Health Reform and the Substance Use Disorder Treatment System: A Time of Change

KEYWORDS:

• Health reform
• substance use disorder treatment

This issue of the Journal of Psychoactive Drugs appears at a time when the United States is caught in the political turmoil of the nature of health care financing reform and an epidemic of opioid use that includes the overdose deaths of thousands of individuals. The Patient Protection and Affordable Care Act (ACA) promulgated during the administration of Barack Obama has been challenged by the administration of Donald Trump and a Congress with a Republican majority. The promise of “repeal and replace” echoed in the halls of Congress and was manifest in the failed legislation of the American Health Care Act of 2017. The supporters of the American Health Care Act of 2017 promise that they will re-introduce legislation to repeal and replace the ACA. While these political debates have been going on, another issue has been holding sway over the American public: the misuse of opioids and the overdose deaths that follow.

Data from the Substance Abuse and Mental Health Services Administration (SAMHSA) revealed that, in 2015, approximately 97 million people used prescription pain relievers in the past year. Of those who used these medications, 12.5 million misused them in the past year and 3.8 million misused them in the past month (SAMHSA n.d.). That 97 million people are using controlled substances to treat pain has sparked a hue and cry to address what is too often the incautious use of dangerous medications. President Trump expressed concerns about the opioid epidemic by asking Congress to support the additional $500 million for state grants in FY2018 as proposed by the 21st Century Cures Act of 2016.¹ President Trump also, by Executive Order, created the President’s Commission on Combating Drug Addiction and the Opioid Crisis.² This new Commission will:

(a) identify and describe existing Federal funding used to combat drug addiction and the opioid crisis; (b) assess the availability and accessibility of drug addiction treatment services and overdose reversal throughout the country and identify areas that are underserved; (c) identify and report on best practices for addiction prevention, including healthcare provider education and evaluation of prescription practices, and the use and effectiveness of State prescription drug monitoring programs; (d) review the literature evaluating the effectiveness of educational messages for youth and adults with respect to prescription and illicit opioids; (e) identify and evaluate existing Federal programs to prevent and treat drug addiction for their scope and effectiveness, and make recommendations for improving these programs; and (f) make recommendations to the President for improving the Federal response to drug addiction and the opioid crisis. (The White House 2017)

Clearly, there has been a lot of activity in the realm of addressing the opioid crisis from a policy perspective. The question is whether there is a trickle-down effect that benefits communities and individuals experiencing opioid use disorders.

David E. Smith leads off the series of articles in this issue of the Journal with a discussion of the medicalization of the opioid epidemic. While the diversion of legal prescription drugs has been a problem since the inception of their use, these drugs have been embraced so much by the drug culture that clandestine labs have moved beyond heroin to embrace powerful opioid analogs such as fentanyl and carfentanil (Smith 2017). Frank and Pollack estimated that 41% of the estimated 7100 heroin deaths between 2012 and 2014 involved fentanyl (Frank and Pollack 2017). With the advent of almost unrestricted access to prescription opioids came a new demographic: white middle-class men and women in their twenties.

Smith cites David Musto’s history of opioid misuse centered on patent-based medicines in the nineteenth and early twentieth centuries containing opium, which has given rise to misuse of new prescription drugs such as Oxycontin, spawning this new wave of misusers and the subsequent wave of overdose deaths. As Smith notes, the death toll from prescription opioids is reminiscent of the death toll from HIV in the 1980s, confounded by a heavy reliance on the criminal justice system to incarcerate hundreds of thousands for substance use offenses.

In order for alternatives to incarceration to be functional, prevention, treatment, and recovery efforts need adequate funding and appropriate legislative/regulatory authorization. In addition, the primary care community needs to move to join the specialty substance use disorder (SUD) professional community. Smith’s overview reminds readers of key legislative and regulatory efforts in reaction to the epidemic level of prescription opioid use and misuse, these including the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), the Patient Protection and Affordable Care Act of 2010, the Comprehensive Addiction and Recovery Act of 2016 (CARA), and 21st Century Cures Act of 2016. Although political, the reform of the ACA is still a work in progress; these acts attempt to increase access to SUD treatment by reducing cost barriers associated with the delivery of such services. The question is whether these strategies are actually working.

