By Rachel Swindle and Kristen Ukeomah*
While the federal COVID-19 Public Health Emergency (PHE) ended in May, the U.S. Secretary of Health and Human Services (HHS) just lately renewed the PHE declaration for the opioid disaster and the Biden administration introduced new proposed guidelines with the purpose of bettering entry to therapy. Overdose deaths—the majority of that are attributable to opioids—stay alarmingly excessive, and the reported variety of artificial opioid overdose deaths has continued to extend over the previous 12 months. Policymakers have explored quite a lot of approaches to curb this disaster and broaden entry to evidence-based therapy for individuals with opioid use dysfunction (OUD). Decades of medical analysis reveals that FDA-approved drugs for OUD (MOUD**), equivalent to buprenorphine and methadone, are the best therapy choices. Last 12 months, CHIRblog detailed among the personal insurance-related obstacles to drugs used to deal with opioid use dysfunction, in addition to federal and state initiatives to ameliorate entry points. This weblog expands and updates that data, highlighting latest federal and state-level coverage developments that goal to take away among the obstacles to this life-saving therapy for individuals with OUD.
Recent Federal Policy Changes and Proposals Aim to Improve MOUD Access
Proposed Improvements to Federal Parity Law Enforcement
Most just lately, the Biden administration proposed new regulations underneath the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008. The regulation requires parity between psychological well being and substance use dysfunction (MH/SUD) advantages and medical/surgical advantages, together with parity in therapy limits, utilization administration strategies, and cost-sharing necessities between MH/SUD-related care and medical/surgical care. But many insurers have didn’t comply with the parity necessities, and enforcement is difficult and inconsistent. The new proposed rule would require well being plans to gather information and conduct comparative analyses on supplier networks (the quantity MH/SUD suppliers in plan networks and reimbursement charges), prior authorization requests and the outcomes of these requests, and different therapy limits imposed on MH/SUD advantages. Those experiences could be made accessible to federal regulators, which can enhance the flexibility of regulators to make sure compliance with the regulation’s parity necessities–an essential step for sufferers to have significant entry to OUD therapy.
Health Insurer Provider Networks
An insufficient provide of MOUD suppliers, notably in-network suppliers, continues to complicate or preclude OUD sufferers’ therapy entry. The Centers for Medicare & Medicaid Services (CMS) is hoping to enhance therapy entry for enrollees on the Affordable Care Act’s Marketplace by including Substance Use Disorder Treatment Centers as new class of “Essential Community Provider” (ECP) for plan 12 months 2024. Insurers taking part within the Marketplace should contract with a minimal 35 p.c of ECPs throughout the plan’s service space, and in addition make a great religion effort to contract with not less than one therapy middle in every county within the service space, if accessible. This coverage is anticipated to broaden entry to substance use dysfunction (SUD) therapy, equivalent to MOUD, for the record-large inhabitants of Marketplace enrollees.
Increasing the Supply of MOUD Providers
Increasing entry to MOUD additionally requires a ample variety of suppliers who can prescribe MOUD. Previously, suppliers had been required by federal regulation to acquire an “X-waiver” with the intention to prescribe buprenorphine – some of the efficient drugs for treating OUD. In a 2020 report from the U.S. Government Accountability Office, practitioners reported that the time-intensive trainings and administrative hurdles related to securing an X-waiver discouraged some suppliers from making use of for one. Further, as soon as the waiver was obtained these suppliers had been topic to strict caps on the variety of sufferers they may deal with. The Consolidated Appropriations Act of 2023 eliminated the requirement to acquire this X-waiver in addition to the affected person caps, rising the provision of suppliers who can prescribe MOUD drugs and making it simpler for insurers to construct ample networks with MOUD suppliers. While extra could be carried out to educate potential suppliers of MOUD, eradicating the X-waiver opens the door for extra suppliers in new settings (equivalent to major care) to prescribe this evidence-based therapy.
States Take Action to Lower Insurance-related Barriers to Treatment
In addition to efforts on the federal stage, states have taken motion to scale back insurance-related obstacles to OUD therapy. Several of those state reforms, highlighted under, assist illustrate methods during which policymakers in different states may enhance affected person entry to care.
Mandating Coverage of all FDA-approved MOUD
Commercial well being plans usually don’t cowl the total spectrum of MOUD choices. Several states require well being plans to cowl not less than one of many FDA-approved MOUDs, however the drugs are supplied in several settings: some suppliers can prescribe buprenorphine, whereas methadone is just accessible at opioid therapy applications (OTPs). Plans that cowl just one MOUD depart gaps in OUD affected person entry, for instance, if the plan solely covers buprenorphine however enrollees solely have entry to an OTP. Earlier this summer season, Nevada enacted legislation mandating that state-regulated well being plans cowl all FDA-approved MOUD.
