Wisconsin’s Opioid Agenda Misses Health Insurance Parity

By Selahattin Kurter, MD & Robert Miranda

Wisconsin has established itself as a proactive state in fighting opioid addiction. With Governor Walker’s initiatives, 30 pieces of legislation to fight the opioid crisis have been signed as part of the Heroin, Opiate Prevention and Education (HOPE) Agenda. Such initiatives allow immunity for people contacting authorities to help someone suffering an overdose, the “Good Samaritan Law,” and developed the Wisconsin Prescription Drug Monitoring Program (PDMP).  Also, pharmacists can now dispense Naloxone, the medication that reverses the effects of an opioid overdose, without requiring individual prescriptions.

In January 2018, Wisconsin Medicaid increased reimbursement for outpatient mental health and substance use disorder treatment. Additionally, Governor Walker signed an executive order creating a commission to study the hub-and-spoke model, which integrates resource centers and community services for addiction treatment. Some of these initiatives appear to be working, as the number of prescribed opioids in Wisconsin have dropped more than 20 percent between 2015 to 2017.

However, as a reflection of the urgent nature of this crisis, the rate of opioid overdoses has increased, doubling the past decade. The rates of heroin and synthetic opioid overdoses, such as fentanyl, have quadrupled since 2010 because of the increasing use of intravenous opioids rather than opioid pain pills. Far more opioid overdoses are occurring because of heroin and fentanyl related opioids compared to opioid pain pills. Milwaukee county’s drug overdose rate almost tripled the homicide rate last year.

The federal government has demanded equity and more provider participation in substance abuse treatment with the Mental Health and Addiction Parity Act, which requires that health insurers provide coverage for substance abuse treatment equal to medical and surgical benefits.  The Substance Abuse and Mental Health Services Administration (SAMHSA), at the direction of the Trump administration, has reinforced the importance of evidence-based treatment for opioid addiction, such as Medication Assisted Treatment (MAT). MAT has been shown scientifically to reduce the cycle of cravings, use, and eventual overdose with opioids.

Innovative treatments, such as oral or injectable buprenorphine commonly called and branded as “Suboxone,” and others such as Vivitrol injections and Methadone, have all been shown effective at reducing illicit opioid use and overdose risk.  As a prescriber and an educator for over a decade of MAT, I have personally seen the dramatic improvements in patients’ lives and substantial reductions in overdose death risk, leading more patients to reintegrate as functioning members of society. 

Yet, with effective treatments available such as MAT, health insurers are continuously and systematically placing roadblocks for patients and providers of substance abuse treatment.  Insurers are limiting substance abuse treatment by unnecessary medical authorizations, excessive paperwork, arbitrary and nonstandard treatment guidelines, restrictive quotas on urine drug screens, and reduced reimbursement rates to substance abuse health providers. 

A December 2017 report conducted by the actuarial firm Milliman, Inc. and commissioned by the Bowman Foundation independently analyzed insurance claims by 42 million Americans. The findings paint a stark picture of restricted access to mental health and substance abuse treatment, as they identified a pattern of behavior by insurance companies that forces patients to use costly out-of-network substance abuse care compared to medical benefits.  The report points to potential violations of federal and state parity laws, as does another study by economist Dr. Tami Mark. Her study reviewed the claims of 30 million patients and found that insurers are not following parity with patient access to in-network providers and by providing lower pay for mental health and substance abuse psychiatrists compared to medical doctors for the same service.

To improve access to treatment and fundamental change to the opioid crisis, Governor Walker should galvanize his opioid agenda to address the lack of substance abuse parity with health insurers. State regulators should conduct audits of insurers and impose fines on those that sell non-compliant plans, and Wisconsin’s Office of the Commissioner of Insurance should be more empowered to investigate parity violations and resolve matters decisively, compared to today’s ineffectual and bureaucratic office. In the last several years, the New York Attorney General has sued and reached settlements with several health insurers for wrongly denying coverage for mental health issues and drug treatment, resulting in millions of dollars in fines and changes in their discriminatory practices.

Wisconsin’s Attorney General, Brad Schimel, has been aggressively fighting the opioid crises, campaigning on the issue during his re-election, with increased law enforcement to prosecute drug crimes. However, his office has not sought legal enforcement action for health insurer parity.

Wisconsin is making strides in denting the opioid epidemic. With the HOPE bills and a State administration that is aggressive in addressing the rising opioid death rate, we are starting to see a trend towards decreasing prescription opioids. However, the most effective course out of this epidemic is more evidence based treatments and enforcement of health insurance parity laws.  Providers need to be empowered to treat patientsand be assured they are not hamstrung by discriminatory and illegal insurance practices that limit treatment access and reimbursement.

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