Kaiser Health News Insurance plans loosen rules for covering addiction treatment
Portsmouth HeraldFeb 27, 2017
Specifically,
The change comes as addiction to opioids, which include heavy-duty painkillers and heroin, still sweeps the country. More than 33,000 people died from overdosing on these drugs in 2015, the most recent year for which statistics are available. And it puts
Both companies took the step after facing investigation with New York’s attorney general, whose office was probing whether their coverage practices unfairly barred patients from needed treatment. They made this adjustment as part of larger settlements.
It sounds like just a technicality a brief delay before treatment. But addiction specialists say this red tape puts people’s ability to get well at risk. It gives them a window of time to change their minds or go into withdrawal symptoms, causing them to relapse.
“If someone shows up in your office and says, ‘I’m ready,’ and you can make it happen right then and there that’s great. If you say, ‘Come back tomorrow, or Thursday, or next week,’ there’s a good chance they’re not coming back,” said
As these major carriers drop the requirement, treatment specialists hope a trend could be emerging in which these addiction meds become more easily available. In
Meanwhile, though little research pinpoints precisely how widespread this coverage practice is for drugs that treat opioid addiction, experts say it’s a fairly common practice.
“Just think of any big health insurance company that hasn’t recently announced they’re doing away with this, and it’s a pretty safe bet they’ve got prior authorization in place,” said
How does the problem manifest?
But prior authorization requirements have been intense, said
“It was like, ‘This is insanity,’” Green said, adding that “navigating the insurance was a huge problem” for almost every patient.
But defenders of the requirement maintain that such controls have value. Insurance plans using prior authorization may view it as a safeguard when prescribing a potentially dangerous drug. “[It’s] not a tool to limit access. It’s a tool to ensure patients get the right care,” said
Other large insurance carriers such as
Also, though, it is generally agreed that the practice is used to control the prescribing of expensive medications. Per dose, the cost of these drugs varies based on brand and precise formulation, but it can go as high as almost
Regardless of intent, critics say, those extra forms and hoops do make it more difficult for patients in need to get these medications ? ultimately, they say, doing more harm than good.
“If you would like a physician to not do a particular treatment, put a prior authorization in front of it,” Rich said. “That’s what they’re used for.”
Meanwhile, addiction treatment advocates and health professionals are hoping to build on what they see as new momentum.
Earlier this month, the
Minnesota’s attorney general has written to health plans in the state, asking they end prior authorization for addiction treatment.
They’re arguing based on a requirement that insurance plans, thanks to so-called “parity laws,” must cover addiction treatment, and cover it at the same level as they do other kinds of health care.
The prior authorization requirement “doesn’t meet the sniff test for parity,” said
But the justification for legal cases like New York’s could get weaker. The 2010 health law, which lawmakers are working to repeal, included requirements that mental health and addiction treatment be considered an “essential health benefit.” If that disappears, robust coverage for addiction could be less widely available, several noted.
Meanwhile, the stakes are substantial, Rich said. He recalled a patient who was taking a version of buprenorphine ? the active ingredient in Suboxone ? who had a brief relapse with heroin. That led to complications in the paperwork for renewing his prescription for treatment.
“Now he’s out of the office, in the street, using more,” Rich said of that case. “Incumbent upon (effective treatment) is the ability to get people started right away. If there’s prior authorization? It’s infuriating.”