Even Under the ACA, Your Health Insurer Is Playing God When It Comes To Opioid Addiction

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Recently, a 27-year-old patient who was using 10 bags of heroin and smoking marijuana daily for the past six months came to our treatment program. He was sharing needles and occasionally using Xanax. He had a history of three overdoses and reported a trauma history, having watched his friend OD and die. He was on two medications for depression and told us that he would rather put a bullet through his head than continue using. He reported driving under the influence with a history of DUIs as well as working under the influence which resulted in him being unable to hold down a job. His insurance company approved just three days of residential treatment and said that outpatient treatment would be sufficient even though he had no means of transportation and no stable living arrangements.

Here are some startling numbers: in Philadelphia recently, 50 people overdosed in one day, and there were 35 overdose deaths in five days. Western Pennsylvania had 200 ODs in one region, in one day. In Cincinnati, there were 174 ODs in six days and in Cleveland there were 46 heroin ODs in one day. Akron had 236 ODs within 20 days. And these are just a few of the headlines. Opioid use, including heroin and prescription drugs, is killing Americans at an alarming rate with devastating effects in city after city across the nation.

The U.S. population represents 4.6 percent of the world’s population, yet we consume 80 percent of its opioids. In 2012, 259 million prescriptions were written for opioids, enough for every American adult to have their own bottle of pills. And now, drug overdose is the leading cause of accidental death in the U.S. with someone dying every 19 minutes.

In the substance abuse treatment world, we have seen a significant change in who is coming in for treatment for heroin/opioid problems. Heroin is no longer just the drug of choice for people well into a 15-20-year history of substance use and abuse. Today, treatment programs are flooded with young people who have transitioned to heroin after just a few months of prescription drug abuse, when the former became cheaper than the latter.

The Affordable Care Act (ACA) resulted in more Americans having healthcare insurance, but just what kind of care are we getting?

The reality is that insurance companies frequently deny effective forms and durations of treatment for many diseases, particularly opioid abuse. The stigma of addiction as a moral failing of the weak, the impulsive, and the unmotivated – rather than the chronic disease research has proven it to be – only helps justify these decisions.

Although drug overdose is the leading cause of accidental death in this country, opiate/heroin withdrawal is not directly deadly, so most insurance companies decline to pay for inpatient detoxification or treatment. They either claim that the insured individual who is addicted to heroin or prescription painkillers does not meet the criteria for medical necessity — that inpatient care would be an unnecessary treatment — or they require that the user first try outpatient rehab and “fail” before he or she can be considered for inpatient.

Our nation’s insurance companies have erroneously cited studies that seem to suggest that patients receiving outpatient treatment, where they live at home and drive to treatment daily, do just as well as patients who receive inpatient or residential treatment, where they live at the treatment program. In actuality, in order be in those studies, every one of the patients was evaluated and determined to be able to be adequately and ethically served in an outpatient setting. Scientific studies can’t knowingly subject people to harm, or randomly assign them to a treatment that is not adequate, you see. So these patients were randomly assigned to receive one of the various treatments, but only patients who could be adequately and ethically served in an outpatient setting were included in the studies.

Insurance companies use these types of studies as justification to implement their “fail first” practice, paying only for the minimum level of care until a patient relapses/fails repeatedly and requires more treatment. Sadly, individuals with opioid problems relapse and die while waiting for adequate treatment every day.

Residential treatment offers the first part of a solution to this epidemic. Scientific studies show us that time in treatment matters and longer is better. And over and over again, studies show the best results with treatment that includes residential treatment followed by outpatient services, ongoing drug use monitoring and support groups, and some form of continuing care treatment (often just monthly check-ins or peer recovery support) for 1-5 years. This is the treatment we provide to professionals (physicians, pilots, nurses, etc.) in this country and it has a markedly higher success rate compared to “treatment as usual,” with 70-96 percent achieving long-term recovery.

As I write this, thousands of Americans continue to be denied insurance coverage for these evidence-based protocols. Could it be that residential treatment is too costly for our health insurers? Unlikely. The nation’s largest insurer, UnitedHealth Group, reported a profit of $11 billion on revenues of more than $157 billion in 2015. And company filings show that UnitedHealth’s CEO Stephen J. Hemsley made over $66 million in 2014. Kaiser Permanente reported revenues of $60.7 billion in 2015. Aetna reported annual operating revenue of over $60.3 billion in 2015, a record for the company.

It’s time that we as treatment providers deliver and the American public demand that insurers pay for transparent, effective, outcomes-based care for addiction. It’s time we stop hiding beneath a veil of shame or secrecy about addiction and bring the issue out into the open. We can keep arguing over whether to repeal or replace the ACA, but the larger issue is our standard of care and what we demand as basic human rights. Appropriate treatment for addiction, this nation’s leading cause of accidental death, doesn’t seem too much to ask.

Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.

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