Private insurers in New York see surge in claims related to opioid addiction

Data obtained by Crain's reveal alarming regional trends in opioid abuse and dependence in New York

Private insurance claims for emergency room visits, substance use treatment and other services related to opioid addiction surged in New York state between 2007 and 2014, well before the latest coverage mandates took effect, new data show.

During that period, the number of claims related to opioid abuse and dependence—two similar but distinct diagnoses—increased 487%, with the sharpest increase taking place between 2011 and 2014, according to a report provided to Crain's by the health care transparency group Fair Health, which has the largest private health claims database in the country.

The state's problem with heroin and opioid painkillers, which mirrors a nationwide trend, has been well-documented, but Fair Health's data identify some alarming local pain points.

For instance, between 2007 and 2014, New York City experienced an 2,600% increase in private insurance claims for treating pregnant women for drug dependence, far outpacing the rest of the state and country.

Such claims, which include dependence on opioids and other drugs, increased about 292% in the city's suburbs during that period; nationwide, they rose about 511%, according to a separate Fair Health report.

The New York City Department of Health and Mental Hygiene didn't respond to a request for comment on the increase in drug dependence claims among pregnant women after being provided a copy of the report.

Overall, private insurance claims related to opioid abuse and dependence rose at the highest rate in the suburbs. They increased 1,459% in Nassau, Rockland, Suffolk and Westchester counties during the study period, compared with 324% in New York City and 310% in the rest of the state, the report shows. Although New York City is the most populous part of the state, city residents only generated 13% of the private insurance claims related to opioid abuse and dependence during the study period, compared with 37% in the city's suburbs.

The fact that the Fair Health data excluded Medicaid enrollees, who are more concentrated in New York City than in the suburbs, may account for some of the regional disparities shown in the study, said Robin Gelburd, president of Fair Health. However, state data also show that Long Island has been particularly hard hit by the current opioid epidemic. Suffolk County had the most heroin overdose deaths and the most deaths in which prescription opioids were a factor in 2014, according to a report from the state comptroller's office.

Fair Health is planning statewide follow-up studies that will look at the cost of the services plans are covering to treat opioid addiction, but a national study released last year offers a hint.

In 2015, private payers' average cost for a beneficiary diagnosed with opioid abuse or dependence was almost $16,000 higher than the average per-person cost for all patients, according to a Fair Health report.

Recent state and federal regulations are expanding private insurance coverage for substance-use treatment services. Plans weren't required to cover residential treatment for substance use disorders to the same degree as other inpatient services until July 2014, when an update to the federal Mental Health Parity and Addiction Equity Act went into effect. As of January, insurers in New York must wait two weeks after a patient has been admitted to residential treatment before conducting a review of whether those services are needed—one of several new rules to expand access to opioid abuse treatment that went into effect in the state this year.

"Clearly, the access to treatment and increase in people seeking treatment is driving up costs," said Shira Irizarry, director of behavioral health services at Empire Blue Cross Blue Shield. "But we can't look at those costs in a vacuum."

Empire BCBS now views substance use disorder as a chronic condition and is seeking to expand members' access to community-based services that could help them avoid expensive hospital admissions and emergency room visits, said Irizarry.

For instance, the insurer started contracting about a year ago with the New York Foundling, a human services organization based in Manhattan that provides intensive in-home care for people with substance use and mental health diagnoses.

"I don't think we will know what the outcome is really going to look like," said Irizarry, "until we address what types of treatments are available and make sure our members have access to those treatments that have the proven ability to support long-term sobriety."

"Private insurers in the state see surge in claims related to opioid addiction" originally appeared in Crain's New York Business.