For Kennedy, the Opioid Epidemic Is the Latest Front in the Long War for Mental Health Parity

A report finds that access to buprenorphine in Medicaid varies widely depending on where patients live. It's the latest example of the lack of mental health parity that former Congressman Patrick J. Kennedy confronts in his long quest for equity in care.

Eight years after he was the lead sponsor of the Mental Health Parity and Addiction Equity Act of 2008, former US Representative Patrick J. Kennedy says the fight to end the runaround for people who need behavioral health services is far from over.

Time is short in the Obama administration, and Kennedy’s plate is full: he has items to complete before the president leaves office in January. Now a full-time mental health advocate, Kennedy has his eyes on an upcoming White House task force report that will identify remaining gaps in coverage between behavioral health and medical and surgical care, and, perhaps, the need for a rule change for insurers.

His task today is to highlight findings in a new report from the IMS Institute for Healthcare Informatics, which found yet another instance of inequity: depending on where they live, Medicaid clients with opioid addiction have wildly different access to buprenorphine, a drug known to help those trying to stay away from oxycodone or heroin.

Kennedy spoke with The American Journal of Managed Care about the findings on behalf of Advocates for Opioid Recovery, a bipartisan group that also includes former House Speaker Newt Gingrich and social activist Van Jones. Kennedy also leads The Kennedy Forum, which works on parity in mental health coverage, including a project he hopes will create data to aid consumers.

He asks only that insurers provide the same level of transparency he’s demanded of himself: Ten years ago this week, Kennedy, who represented Rhode Island, set a new standard of openness for elected officials when he and Republican Congressman Jim Ramstad of Minnesota shared their story of recovery on the front page of The New York Times. Kennedy’s 2015 book, The Common Struggle, chronicles not only his journey with mental illness and substance abuse, but also his determination to include addiction in the nation’s healthcare parity laws.

Kennedy’s work on the parity law took place before opioid addiction exploded into the national consciousness. The IMS report, “Use of Opioid Recovery Medications: Recent Evidence on State Level Buprenorphine Use and Payment Types,” found that while the epidemic has skyrocketed in the past 5 years, the volume of prescriptions for buprenorphine has tapered off, even if the raw numbers are rising. Prescriptions reached 12.5 million for the 12 months that ended June 30, 2016. But the rate of growth was 6.4%, down from 22% in 2012.

The report found that many states with the highest rates of opioid use have the fewest buprenorphine prescriptions—and the lowest levels of public funding to support reimbursement. These states include Alabama, Oklahoma, and Mississippi, where Medicaid’s share of buprenorphine prescriptions is 5.5%, 6.9%, and 4%, respectively.

However, there are some notable exceptions—Kentucky and West Virginia have high rates of opioid abuse, but Medicaid pays for 44.2% and 44.7% of buprenorphine prescriptions in those states. Of note, both states have expanded Medicaid to individuals earning up to 138% of the federal poverty level, although Kentucky has revisions to its program pending at CMS.

Why does Medicaid’s support for buprenorphine matter? Unfortunately, Medicaid beneficiaries account for more than their share of the opioid epidemic. According to a CMS memo from January 2016, Medicaid beneficiaries are prescribed painkillers at twice the rate of those outside the program and their risk of a prescription painkiller overdose is 3 to 6 times greater. Yet, according to the IMS report, Medicaid pays 24% of buprenorphine prescriptions nationally, with commercial plans paying 57%, Medicare paying 7%, and 11% being paid in cash.

“We’re staring a national public health crisis in the face. We have to fundamentally change our approach,” Kennedy said. He noted that the Medicaid-funded epidemic had occurred, in part, because doctors and hospitals feared low scores on patient satisfaction surveys. “We’ve been our own worst enemy.”

The national picture is not good, according to the report. Almost half—24 states—have lower-than-average rates of buprenorphine use relative to overall prescription opioid use, and public financing plays a limited role. These states include Mississippi, Georgia, and Texas.

“This is the most upside down situation,” Kennedy said.

As more and more states embrace Medicaid managed care, patients with opioid addiction encounter rules that require them to seek counseling before gaining access to medication—so-called “fail first’’ policies. Key experts find barriers to medication-assistance therapies (MATs), such as buprenorphine, to be counterproductive, especially when there are long waits to see a counselor.

In a 2014 commentary, led by the heads of the National Institute on Substance Abuse and the CDC, published in the New England Journal of Medicine, the authors wrote: “Although these policies may be intended to ensure that MAT is the best course of treatment, they may hinder access and appropriate care. For example, maintenance MAT has been shown to prevent relapse and death but is strongly discouraged by lifetime limits.”

Health plans, Kennedy said, are failing to distinguish MATs from opiates. He cited a key recommendation from Advocates for Opioid Recovery (AOR): that Congress direct the Medicaid and CHIP Payment and Access Commission (MACPAC) to survey state Medicaid programs to find out if coverage, payment, and policies follow evidence-based guidelines. Governors and state Medicaid officials need to do the same, AOR recommends.

The Fight for Transparency

The Obama administration has taken several steps to stem the opioid epidemic, including targeting $100 million in new dollars for treatment, expanding care for members of the military, supporting telemedicine for addiction treatment, and increasing patient counts from 100 to 275 for doctors who prescribe buprenorphine. But Kennedy said there’s more to do.

A decade ago, it would still have been hard to imagine suburban parents coming up to presidential candidates asking for help for their heroin-addicted children. But the crisis has exploded in the past decade, fueling a 200% rise in overdose deaths in the United States since 2000, according to the CDC, including a 137% increase from opioids alone.

Though the parity law was updated in the Affordable Care Act and rules were issued in 2013, more work is needed to uncover the hurdles that patients and families encounter to get care, Kennedy said. He’s hopeful the White House Task Force report, which is due within weeks, will call for insurance companies share their medical management plans for “non-quantitative treatment limitations.” That’s the term for rules for things like prior authorization, exclusions for residential treatment, geographic limits, or any other barriers to substance abuse care that may differ from what’s permitted in medical or surgical care.

Right now, Kennedy said, the parity law doesn’t stop patients and families from facing a black box of information about how insurers manage their cases, so the typical consumer can’t tell if a denial is legal without cumbersome appeals. “If they are simply required to disclose, there will be a huge change of behavior,” he said.

His goal is to create a parity registry, so that patients who are given a denial can enter it into a central database. As complaints accumulate, advocates will be able to see if a cluster of similar complaints emerges for 1 insurer in a single location. That’s when they will know to ask the attorney general in that state to file a consumer protection action on behalf of the patients, he said.

“I’ll be able to go to the big insurance companies and say, ‘I’m getting complaints; where’s there’s smoke there’s fire.’”