In this issue of the Journal of Psychoactive Drugs, Reif et al. examine how commercial health plans managed coverage for treating of opioid use disorders—including by opioid treatment programs covered as a treatment service benefit and buprenorphine covered as a pharmacy benefit—before, during, and after MHPAEA and ACA implementation. Reif et al. look at health plan products which include the health maintenance organization (HMO), preferred provider organization (PPO), and point of service (POS) products; they look at three time frames: 2003, 2010, and 2014. They also note that, in 2010, consumer-directed products (CDP) (i.e., those products that have high deductibles and health savings accounts) were common. Other techniques, such as prior authorization, in which the provider or enrollee needs to obtain approval for treatment prior to admission in order for the health plan to pay for care, limits on the length of time service is provided, and continuing review are used by health plans to manage cost and access to treatment.

Reif et al. found that treatment options for opioid use disorders were covered by nearly all private health plan products over the time period of their survey. They also observed that there was a decrease in methadone-specific coverage, which was attributed to the growing use of buprenorphine. In their discussion, Reif et al. note that coverage for both OUD treatment services and medications is necessary to begin to address the opioid crisis.

Knudsen and Studts, in this issue, recognize that the ACA used a number of approaches to extend the reach of insurance: (1) the individual mandate requiring that all Americans purchase health insurance; (2) the requirement that large employers offer affordable insurance; (3) the establishment of health insurance exchanges; and (4) Medicaid expansion to individuals with incomes under 138% of the federal poverty level. In an earlier article, Knudsen et al. described an observational study of the United States, revealing that the rates of growth in the supply of buprenorphine-waivered physicians differed by state-level approaches to the ACA. In fact, states that made an early commitment to both expand Medicaid and to establish state-based insurance exchanges had a greater growth in their total supply of waivered physicians than states that did not embrace Medicaid expansion or state-based insurance exchanges (Knudsen et al. 2015). Access to medication-assisted treatment using buprenorphine depends on the perceptions of physicians (and since the CARA act, nurse practitioners and physician assistants). In the Knudsen and Studts article in this issue, a large national sample of physicians expressed ambivalence about the ACA; the physicians in this sample, on average, did not conclude that the ACA had improved buprenorphine treatment access (Knudsen and Studts 2017). Knudsen and Studts point out that insurance plans vary in terms of co-pays, deductibles, and premiums; they recommend research to address the impact of these issues. One further point that needs to be considered is the view by those suffering from opioid use disorder (OUD) and other SUDs involving the lack of perception of need for treatment.

Where Knudsen and Studts captured the ambivalence of physicians about the impact of the ACA on treatment utilization, Danovitch and Kan propose an addiction benefits scorecard as a framework to promote health insurer accountability and consumer engagement (Danovitch and Kan 2017). Danovitch and Kan’s article describes using criteria developed by the American Society of Addiction Medicine to assess addiction services covered by plans: (1) screening, brief intervention, and referral to treatment (SBIRT); (2) outpatient services; (3) intensive outpatient services; (4) residential services; (5) inpatient services; (6) pharmacy benefits; and (7) methadone maintenance/buprenorphine. Moving beyond their broad categories, the study data were summarized and packaged in a patient-facing document published by the California Society of Addiction Medicine in December 2014 as “The Consumer Guide and Scorecard: Health Insurance Coverage in California for Substance Use Disorders & Mental Health,” a 20-page report designed for readability and clarity.

Danovitch and Kan are correct; consumers are rarely in a position to advocate for themselves when it comes to specific benefits. Without some guidance about what constitutes adequate SUD benefits, trying to select a plan means evaluating, on their own, the types of addiction services offered, the level of coverage, and the differences among the plans. Keep in mind that plans in the health insurance marketplace in the four “metal” categories differ in cost sharing. Those individuals who buy Bronze coverage must pay 40% of the cost, those with the Silver plan pay 30% of the costs, those with Gold plans pay 20% of the cost, and those with Platinum plans pay 10% of the cost (Healthcare.gov n.d.). So, while a Bronze plan generally has a low monthly premium, the subscriber will have to pay for most routine care. Without some mechanism to judge the quality of a health plan based on individual risk and need, the consumer is left uncertain. The scorecard discussed by Danovitch and Kan produced an overall ranking of the 16 Bronze-level plans available through Covered California in 2014. However, such a scorecard needs to be updated annually and should reach beyond Bronze-level plans.

