Medication-assisted treatment (MAT) is being thwarted by state governments and insurance companies, the American Society of Addiction Medicine (ASAM) warned in a scathing report released June 20. The report, which details practices by governments, Medicaid, and insurance companies, shows that by restricting the use of methadone, buprenorphine, and naltrexone, policymakers are doing nothing to stave off the opioid addiction and overdose epidemic. And they may even be adding to it by denying patients MAT, according to the report, which was prepared by the consulting and research firm Avisa Group and the Treatment Research Institute (TRI).
The main point of the report is that the medications work only when used as long-term, maintenance treatment. There is very little evidence that short-term treatment is effective. Yet, short-term, curtailed, or no MAT is what many politicians and insurance companies are calling for
“I wonder how many governors are actively intervening to dictate the nature, amount, and duration of cancer treatment or hypertension medications that are available,” said A. Thomas McLellan, PhD, CEO of TRI, in an interview with AT Forum after the report was released. “I wonder how many state insurance authorities would get away with restricting the amount, duration, and coverage for cancer, pain, asthma, hypertension care.” Treatment of addiction needs to be governed by the same rules of clinical science that govern the rest of medical care, Dr. McLellan said. “At the end of the day this is a medical illness. It is that simple. If you can say a sentence about diabetes treatment and its coverage, and then replace the word diabetes with addiction and have the sentence still make sense, you are probably on the right track.”
Medicaid
In 31 states, methadone maintenance treatment in OTPs is covered by fee-for-service (FFS) Medicaid. In some states, additional funding comes from the federal Substance Abuse Prevention and Treatment (SAPT) block grant and state funds. In three states, methadone treatment is funded only through the SAPT block grant or state or county funds, with no Medicaid coverage. Medicaid does not cover methadone maintenance at all in 17 states. States having no public funding for methadone maintenance, according to the report, are:
- Arkansas
- Colorado
- Idaho
- Indiana
- Iowa
- Kansas
- Kentucky
- Louisiana
- Mississippi
- Montana
- North Dakota
- Oklahoma
- South Carolina
- South Dakota
- Tennessee
- West Virginia
Although addiction is a chronic disease, with opioid addiction best treated with medications and behavioral interventions, not only are the medications underutilized, but their use is deliberately being foiled for reasons related to cost and stigma.
“These reports show that we could be saving lives and effectively treating the disease of addiction if state governments and insurance companies remove roadblocks to the use of these medications,” said Stuart Gitlow, MD, president of ASAM. “Treatment professionals need every evidence-based tool available to end suffering from this chronic disease.
The report on effectiveness of opioid medications looked at 642 different studies evaluating the three medications—the only medications approved by the Food and Drug Administration for the treatment of opioid addiction. The report also shows that the medications are cost-effective, roughly comparable to diabetes medications.
Restrictions by Payers
A major part of the report is a survey of state Medicaid and other insurer restrictions. “We really learned something there,” said Dr. McLellan. “I thought there were frank restrictions on MAT, but that is not the case.” Instead of explicit, written restrictions, there are non-quantitative treatment limitations, to use the language of the parity law. Insurance companies make it very difficult for patients to get the right amount of medication, and to access MAT in general.
The report found that insurance company representatives did not want to discuss opioid treatment medications, and that while every state covers at least one opioid addiction medication on the Medicaid formulary, restrictions vary and often amount to a complete denial of access, with coverage limits and onerous utilization review common by states. The situation is similar for private insurance companies, which have utilization management techniques that can be contradictory and arbitrary, and often limit quantities and dosages.
The situation is similar for private insurance companies. They have utilization management techniques, which can be contradictory and arbitrary, and often limit quantities and dosages.
These limitations are in direct opposition to recommendations by medical associations and the Substance Abuse and Mental Health Services Administration (SAMHSA), according to ASAM. Not only do these limitations have no therapeutic goal, but they can risk patient safety and lead to suffering and death.
Little Support from Insurance
Mady Chalk, PhD, of TRI, conducted the survey of commercial insurance plans for the report. “I was surprised at the extent of the comments that we got,” Dr. Chalk told AT Forum. “One was ‘How did you get my name and my email address?’ Another was ‘I sent this up the chain, and my CEO says I can’t respond.’” Most of the data for the commercial report was culled from secondary sources.
Public insurance—Medicaid—officials also did not want to discuss the restrictions on MAT. The National Association of Medicaid Directors refused to write a letter of support for the survey (which would have encouraged state Medicaid directors to respond), said Dr. Chalk. “They said they couldn’t support it because it would mean that the Medicaid directors would have to change their practices, and ‘we can’t put them in that position.’” Dr. Chalk was surprised at the extent of the resistance to even examining policies related to MAT. “Of course it might mean you would have to change some practices,” she said.
A number of insurance companies use “step therapy,” also known as “fail-first,” in which patients have to fail on a certain dose before it can be increased. “They can have a requirement that you have to start with 8 milligrams of buprenorphine, and if that doesn’t work then you can move up to 16,” said Dr. Chalk. One state said that in order for Medicaid to pay for Vivitrol, the patient would have to fail first at two attempts of residential treatment and fail two attempts at buprenorphine, she said.
Another general practice of many insurance companies is to allow patients to have a prescription for buprenorphine, for example, for six months, and then require a renewal of the prior authorization, said Dr. Chalk. But there’s a catch—“they say if you’re not at the moment in “active treatment”—which they don’t define—then no renewal.”
OTPs as Silos
Ironically, the price objections by payers to buprenorphine and extended-release naltrexone are not there for methadone, which is very inexpensive as a medication. But since it can only be given in OTPs, they don’t know how to deal with the modality.
Addiction treatment is often criticized as being a separate “silo” from medical care, but OTPs are like silos within silos, according to the report. Even though the report treats methadone, buprenorphine, and naltrexone equally, methadone is unique. Methadone tablets cannot be prescribed for opioid dependence on an outpatient basis; they can only be provided in OTPs, which have their own accreditation and licensing systems. Anyone closely involved with regulation and reimbursement of OTPs is unlikely to be familiar with other reimbursement systems, the report noted. In many cases, OTPs are not familiar with Medicaid, even when Medicaid covers some of the costs of treatment. Likewise, Medicaid staff who are not involved with OTPs or methadone know little about that system—even if their agency pays for treatment.
“We found virtually no commercial insurance coverage for methadone in OTPs,” said Dr. Chalk. Many insurance companies don’t want to reveal publicly that they cover addiction treatment because they are worried about “adverse selection,” a phenomenon in which people with a certain disease sign up for the insurance company that covers its treatment. However, if all of the insurance companies had coverage and benefits for addiction treatment, adverse selection would not be such an issue, said Dr. Chalk. Because of adverse selection concerns, access to medications is likely to continue to be a problem, even when health care reform is implemented.
“It is essential that there be greater transparency on the part of commercial plans and Medicaid agencies, so that consumers and treatment programs and clinicians are able to understand what their access is to medications,” said Dr. Chalk.
For the full report, go to: http://www.asam.org/docs/advocacy/Implications-for-Opioid-Addiction-Treatment