ACCESS DENIED
Insurers slowly removing barriers to addiction treatment
Psychiatrist Dr. Jerry Halverson had just finished a frustrating phone call with a health insurer. The insurer had refused to authorize a troubled teenager’s inpatient stay at Rogers Memorial Hospital, a behavioral health facility where Halverson serves as medical director.
The patient, from West Virginia, was using opioids and other drugs and suffering from depression. He recently dropped out of college. He stopped taking showers. His desperate parents wanted him to receive intensive residential treatment at Halverson’s Oconomowoc, Wis., facility, which is part of the Rogers Behavioral Health System.
But the insurer insisted residential treatment wasn’t medically necessary. And the family couldn’t afford the program’s high cost on their own. Without insurance, a 30-day stay at Rogers Memorial would cost $30,000. The average stay is 30 to 45 days. Out of options, the patient had to go back to a less-expensive outpatient program that he had previously failed.
This is the type of battle with insurers that patients and their doctors face every day, Halverson said. Even as the death toll rises, opioid addiction isn’t treated with urgency like other chronic and deadly diseases. Health insurers make patients and families jump through too many hoops to get coverage for needed inpatient and outpatient care for addiction, including medication-assisted treatment, doctors say.
The medical necessity requirement is just one obstacle. Health insurers also apply lofty deductibles and copayments. Prior authorization rules delay medication-assisted treatment, or MAT, when it’s most needed. Low reimbursement rates for MAT are one reason for the shortage of physicians and other professionals willing to treat addiction patients, experts say.
But some insurers are taking steps to improve access and coverage for addiction treatment in the face of the nation’s opioid crisis. That’s come in response to pressure from the public, policymakers and law enforcement officials, as well as the soaring cost of opioid prescriptions. Insurers also are working to reduce inappropriate prescribing of opioid pain medications to prevent patients from becoming addicted.
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“We have a lot to bring to the table to help address the different pieces of the epidemic,” said Dr. Sherry Dubester, vice president of behavioral health and clinical programs for national insurer Anthem, which has doubled down on efforts to reduce the number of opioids prescribed and ensure patients receive holistic substance-abuse treatment.
Still, experts say insurers aren’t doing nearly enough to increase access to treatment for the millions of Americans suffering from addiction. It’s “very little, very late,” said Dr. Andrew Kolodny, co-director of opioid policy research at Brandeis University.
Beyond that, advocates for better addiction treatment fear the limited progress that’s been made will be rolled back if Republicans in Washington succeed in dismantling the Affordable Care Act. That law boosted access to addiction treatment and behavioral healthcare through its requirement that all ACA-compliant health plans provide treatment for substance abuse disorders and mental health issues, and through its expansion of Medicaid coverage to low-income adults.
It is estimated that as many as half of the beneficiaries of expanded Medicaid in some states have mental health and/or addiction problems. Led by Ohio’s John Kasich, governors have said the Medicaid expansion has been critical in broadening access to addiction treatment services.
It’s relatively easy for patients to get a prescription from a physician for powerful addiction-causing opioids to treat pain. But it’s hard for the same patient who becomes addicted to access substance-abuse treatment.
Insurers often require patients to be diagnosed as suicidal before they will pay for a stay at a detox facility or residential rehabilitation center, Halverson said. Patients instead must tough out detox at home, where they face a greater risk of relapse than they would in a facility. And patients seeking treatment are often referred to an outpatient program with less oversight than a residential inpatient program.
For some patients, an outpatient program is effective. But others may require the structure and 24-hour care provided in a residential facility.
Sean Mattos, 29, twice went through an outpatient program to treat his opioid addiction, but it didn’t work. There was “too much freedom,” he said. Mattos’ therapists next recommended he go to a residential facility in South Florida. That’s when his health insurer’s medical-necessity requirement got in the way. While at the residential facility, the health insurer would abruptly end Mattos’ stay and try to transfer him to a lower level of care, even though he and his doctors felt he wasn’t ready. Mattos even had to call his insurer while in treatment to convince it to let him stay. He ended up paying $8,000 out of pocket, while his insurer covered the rest of the $15,000 bill for the 28-day stay.