Coverage alone does not create access to appropriate SUD or OUD care. It is important to ask about SUD treatment programs and how they are adapting to the ACA. Lydia Aletraris et al. look at SUD treatment programs from two perspectives. First, a nationally representative sample of SUD treatment programs was examined to determine if the ACA has facilitated an alignment with its goals (Aletraris, Roman, and Pruett 2017). Second, a random sample of treatment programs was examined to determine Medicaid and private insurance acceptance (Aletraris, Edmond, and Roman 2017).

In their first report, Aletraris reported that they found an increase in the percentage of treatment referrals from other health care providers, an increase in the number of physicians for programs that did have a physician on staff, and an increase in counselors certified in treating alcohol and drug addiction. What is interesting is the question of what kind of treatment services should be provided to patients engaged in care? There was a decrease in support for the 12-step model and an increase on the emphasis on a medicalized model, but this decrease was modest, leaving the 12-step model greater than the medical model. Still, these data show that reimbursement may drive care, leaving the question of appropriate care open for consideration.

In their second report, Aletraris et al. looked at the readiness of SUD treatment programs to change to accommodate the ACA. Among other things, they found that newly insured individuals under the ACA may have difficulty finding a program that accepts insurance. Treatment centers with greater resources will be better equipped to invest in insurance billing systems and evolve as the health care sector changes. For example, larger programs have greater staffing and technological resources to devote to insurance billing and coordinated care. Others have found that Medicaid acceptance is more common in large programs

What Aletraris et al. found in their two studies was presaged by the experience in Massachusetts. Quinn et al. share the experiences of Massachusetts treatment providers, both under Massachusetts reform and subsequently under the ACA (Quinn et al. 2017). Quinn et al. noted increased admissions, increase in the number of services offered, increased use of pharmacotherapy, and an increase in acceptance of private insurance. However, programs for seniors, LGBTQ and criminal-justice-involved individuals decreased. After the learning curve of Massachusetts reform, programs operating under the ACA were propelled into making administrative and systems changes. All but one of the organizations surveyed was working with a local community health center on coordination and integration initiatives. However, many organizations are participating in integrated care models that lack sustainable funding. It is clear that health reform such as embodied in the ACA can result in systems transformation.

Conclusion

“He, who pays the piper, calls the tune.” This issue of the Journal of Psychoactive Drugs captures the essence of system transformation catalyzed by the Affordable Care Act. Efforts to repeal and replace the ACA can put the efforts to expand and integrate SUD treatments on hold. If a replacement to the ACA occurs that does not reinforce the importance of SUD treatment, then those in need of services will be left to their own devices. The 10 essential benefits of the ACA include mental health and SUD treatment. Abandoning a mandatory benefit package could mean abandoning access to substance use treatment for those with SUDs. While the political limelight is on OUDs, it is important to recognize that alcohol use disorders, stimulant use disorders, marijuana use disorders, and other SUDs require a treatment system that has a workforce trained to diagnose, treat, and facilitate the recovery of those adversely affected by substance use. The notion that medication alone can treat the spectrum of co-occurring conditions associated with a chronic condition like an SUD is disingenuous. Without adequate reimbursement, the SUD treatment system can only cater to those who have the resources to pay out of pocket. And, as David E. Smith points out in his article in this journal, African Americans, Hispanics, those who are financially stressed, and those with co-occurring disorders will be left to fend for themselves. We are at the cusp of addressing SUDs in an appropriate way. If partisanship can be set aside and public health elevated, appropriate solutions can be found.

Notes

¹ https://www.gpo.gov/fdsys/pkg/BILLS-114hr34enr/pdf/BILLS-114hr34enr.pdf

² https://www.whitehouse.gov/the-press-office/2017/03/30/presidential-executive-order-establishing-presidents-commission