Alex Dodd, president and CEO of Aegis Treatment Centers, divides Obamacare─the Affordable Care Act (ACA)─into Covered California, which is commercial insurance with subsidies for people earning up to 400 percent of the federal poverty limit, and expanded Medi-Cal (California’s Medicaid program). He’s thrilled about both, and although there are a few more challenges on the commercial side than with Medi-Cal, the progress in educating people in managed care about opioid treatment programs (OTPs) has been dramatic.
“It’s great for society, and hopefully will be good for us,” said Mr. Dodd of the ACA. Both Covered California and expanded Medi-Cal now mean that many people who weren’t eligible for funding for care in an OTP now will be. Expansion of Medi-Cal means that everyone─including single men─earning up to 137 percent of the federal poverty level, when Covered California kicks in, is covered for health care.
“Hundreds of thousands of Californians became eligible for Medi-Cal,” said Mr. Dodd. At Aegis’ 25 clinics in 14 counties, there’s been a definite increase in patients. “It’s been good for us,” he said of Medi-Cal expansion. “Now, more people who suffer from this acquired, chronic, relapsing disease are going to our clinics, no longer going to the emergency department. It’s been a lot of hard work, but it’s worth it.”
Logistics of Billing
Billing for Medi-Cal is in transition in California. Currently, providers invoice the county, and the county pays the bill. But the funding actually comes from the state and the federal government under Medi-Cal and the ACA. For the first three years, the federal government pays 100 percent for the expanded population─adults without dependents, and adults earning between 100 percent and 137 percent of the federal poverty level. For Medi-Cal patients who were already covered, the state pays 50 percent and the federal government pays 50 percent. Going forward, it is expected that under a 1115 waiver, the counties will have more authority in how treatment paid by Medi-Cal is administered and reimbursed, said Mr. Dodd.
As for commercial plans, which include plans in Covered California and other private plans, Aegis has contracted so far with six managed care organizations. With the exception of Kaiser Permanente, all are in catch-up mode when it comes to understanding substance use disorders and addiction treatment in general. They have not covered it for so many years. So treatment in an OTP, which is a very specific form of treatment─not at all the same as office-based opioid treatment─is a complete mystery. “It’s all so new to them,” said Mr. Dodd. One positive sign is that so far, with some providers, there has been no discussion of preauthorization and utilization review for OTP patients, he said.
An example of the learning curve some providers are going through concerns 25 Aegis patients signed up for insurance with one managed care organization. When Aegis checked, however, only one of these was covered for the OTP treatment. “We met in person with them and said, ‘What’s wrong? We have 25 patients who took out insurance with your company, but only one is covered.’” The response from the company to Aegis officials was, “We’re not surprised, because these things take time to implement.” And even though there was only one insurance company involved, the plans could have been all different─each plan has its own design, and the 24 patients who weren’t covered might have had plans that specifically excluded OTPs─a major problem. “Even though behavioral health coverage is one of the 10 essential benefits, there’s a long road between that and patients actually getting treatment,” said Mr. Dodd.
Managed Care Problems
Currently, managed care is “erratic” when it comes to OTPs, said Mr. Dodd. “But we do have a number of managed care patients, and I’m very hopeful.” Aegis is currently finalizing contracts with Anthem BC/BS. “They now get it, they understand” how OTPs work, he said. It’s maintenance, not detox; it includes counseling and other services, and significantly, it’s not the same as office-based opioid treatment.
“There’s a big education process that we all need to do with the insurance companies,” said Mr. Dodd. Even though OTPs know that addiction is like diabetes and high blood pressure─it’s chronic, and medication maintenance is key to treatment for many─most insurance companies don’t know this yet. The cost offset of treatment in an OTP─saving dollars that would otherwise be used on hospitalizations and emergency departments are recognized by the more enlightened managed care companies, like Kaiser, but most are still “not there yet,” said Mr. Dodd.
Problems with Parity
“With the exception of Kaiser, we’ve been disappointed with how long it has taken managed care organizations to understand substance use disorders and to contract with us and provide benefits,” Mr. Dodd commented. Also with the exception of Kaiser, insurance companies have not been abiding by the terms of the Mental Health Parity and Addiction Equity Act. Mr. Dodd met in December with the chairman of the California Association of Health Plans to say that “what they’re doing is wrong” in terms of discrimination against people with addiction. “If they’re not careful, they’re going to have a class action on their hands,” he said.
Often, it takes personal tragedy to convince someone─a politician, a regulator, an insurance executive─that addiction is a real disease. “Until somebody is touched by addiction, either in their family or in someone close to them, they just don’t get it,” said Mr. Dodd.
Ultimately, though, it will be through lobbying, negative publicity about denials, and legal action, that the insurance companies will “sit up and take notice,” he added. “I’m certain we’ll get there.”