Insurers “rush the process as quickly as possible so they don’t have to pay for it,” said Mattos, who finally kicked his substance abuse disorder after moving to a sober living community, which isn’t covered by insurance. He now works at the GateHouse Sober Community, a Nashua, N.H.-based residential treatment program, where he witnesses the same insurance issues that frustrated him.
“Instead of letting a client do it right one time, (insurers) are paying triple the amount because a client’s going to treatment three, four, five, six times” before they get better, Mattos said.
Health insurers argue that medical-necessity requirements are in place to ensure patients receive appropriate care at the right level. Bloomfield, Conn.-based Cigna Corp. and Hartford, Conn.-based Aetna said they don’t require patients to fail at outpatient treatment before they will authorize residential care. And Anthem said it doesn’t place any time limits on services. The Indianapolis-based insurer said it approves treatment based on medical necessity, and more than 95% of its patients’ requests for inpatient and residential care are approved.
Prior authorization for medication-assisted treatment is another big roadblock.
MAT combines medication with behavioral counseling. It is considered effective at reducing the risk for relapse and improving chances of recovery. But just one in 10 patients who need treatment receive it, according to the National Center on Addiction and Substance Abuse.
Insurers’ prior authorization policies require physicians to answer numerous questions about a patient’s treatment and medication history before they receive approval to prescribe MAT. It can take days or even months. But patients often won’t return for treatment if there are lengthy delays, experts say.
Just one in 10 patients who need
treatment receive MAT.
— the National Center on Addiction
and Substance Abuse
In recent months, Aetna, Anthem, Cigna and UnitedHealth Group—the nation’s largest insurer—lifted prior authorization policies for MAT. Anthem and Cigna did so after New York Attorney General Eric Schneiderman investigated barriers to treatment resulting from the policies.
That’s a step in the right direction, said Mady Chalk, senior policy adviser at the Treatment Research Institute and a former official at the federal Substance Abuse and Mental Health Services Administration.
Insurance barriers can make the difference between someone getting and not getting treatment.
When somebody is ready to receive treatment and they come into the doctor’s office, “that is not the time when you get in their way,” Chalk said.
High deductibles and copays further prevent patients from accessing care when they are ready. Many patients can’t afford treatment because of sky-high out-of-pocket costs. It’s much cheaper for a patient to stick with heroin, Halverson said.
The Mental Health Parity and Addiction Equity Act of 2008 prohibits insurers from applying cost-sharing and benefit limits on treatment for substance use disorders that are more restrictive than those placed on other medical services. But there’s little enforcement of the law, experts say.
On top of that, there aren’t enough physicians trained and licensed to administer MAT, partly because of low payment rates and the many administrative hassles associated with providing this type of care.
If payment rates aren’t adequate, patients won’t receive treatment, said Dr. Shawn Ryan, president and chief medical officer at BrightView Health, a Cincinnati-based outpatient addiction treatment center. “We do what we get paid to do,” he said.
The ACA requires insurers to cover substance use and behavioral health treatment as an essential benefit. But that doesn’t necessarily mean insured patients have access to treatment that works.
Insurers that cover MAT may pay for only one of the three Food and Drug Administration-approved MAT medications—methadone, buprenorphine or naltrexone. But doctors say the drugs aren’t interchangeable, and that a particular drug or form of a drug may work better for an individual patient.
For instance, the naltrexone injection, which blocks the effects of opioids, may work better than the pill form of the drug for a patient who has a hard time staying sober. The injection requires one monthly shot, while the pill must be taken daily. Insurers rarely pay for the injection, Halverson said.
A 2016 report from the National Center on Addiction and Substance Abuse found that among 2017 state benchmark health plans, none explicitly covered all three MAT medications. (Benchmark plans determine the minimum level of benefits available to those covered in state exchange plans. States defined their 2017 benchmark plans in 2015).
Nearly all state Medicaid programs cover some form of substance-abuse treatment, but the services covered vary widely. Just 13 states and the District of Columbia covered all seven services in the American Society of Addiction Medicine guidelines for substance use disorder treatment in 2014, a December 2016 Health Affairs study found.
