Facing Pressure, Insurance Plans Loosen Rules For Covering Addiction Treatment

Naloxone blocks or reverses the effects of opioid medication. (Seth Herald for NPR)

Aetna, one of the nation’s largest insurance companies, will remove a key barrier for patients seeking medication to treat opioid addiction: The requirement that doctors seek approval before prescribing  medications ― such as Suboxone ― that are used to mitigate withdrawal symptoms.

The insurance practice, called “prior authorization,” can result in delays of hours to days in getting a prescription filled.

The change comes as addiction to opioids — including heavy-duty painkillers and heroin — is sweeping the country. More than 33,000 people died from overdosing on these drugs in 2015, the most recent year for which statistics are available.

The move, slated for March, puts Aetna in the company of Anthem and Cigna, which both recently dropped the prior authorization requirement for privately insured patients across the country. Anthem made the switch in January and Cigna this past fall.

Both companies took the step after facing an investigation by New York’s attorney general into whether their coverage practices unfairly barred patients from needed treatment. They made this adjustment as part of larger settlements.

Addiction specialists say the drug gives patients a window of time to seek treatment without going into withdrawal.

“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 Josiah Rich, a professor at Brown University and a doctor at Providence-based Miriam Hospital who frequently treats opioid-addicted patients. “Those windows of opportunity present themselves. But they open and close.”

As these major carriers drop the requirement, treatment specialists hope addiction meds become more easily available. In New York, for instance, the attorney general’s office will examine other carriers who still have prior authorization requirements, an office spokesperson said. The office would not specify which ones.

Meanwhile, though little research pinpoints how widespread prior authorization requirements are for drugs that treat opioid addiction, experts say it’s fairly common.

“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 Andrew Kolodny, a Brandeis University senior scientist and the executive director of Physicians for Responsible Opioid Prescribing, an advocacy group.

(Wikimedia Commons)

Aetna will stop requiring doctors seek approval before prescribing particular medications such as Suboxone. (Wikimedia Commons)

That translates into a lot of paperwork for providers. At Boston Medical Center, in a region that’s been hit hard by opioid addiction, doctors wanted to launch an urgent care center focused on this patient population. Less than a year old, the program has treated thousands of people.

To help people get needed care ― before it was too late ― the center hired a staffer devoted specifically to filling out all the related insurance documents, said Traci Green, an associate professor at Boston University’s School of Medicine and deputy director of the hospital’s injury prevention center.

“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 prior authorization requirement maintain that such controls have value. Some insurers 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 Susan Cantrell, CEO of the Academy of Managed Care Pharmacy, a trade group.

Other large insurance carriers ― such as United Healthcare and Humana ― list on their drug formularies a prior authorization requirement for at least some if not all versions of anti-addiction medication. A spokesperson from Humana said the practice is used “to ensure appropriate use.”

The practice also can be 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 $500 for a 60-pack dose, which can last a month.

Regardless of intent, critics say, those extra forms and hoops do make it more difficult for patients in need of 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 American Medical Association sent a letter to the National Association of Attorneys General, calling for increased attention to insurance plans that require prior authorization for Suboxone or other similar drugs.

Minnesota’s attorney general has written to health plans in the state, asking they end prior authorization for addiction treatment. New York has heard from other states interested in tackling the issue, the attorney general spokesperson said. A project called Parity Track is soliciting complaints from consumers.

They’re basing their argument on so-called “parity laws,” which require insurers to cover addiction treatment 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 Corey Waller, an emergency physician who chairs the American Society of Addiction Medicine’s legislative advocacy committee. “It’s a first-line, Food and Drug Administration-approved therapy for a disease with a known mortality. Every other disease with a known mortality ― the first-line drugs are available right away.”

But the justification for legal cases like New York’s weaken if the 2010 health law is repealed. The law 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.

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. Complications arose in the paperwork required to renew his prescription.

“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.”

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Categories: Innovations, Insurance, Mental Health

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