Unusual Variability in How States Use, Pay for Opioid Addiction Treatment

IMS Institute for Healthcare Informatics released a new research report that revealed dramatic variations in how states prescribe and reimburse opioid addiction recovery medications, specifically buprenorphine, a press release from Advocates for Opioid Recovery (AOR) notes.

The report also showed that, despite a dramatic rise in overdoses and opioid-related deaths over the past five years, the growth rate for addiction treatment with buprenorphine has slowed – even as government agencies accelerate their efforts to expand access to medication assisted treatment.

The report, funded by Advocates for Opioid Recovery (AOR), concluded “Patient access to – and reimbursement for – buprenorphine medications used in addiction recovery varies widely across states and suggests inconsistent and suboptimal approaches in many parts of the country.”

The IMS data shows huge variability in how states use and pay for medication assisted treatment. The share of MAT prescriptions paid for by state Medicaid programs ranges from 4% in Mississippi to 68% in Vermont.

“There is no better litmus test for mental health equality than medication assisted treatment. The evidence is undeniable that medication, along with behavioral counseling, is the best course of treatment. Restrictive policies, like ‘fail first’ or dosage and duration limits, should be a violation of the 2008 mental health parity law,” said AOR advisor, former Congressman Patrick J. Kennedy (D-RI). “That was certainly my intention when I introduced the bill in the House. If that is not a violation, I’m not sure what is.”

The share of prescriptions paid for by state Medicaid programs, the federal-state health care program for low-income families or individuals, ranged from 68% in Vermont to 4% in Mississippi. In nine states, at least 40% of the buprenorphine prescriptions were paid for by Medicaid between June 2015 and June 2016. In 12 states, the share of Medicaid payment was less than 10%. In four state programs, Alabama, Florida, Mississippi and Utah, Medicaid programs make up less than 5% of the payments and they also are among the states with the most out-of-pocket expenses for buprenorphine.

“Even in the best of circumstances, obtaining access to opioid recovery programs that include medication is tough,” said Van Jones, civil rights advocate and AOR advisor. “For the most vulnerable in our country who rely on Medicaid, this data proves it is nearly impossible in many states.”

A 2013 review of Medicaid and private insurance commissioned by The National Institute for Drug Abuse and the American Society of Addiction Medicine found common insurance barriers to medication assisted treatment included prior authorization, counseling requirements, quantity limits, step therapy requirements, duration limitations and network requirements.

“We would never give a person with diabetes testing strips with no insulin, yet that is exactly what we do when we pay for behavioral counseling while restricting recovery medications for opioid addiction,” said former Speaker of the House and AOR Advisor Newt Gingrich. “The idea is morally outrageous and fiscally irrational. Federal and state officials have a real opportunity to provide leadership in dealing with the opioid addiction crisis that threatens all of us and our loved ones by examining how government insurance is covering opioid recovery treatment.”

Based on the report findings, Advocates for Opioid Recovery advisors are advocating three immediate actions for federal and state government leaders:

  1. Governors should review their Medicaid policies related to medication assisted treatment and rectify any policies that are not promoting care based on clinical guidelines.
  2. Congress should direct the Medicaid and CHIP Payment and Access Commission (MACPAC) to conduct a survey and analysis of state Medicaid programs to determine the extent their coverage, reimbursement, and managed care policies support best practices in opioid addiction recovery and guidelines-based medication assisted treatment.
  3. As they revise their Medicaid managed care programs to comply with new federal managed care rules and verify plan compliance with the mental health parity law, states should require performance standards related to opioid addiction recovery and ask plans to demonstrate how their providers adhere to guidelines on opioid recovery.

Nearly 50,000 people died of accidental drug overdose in 2014, of which 29,000 were opioid related. Most people living with addiction are not receiving treatment, and when they are, they aren’t receiving the most effective care: behavioral counseling with medication. Treatment with medication is dramatically more effective than behavioral counseling alone, yet less than 30% of contemporary addiction treatment programs offer medications and less than half of eligible patients in those programs actually receive medications. The World Health Organization, UNAIDS, the United Nations Office on Drug Policy, and the National Institute on Drug Abuse (NIDA) all agree that people dependent on heroin and other opioids should have access to medication assisted treatment.

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