The legislature is expected to give final passage to the nation's strictest treatment mandates and a 5-day cap on the initial opioid prescription. Governor Chris Christie's plan has met little resistance, even though the cost is unknown.
This week, New Jersey Governor Chris Christie will likely sign into law the centerpiece of his plan to fight the state’s opioid crisis, giving teeth to a crusade that was a high point of his presidential campaign. So far, a snowstorm has been the only obstacle to the far-reaching bill, which features:
· the nation’s strictest mandates for getting patients into treatment
· a 5-day cap on the first opioid prescription—the tightest limit in the United States
· opioid education requirements for every licensed healthcare professional who prescribes them, from physicians to midwives.
After being snowed out last week, the General Assembly will vote Wednesday, February 15, on S3/A3, a bill that has already cleared the Senate 33-0. Christie called for the nation’s first 6-month treatment mandate in his State of the State address January 10, 2017, and has met little resistance, even though no one knows how the plan will affect premiums. The biggest controversy, in fact, isn’t Christie’s plan, but his appearance in TV ads encouraging addicts to seek care.
A rising death toll has fueled united, bipartisan support, and Christie has already signed a bill that requires health professionals to educate youth about the risk of addiction before prescribing drugs. In all, more than 10 different bills addressed aspects of treatment, prevention, and recovery, but S3/A3 is the key, designed to end the “runaround” the governor said too many addicts and families experience. Once signed, the law takes effect in 90 days.
New Jersey’s health plans, rather than fight Christie, opted for tweaks that will give them more say in where care occurs. According to testimony, the NJ Association of Health Plans (NJAHP) pointedly did not oppose the bill, but sought to keep addiction services within the umbrella of “accountable care,” and to not assume inpatient care is best. On Friday, the CEO of the largest plan, Horizon Blue Cross Blue Shield of New Jersey, published a guest column that did not explicitly endorse or oppose the bill, but supported the handling of addiction as “a disease—not a behavior, choice or moral failure.”
“Mandating that insurance policies include a specific benefit requires striking the right balance between affordability and coverage,” Horizon’s CEO, Robert A. Marino, wrote. “I applaud the governor and legislative leaders for working to strike the right balance, engaging all parties to face the problem and advancing a comprehensive solution.”
Prescription opioids and their chemical cousins, heroin and fentanyl, have New Jersey in their grip: in December, the state medical examiner reported there were 1587 drug overdose deaths in 2015—a 21% jump from the prior year—and heroin deaths reached the highest ever recorded, at 918. The CDC has listed New Jersey as 1 of 19 states with “statistically significant” increases in drug overdose deaths.
But the statewide numbers don’t tell the whole story. Pockets of New Jersey—especially Ocean County, which is home to a sizable senior population—are so devastated that death tolls rival those in all of New Hampshire and Kentucky, which have the second- and third-highest death rates from opioids per 100,000 population. Ocean County recorded 205 opioid-related deaths in 2016, which means Ocean County has an unadjusted rate of 34.8 deaths per 100,000 population, using US Census figures.
Ocean County Prosecutor Joseph D. Coronato, who has pioneered strategies like equipping local police with Narcan (naloxone) and using “recovery coaches” in the emergency department, told The American Journal of Managed Care® (AJMC®) that Christie’s plan targets a critical need: getting addicts who are saved from an overdose into treatment without delay. The “coaches,” recovered addicts who counsel overdose patients right after they have been spared, can be highly effective, but only if the path to treatment is uninterrupted. “If you don’t get them when the tear drops are warm, that’s a lost opportunity,” he said in a video interview with AJMC®.
He sees the 6-month treatment requirement—more so than the 5-day pill limit—as the “game changer” of the governor’s plan, but emphasized that continuous support from a mentor is key to preventing relapses after an addict leaves the treatment facility.
He also discussed how the Narcan program does more than just stop overdoses; it has actually given the police officers a more personal look at the effects of addiction, changing their perceptions of what a drug addict looks like.
“It’s somebody’s son, it’s somebody’s daughter, it’s someone’s loved one,” he told AJMC®, “and I think the police officers now can relate better to that.”
New Jersey Breaks New Ground
As written, S3/A3 gives addicts unfettered access to care for the first 28 days. The doctor decides if inpatient care is warranted, and after that, health plans can guide the care setting with concurrent reviews no more frequently than every 2 weeks. The bill also gives providers, after the initial opioid prescription, the ability to write subsequent scripts for up to 30 days, as long as the patient or parent has been counseled and signs a form confirming this. Patients with cancer or those in hospice are exempt.
Less-noticed parts of the bill are groundbreaking in an era of narrow networks and cost control: if no inpatient bed is available in network when an addict seeks help, the health plan must approve an out-of-network bed “to ensure admission into a treatment facility within 24 hours.” Also, the treatment mandates are not limited to care for opioid use—they apply to all who seek care for a “substance abuse disorder,” as defined by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders.
The potential cost is such an unknown that the legislature’s fiscal officers could only predict an “indeterminate increase.” The bill calls for state health and insurance regulators to report back to the Legislature after 6 and 12 months. In its testimony, NJAHP said, “We are trying to simulate the effects of the bill and produce good-faith estimates of the bill’s fiscal impact to the state and policyholders. But this bill does not have analogues in other states, so this is a challenging task.”
