The conflict between health plans and providers over coverage of medication-assisted treatment for patients with opioid addiction highlights the ongoing tensions over government regulation of insurance benefit packages. And it raises questions about whether current benefit designs of private health plans are necessarily consistent with the broader public health goals.
Modern Healthcare's Bob Herman reported last week that health insurance trade groups and provider groups are on opposite sides of a debate over whether the Obama administration should deem medication-assisted treatment (MAT) a mandated benefit under the Affordable Care Act's essential benefits provision.
Many hospital associations, drug treatment centers, psychiatrists, primary-care physicians and individual patients recently sent the CMS written comments supporting full coverage of MAT. A married couple who are both MAT patients and take methadone daily wrote to say their insurer, Blue Cross and Blue Shield of Tennessee, denied them coverage for methadone because it only covers a different drug, buprenorphine, for addiction treatment. The husband said his and his wife's addiction treatment is “by far our largest medical expense, and for it to not be covered by the insurance that we are required by law to have is nothing more than a proverbial kick in the teeth.”
But America's Health Insurance Plans, the Blue Cross and Blue Shield Association, the Pharmaceutical Care Management Association, Express Scripts Holding Co., CVS Health Corp., and UnitedHealth Group sent the CMS written comments that they should not be required to pay for any specific treatment for opioid addiction. “We are concerned that by mandating specific benefits within an (essential health benefits) category, CMS may establish a precedent of imposing essential health benefit mandates in the future,” the Blues association wrote. That, it warned, could lead to premium increases. The insurance groups said they should be able to make their own coverage decisions for specific drugs.
Many insurers do pay for MAT, which involves a combination of medication and counseling to reduce addicted patients' craving for opioids such as heroin. But providers and patient advocates say insurers often pay for only one of the three FDA-approved drugs for addiction treatment. Providers prescribe different drugs based on their assessment of which is most effective for particular patients.
Or the insurers may set high cost sharing for the drugs, thus reducing the number of addicted patients receiving treatment. And some plans cap the number of covered dosages and refills, according to the Substance Abuse and Mental Health Services Administration. Methadone and buprenorphine, the two most commonly used drugs, can set a patient back thousands of dollars a year in out-of-pocket costs.
Both SAMHSA and the National Institute on Drug Abuse have found MAT to be clinically effective for people with opioid addiction. NIDA said such treatment also saves money by keeping people out of hospitals and treatment centers.
This coverage debate is playing out at a time when the U.S. is facing what many experts consider a national opioid addiction crisis, with sharply rising numbers of Americans becoming addicted and dying from opioid overdoses. Nearly 29,000 people died in 2014 from overdoses of prescription painkillers, heroin and other opioids, according to the Centers for Disease Control and Prevention. Both Republican and Democratic politicians are calling for expanded treatment.
The traditional rationale for cost sharing in health plans is to encourage people to take better care of their health and use medical services more judiciously, thus controlling healthcare spending. And there's no question that insurers and pharmacy benefit managers have to be given leeway to select the most cost-effective drugs for their formularies. As the Blues association wrote to the CMS, “requiring plans to cover specific drugs within a category and class would conflict with this carefully established balance between coverage mandates and affordability…”
One unanswered question is why a drug like methadone that's been on the market for decades is so expensive.
Still, does the usual “skin in the game” justification for high cost sharing really apply to people in the grip of opioid addiction? Are heroin addicts going to think about their deductible and copays before snorting or shooting up? And do we want to make it harder and less affordable for them to receive effective treatment by imposing insurance hurdles and high cost sharing?