Limits on Cost Sharing
Patients proceed to report that out-of-pocket prices hinder their skill to entry wanted medical care. Those prices can mount shortly for care sought at OTPs (presently, OTPs are the one strategy to receive methadone, the medicine with essentially the most proof of efficacy). Patients are required to often test in with an in-house counselor and periodically full drug screenings. Depending on how the OTP payments for providers, these visits and lab work can topic sufferers to out-of-pocket prices on prime of their value sharing for the medicine itself. States have tackled cost-sharing obstacles in several methods. Since 2017, Massachusetts’s ACA Marketplace has required insurers providing ConnectorCare merchandise (sponsored protection accessible for individuals with incomes underneath 300 p.c of the federal poverty) to remove cost-sharing for the medicine itself in addition to any workplace visits related to MOUD therapy. In 2022, New York Governor Hochul signed laws prohibiting state-regulated plans from charging copayments for OTP visits.
Restrictions on Utilization Management
Insurers usually use utilization administration strategies to rein in prices by decreasing well being care consumption and stopping the usage of inappropriate remedies. One such method is the requirement that suppliers receive authorization from the affected person’s insurer earlier than treating or prescribing sure sorts of care. These “prior authorization” necessities may cause significantly delayed and even forgone care. For OUD sufferers, time spent ready on prior authorizations could be lethal as a result of danger of overdose. In a latest report summarizing information submitted by personal well being insurers with not less than 1% of the market share within the particular person, small- and large-group markets, Washington’s Office of the Insurance Commissioner discovered that prior authorization requests for psychological well being and substance use dysfunction therapy had been accredited at decrease charges in comparison with medical/surgical requests, and that the response wait time for MH/SUD codes is greater than twice that of medical/surgical codes—45.4 hours in comparison with 20.3 hours, respectively.
Some states have adopted insurance policies to scale back the burden of prior authorization necessities for sufferers. Since 2020, insurers in Colorado have been prohibited from utilizing prior authorization for FDA-approved drugs to deal with SUD if that medicine is included within the plan’s formulary for the therapy of OUD. Other states can go additional. Minnesota just lately enacted a regulation requiring the state’s Formulary Committee for the state’s Medicaid program to make sure not less than one type of methadone be made accessible with out prior authorization. Though the committee’s purview extends solely to Medicaid—a research final 12 months discovered that half of Medicaid beneficiaries had been subjected to prior authorization for MOUD—this coverage could possibly be replicated for the state-regulated personal market.
Prior authorization is just not the one utilization administration method that may impede care entry. Newly enacted legislation in Vermont prohibits state-regulated insurers from imposing “step therapy” necessities on enrollees with MOUD prescriptions, a course of the place sufferers should attempt an alternate medicine for his or her situation earlier than they will proceed with the initially prescribed course of therapy.
Bolstering Provider Networks and Increasing the Number of Providers for MOUD
Patients in search of therapy for OUD could be stymied by an insufficient provide of suppliers and an absence of in-network suppliers underneath their insurance coverage plan. Congress’s elimination of the X-waiver was an essential step, however some states have tried to deal with the difficulty in different methods. Colorado imposed new necessities that insurers yearly report back to the state’s Department of Insurance (DOI) on enrollees’ MOUD supplier entry, together with the variety of in-network suppliers of MOUD and the corporate’s initiatives to “ensure sufficient capacity for and access to [MOUD].” The DOI has obtained the primary 12 months of provider information from these experiences and is analyzing the findings. Some states have sought to enhance OUD therapy entry by increasing the universe of suppliers who can prescribe MOUD. For instance, by January 2024 Nevada will newly enable pharmacists to prescribe drugs to deal with OUD (and the Consolidated Appropriations Act of 2023 ensures that these pharmacists won’t face the extra burden of the necessities of the X-waiver). This offers individuals with OUD one other level of entry to provoke therapy and expands the pool of suppliers accessible to prescribe MOUD.
Conclusion
The U.S. opioid disaster continues unabated. Insurance protection considerably expands entry to well being care, however along with stigma, logistical obstacles, and affected person demographics, insurers’ profit design, supplier shortages, and insurer-provider contracting practices could make it troublesome or inconceivable for sufferers with OUD to acquire care. Federal and state policymakers are implementing reforms that broaden entry to lifesaving take care of sufferers with OUD—an essential step to assuaging and finally ending the opioid disaster.
* Kristen Ukeomah helps analysis on the Sustainability of Opioid Settlement Funds funded by the Elevance Health Foundation on the Duke-Margolis Center for Health Policy.
**Author’s word: In prior CHIRblog posts, the time period medication-assisted therapy (MAT) is used steadily. In latest years there was a shift in direction of utilizing the time period MOUD (“medications for opioid use disorder”) as an alternative of MAT. This change is a part of broader efforts by clinicians, advocates, and policymakers to scale back stigma related to MOUD and deal with the medicine itself as the important thing to therapy. More data is offered right here and right here.