Physician groups have sounded alarms about the 5-day pill limit; the Medical Society of New Jersey (MSNJ) said in a statement emailed to AJMC® that it opposes “such intrusions into the practice of medicine, especially if they do not take into account individual patient circumstances.” MSNJ cited studies that find doctors are cutting back on opioid prescriptions already, and rising heroin use is the result. The CDC’s new prescribing guidelines, issued in March 2016, do not have hard limits, but instead say that “three days or less will often be sufficient; more than 7 days will rarely be needed.”
Ray Saputelli, MBA, CAE, executive vice president of the NJ Academy of Family Physicians, told AJMC® the group sought to educate lawmakers on the effect a 5-day limit would have on patients after surgery or acute trauma. “Other states with 7-day supply limits recognized that having 1 week will at least allow patients to get through the weekend without concern of running out of essential pain relief prior to getting back to their physician for any appropriate subsequent prescription,” he said in an e-mail. “Those states have exceptions that allow for some discretion for the physician to prescribe beyond the 7-day limit to address patients’ needs,” which can include financial hardship or transportation problems.
As written, the bill allows physicians, after the initial prescription, to give patients a series of scripts with different effective dates, which would allow patients to get successive, limited refills without a return visit. Insurers must prorate co-payments, so patients spend the same amount charged if a 30-day supply is dispensed all at once.
On the Front Lines of an Epidemic
Ocean County, the fastest-growing in New Jersey, is emblematic of how the opioid crisis has made America rethink who suffers from drug addiction. Prosecutor Coronato has asked himself the same question that AJMC® posed in an interview: Why Ocean County? How did this area of pine forests, retirement homes, and beaches—a place that is overwhelmingly white, Republican, older, and better off financially—become ground zero of New Jersey’s opioid crisis?*
“That is an excellent question,” Coronato said. To find answers, he has convened a consortium of leaders from healthcare and law enforcement, including the Drug Enforcement Administration. Coronato wants to dive into individual health records, looking for common threads in education, work history, and “their course in life.”
He has absolutely seen the pattern of teenagers stealing pills their grandparents have left in medicine cabinets, and he has seen the grandparents become addicts themselves. A few things stand out: the opioid and heroin crisis has nothing to do with the annual influx of beachgoers, as most deaths are year-round residents. He does, however, seek a connection to a rising alcohol problem, which matches CDC findings that opioid and heroin users tend to abuse multiple substances: the CDC reports that 96% of heroin users used 1 other drug in the past year, and 61% used 3 or more.
But Coronato’s years on a hospital board, when he was still in private practice, tell him something more. He’s convinced there’s a link between the opioid crisis and the rise of consumer-driven websites that rate hospitals and doctors. He recalls meetings a decade ago, when hospital leaders would obsess over patient ratings for pain management. “It was ‘pain, pain, pain,’” he said. “They were all over the doctors to alleviate these people’s pain.”
This happened as Medicare Part D arrived, increasing seniors’ access to pain medication. A 2016 study in Health Affairs found that by 2013, Medicare Part D had become the largest payer for opioids. A parallel trend—promoted by the Affordable Care Act—to include “patient satisfaction” scores in quality ratings, caused physicians to charge that Medicare was fueling the crisis. Although CMS insisted there was no evidence of this, in July 2016 it dropped pain management questions from its value-based purchasing survey.
To Coronato, the arrival of patient ratings “laid the groundwork for what you have today.”
A Plan Aimed at the Middle Class
In its testimony, NJAHP warns that the treatment mandate will not reach the entire insured population. Instead, the group estimated it will cover 18% of New Jerseyans who have commercial coverage and another 10% covered by various public employee plans. Medicaid is not included in the bill, but this population wasn’t Christie’s target; his proposals were aimed squarely at the middle class.
The rich, he said in January, can afford treatment, while the poor have gained access with Medicaid expansion. “Who has the biggest economic barriers to drug abuse treatment?” Christie asked. “It is the working men and women of the middle class of New Jersey, not wealthy enough to pay privately, too high in income to qualify for even expanded Medicaid. They are dependent on a health insurance industry that too often finds a way to say, ‘no.’”
After being targeted in Christie’s January address, health plans backed education and accountability requirements for others in the chain of care, including providers. NJAHP testified: “We are of the view that the opioid and heroin epidemics have been fueled, in part, by aggressive sales tactics by pharmaceutical companies coupled with a provider community that has been too willing to overprescribe.”
In his commentary, Horizon’s Marino highlights the insurer’s long-term drug abuse prevention efforts, its use of data to spot doctor shopping, and its pursuit of collaborative care, which integrates mental health into primary care practices. Addiction science is a young field, Marino wrote, and the insurer of 3.8 million will pursue evidence-based guidelines as they emerge.
Coronato said more must be done for the addict who has lost everything—jobs, housing, family connections, and health coverage. Sober housing works, but state land use laws make it hard to locate in residential areas, and privacy laws can make it hard for hospitals to share information. As police officers and recovery coaches get more people into treatment, Coronato is most interested in tracking outcomes: what works and what doesn’t.
“The first block is education and prevention. The second block is strong law enforcement,” he said. “The third block is breaking the cycle of addiction.”
*Demographic Notes, Ocean County
The US Census Bureau reports that Ocean County, NJ, population is 92.8% white, with 22.1% of the population age 65 or older, compared with 14.5% nationally. The Census Bureau reports that the county’s poverty rate is 10.9%, compared with the nationwide rate of 13.9%. The NJ Secretary of State reports that 65.5% of Ocean County voters supported Donald J. Trump; Ocean delivered the most votes for Trump of any New Jersey county in the general election.