Just 13 states and the District of
Columbia covered all seven services
in the American Society of Addiction
Medicine guidelines for substance use
disorder treatment in 2014.
— Health Affairs
Insurers and industry groups, including UnitedHealth, the Blue Cross and Blue Shield Association and America’s Health Insurance Plans, have argued the federal government shouldn’t force insurers to pay for specific treatments.
Some insurers, however, have taken proactive steps to address the opioid addiction crisis. They have established programs to reduce cases of opioid addiction that arise from physicians overprescribing pain medications and abusive marketing of these products by drug companies. Prescription opioid abuse often leads to use of heroin, fentanyl and other street narcotics.
Experts point to Stamford, Conn.-based Purdue Pharma as one of the biggest culprits in the epidemic. In 1996 the drugmaker developed OxyContin, a form of the opioid pain medication oxycodone, and soon began marketing it as a safe, non-addictive drug that could effectively treat chronic pain.
Professional groups, such as the American Pain Society, advocated for the use of prescription opioids to relieve pain. The Joint Commission, which certifies quality and safety at U.S. hospitals, urged providers to prioritize pain treatment. Doctors aggressively treated pain with opioids, though they had little knowledge of the drugs’ long-term effects.
It was a perfect storm, said Dr. Joel Hyatt, emeritus assistant regional medical director of community health improvement at Kaiser Permanente Southern California. “The medical community and doctors were being accused of undertreating pain, so there was an emergence of efforts to treat or eliminate pain, which is impossible to do totally.”
Opioid drug sales surged. So did overdose deaths. The sales of opioid painkillers reached $9.6 billion in 2015, according to IMS Health. In that year, opioids led to more than 33,000 overdose deaths, up more than 15% from 28,600 in 2014, according to the Centers for Disease Control and Prevention. In half the fatal cases, the overdose involved a prescription opioid.
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Note: Age-adjusted death rates were calculated by applying age-specific death rates to the 2000 U.S. standard population age distribution. Death Rates are deaths per 100,000 population (age-adjusted).
Source: Kaiser Family Foundation
Much of the epidemic’s cost has landed on private insurers. They paid out $445.7 million for treatment of opioid abuse and drug dependence disorders in 2015, up from $32.4 million in 2011, according to a report by not-for-profit Fair Health.
The growing cost burden has spurred many insurers to action.
In 2012, Blue Cross and Blue Shield of Massachusetts, after experiencing an uptick in claims related to opioid addiction treatment, launched its Prescription Pain Medication Safety Program.
The Massachusetts Blues plan requires doctors to seek prior approval for opioid prescriptions, except in the case of cancer and terminally ill patients. It puts quantity limits on how many opioids doctors can prescribe. It also requires patients to take a risk assessment for addiction.
In the first three years of the Massachusetts program, about 21 million fewer opioids were dispensed to the insurer’s members, according to the CDC, which studied the program. State policymakers have since implemented parts of the program statewide.
The Blues plan also eliminated deductibles and copays in its coverage of methadone treatment, a form of medication-assisted treatment for opioid addiction. It hired social workers to contact plan members when they are admitted to detox facilities to help them figure out next steps for treatment. And it successfully advocated for the state to require insurers to pay for a 14-day residential stay for patients addicted to opioids.
Cigna is another insurer that has taken steps to reduce inappropriate opioid pain prescriptions. In addition to eliminating prior authorization for MAT, last year the insurer set a goal to reduce the amount of opioids dispensed to members by 25% over three years.
Earlier this month, Cigna said its customer’s use of prescribed opioids has declined by almost 12% in the last year.
Cigna builds opioid prescribing profiles of the physicians and accountable care organizations in its network. That information is sent to the doctors on a regular basis so they can see how they compare with their peers. The insurer also encourages its participating ACOs to pledge to fight the opioid epidemic. About 160 have signed the pledge so far.
The insurance industry alone can’t fix the opioid crisis, said Dr. Doug Nemecek, Cigna’s chief medical officer for behavioral health. “We have approached this from the perspective that we have to find the right partners.”
Anthem is also expanding access to comprehensive opioid addiction treatment by maximizing reimbursement for doctors who treat substance-use disorders. It’s working with doctors in rural communities and linking them with behavioral health providers.
