By Joseph Burns
Health care journalists covering addiction, overdoses, and the heroin epidemic are likely to learn that the health insurance system appears to be part of the problem. That’s what Terry DeMio found on her beat in southern Ohio and northern Kentucky. Since January 2016, DeMio has been the Cincinnati Enquirer’s heroin epidemic reporter.
Rather than paying for the best medications for drug addicts in need, health insurers often require patients to start with the lowest-cost drugs. Then if the lowest-cost prescription fails, insurers then pay for the next highest-cost drug. Called fail-first or step therapy, this process repeats until the patient finds the one that works. Meanwhile, the patient suffers or could die, DeMio said.
“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,” wrote DeMio and Jayne O’Donnell, who covers health care for USA Today.
They cited a report, Use of Opioid Recovery Medications, from the IMS Institute that showed that some 2.4 million Americans have an opioid-use disorder and most do not get treatment or are not getting the most effective care. Produced with funding from Advocates for Opioid Recovery, the report focused on the use of buprenorphine, which is used to treat opioid addiction, and how health insurers pay for this medication. Buprenorphine also goes by the brand names Suboxone, Subutex, Zubsolv, Bunavail and Probuphine, according to the National Alliance of Advocates for Buprenorphine Treatment.
In the IMS report, researchers wrote that the use of buprenorphine medications has slowed over the past five years despite increased calls to support opioid-addiction recovery and evidence that medication is the key to long-term recovery. Commercial insurers pay 57 percent of buprenorphine prescriptions, followed by Medicaid (24 percent), cash-paying patients (11 percent), and Medicare Part D (7 percent), the report said. Medicaid coverage varies widely by state. Of the 10 states with the highest prescription opioid use relative to population, Medicaid programs in eight of those states had funding for buprenorphine that was lower than the national average for such payment, the report said.
Ohio and Kentucky were among the states that had the highest rates of public funding for buprenorphine, DeMio and O’Donnell reported, but states and managed care companies often limit treatment for substance-use disorders in ways they wouldn’t for medical conditions. A report from the National Center on Addiction and Substance Abuse showed that no state covers all of the substance use disorder treatments required under the Affordable Care Act without harmful treatment limitations.
For that report, “Uncovering Coverage Gaps: A Review of Addiction Benefits in ACA Plans,” researchers showed that more than two-thirds of health insurance plans nationwide were not covering the necessary services for addicted patients as they should under the ACA’s essential health benefits rules. The ACA requires plans to provide mental health and substance-use disorder treatments at parity, meaning equal to or comparable with the plan’s medical and surgical benefits. Given that few plans have limits on medical and surgical benefits, parity usually means without limits.
In an interview, DeMio cited the report on uncovering coverage gaps as useful for reporting on mental health parity. Other resources for journalists include the following:
Out-of-Network, Out-of-Pocket, Out-of-Options: The Unfulfilled Promise of Mental Health Parity from the National Alliance on Mental Illness,
The Mental Health & Substance Use Disorder Parity Task Force (pdf) report from the White House,
Guide to Finding Quality Addiction Treatment, from the National Center on Addiction and Substance Abuse, and
The Mental Health and Substance Use Disorder Parity page from the U.S. Department of Labor, which describes the rules under the Mental Health Parity and Addiction Equity Act of 2008.
Many physician specialty organizations and patient groups track state legislation designed to limit the use of fail-first or step-therapy strategies, for example, this page from the National Psoriasis Foundation.
Other resources include the Columbia University Medical Center’s Division on Substance Use Disorders. In December, the Mayo Clinic News Network announced a seven-part series of reports for journalists on the opioid-abuse epidemic.
The article DeMio and O’Donnell wrote includes a thorough description of most of the medications in use today for treating patients addicted to opioids and heroin. Those drugs include buprenorphine, methadone, probuphine, suboxone, subutex and vivitrol.
Joseph Burns (@jburns18), a Massachusetts-based independent journalist, is AHCJ’s topic leader on health insurance. He welcomes questions and suggestions on insurance resources and tip sheets at joseph@healthjournalism.org.
