief medical officer for the national chain of Clean Slate treatment centers.

Just as someone with high cholesterol might be able to bring it down with diet and exercise, many can’t rely on willpower alone. Heroin addicts need medication to reduce the risk of injury, infection and disease, so patients can “function at a higher level in society,” Clark said.

THE TREATMENT OPTIONS

Opioids are a class of drugs similar to the compounds in opium poppies. They include controlled substances such as prescription painkillers They’re synthetic opiates, and they have the same effect as heroin, an opiate that is derived from poppies. The FDA-approved medications for opioid addiction treatment are:

  • Methadone, which has been in use the longest, is a synthetic opiate. It binds to opioid receptors in the brain and is used to replace heroin. Provided under strict clinical supervision, methadone can stabilize opioid and heroin users, reduce cravings and withdrawal and help them live normally, working, going to school and caring for their families.
  •  Vivitrol, an injectable form of naltrexone, is a non-narcotic that blocks the effects of heroin and opioids. Anyone prescribed Vivitrol must be detoxed from opioids or heroin first or they will get sick. It’s a shot given monthly.
  • Buprenorphine, a synthetic opiate that links with opioid receptors in the brain, reducing pain, cravings and withdrawal. It’s not as strong as methadone and, when taken properly, helps stabilize patients so they can live normally.
  • Suboxone is a buprenorphine/naloxone mix with the same effects as buprenorphine but also designed to negate euphoria. Suboxone is also a synthetic opiate.
  • Subutex, the brand name for buprenorphine.
  • Probuphine, is a newer, slow-acting buprenorphine in the form of an implant placed under the skin that releases the drug a six-month period.

The full story can be found here.

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