By building awareness among providers on how to bill for these services, Anthem said it increased the number of claims for screening, brief intervention and referral to treatment, known as SBIRT, by 60% from 2015 to 2016.
“We feel very strongly that MAT is there to assist therapy—it’s not there as a solo treatment,” Anthem’s Dubester said. Anthem set a goal to reduce the amount of opioids dispensed to plan members by 30% by the end of 2019.
In Connecticut and New Hampshire, Anthem members can receive in-home addiction treatment. The insurer also is considering using telehealth for providing addiction treatment.
Aetna uses claims data to pinpoint and contact opioid “superprescribers.” It sends those doctors a letter to make them aware of how their prescribing behavior deviates from the norm.
The insurer also notifies clinicians if patients have been prescribed more than three opioids, dangerous combinations of opioids or if they have multiple prescriptions from multiple prescribers.
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Experts in addiction treatment fear the progress made in expanding access to treatment is in jeopardy. That’s because of continuing Republican efforts to roll back the Affordable Care Act’s Medicaid expansion and its mandatory coverage for substance abuse treatment and behavioral healthcare.
Before the ACA, few insurers covered addiction treatment and when they did, coverage was poor and expensive.
Some House Republicans, with support from the Trump administration, are pushing hard to erase the ACA’s minimum essential benefits requirement. They argue that would make coverage more affordable for consumers. But experts say that measure, along with the phaseout of the Medicaid expansion, would make coverage and care inaccessible to many patients who need substance-abuse and behavioral-care services.
Without a mandate, there’s little incentive for insurers to cover treatment for substance-abuse disorders. There is evidence that paying for opioid addiction treatment will save insurers costs in the long run. At least one study published in the American Journal of Managed Care found that MAT was associated with fewer hospitalizations.
But patients often switch insurers. The insurer that paid for addiction treatment may not be the one that reaps the benefit of lower medical costs down the road, Chalk explained.
“I’m very worried,” said Halverson, the psychiatrist at Rogers Memorial Hospital. If the essential health benefits go away, “that’s just going to make the access more difficult. I’m going to have to spend more of my time asking insurers to cover things that they ultimately don’t want to cover.” 
Provider-owned plans have an edge in addiction treatment
Provider-owned health plans have a leg up over traditional insurers when it comes to tackling the opioid epidemic.
Integrated systems that own health plans are better able to directly address over-prescribing of opioid painkillers and expand access to addiction treatment.
Geisinger Health Plan’s special investigations unit analyzes claims data to pinpoint providers who are prescribing opioids inappropriately and removes them from the plan’s network.
Through a state center of excellence grant, Geisinger plans to open three clinics this year devoted solely to medication-assisted treatment, or MAT, which combines medication and behavioral health therapy to treat addiction. The plan will use case management to identify patients early and help them complete the treatment program.
Geisinger also holds community forums on opioid abuse, where Meadows speaks about his own family’s harrowing experience with his stepson’s long-term addiction problems. The stepson got hooked on opioid painkillers after suffering a workplace injury. He still uses heroin and cocaine even after experiencing a near-fatal overdose, during which Meadows had to perform CPR to save his life.
“It can happen to anybody,” Meadows said.
At Kaiser Permanente, providers, pharmacists and the health plan collaborate in addressing opioid abuse. The integrated system removed most of the high-potency opioids from its prescription drug formulary. Only Kaiser’s pain management specialists, oncologists, and hospice and palliative-care doctors are authorized to prescribe these drugs.
The health plan also put limits on the amount of opioid painkillers doctors could prescribe and built alerts into its electronic health record system to ensure doctors aren’t prescribing dangerous combinations of painkillers. The plan’s pharmacy mines data to monitor physicians’ prescribing patterns.
In addition, Kaiser doctors don’t face the disincentive of low reimbursement rates that discourage other doctors from providing needed medication-assisted treatment to addicted patients. That’s because Kaiser doctors are salaried.
“We don’t sit there and worry if the reimbursement for that treatment is too low to be worth our while,” said Dr. Michael Kanter, the system’s chief quality officer.