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Are we making it too hard to get proper opioid addiction treatment?

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Illinois

Frequent denials of payment for substance-abuse and mental-health services in Illinois are creating unnecessary barriers to treatment despite an ongoing opioid crisis, a report released Tuesday says.

“This raises a lot of red flags,” Kelly O’Brien, executive director of The Kennedy Forum Illinois, said during a news conference. The not-for-profit group released the 16-page report with partners that included the Illinois Association for Behavioral Health and the Illinois Health and Hospital Association.

Three out of four treatment providers responding to the non-scientific survey in late 2016 and early 2017 said managed-care companies serving patients on Medicaid denied paying for a range of services either sometimes, often or always.

About 60 percent of those providers said Medicaid managed-care companies always or often denied payment for inpatient treatment.

And when patients were covered by private, commercial insurance plans, nearly half of the plans denied coverage for inpatient mental health and addiction at least sometimes, according to the treatment providers.

* Tribune…

As part of a current overhaul of Illinois’ Medicaid managed care program, the state will include language in its contracts with insurers addressing the need to cover mental health, addiction treatment and medical conditions comparably, Hoffman said. Medicaid managed care organizations also will be required to prove their compliance with those laws, he said.

However, Jeff Myers, president and CEO of Medicaid Health Plans of America, said the report should be taken with a “big grain of salt.” He doesn’t think Medicaid managed care organizations are denying coverage for mental health and addiction treatment services any more than other insurers. He also criticized the way the data was collected, as part of a self-reported survey.

The report’s authors acknowledged in the report that it’s somewhat limited because the nearly 200 Illinois medical practices and organizations that responded to the survey aren’t necessarily representative of all mental health and addiction treatment professionals across the state.

David Lloyd, policy director for the Kennedy Forum Illinois, called the report a “valuable starting point,” providing “more information than we had before.”

* Mark Brown has a really good column about this (of course) that you ought to read in full about the mother of a young man who was addicted to opioids. Here’s one point…

What bothers her even more is the belief that her son would still be alive today if health insurers had made it less difficult for him to access the proper treatment for his mental health problems.

“I think I would have celebrated his 25th birthday,” she said.

Obviously, I can’t speak to whether that’s truly the case, but I believe there’s a lot of truth in her related observation: “They make it real hard for people to get help.”

* The numbers do bear it out, but I’d just make one tiny caveat. This is from the press release with numbers from the actual study in brackets…

Upwards of 75 percent of responding providers reported that Medicaid MCOs sometimes/often/always denied coverage for inpatient treatment [57 percent often, 2 percent always], partial hospitalization [40 percent often, 2 percent always], intensive outpatient treatment [33 percent often, 4 percent always], and medication-assisted treatment [16 percent often, 6 percent always]. Nearly half of responding providers reported commercial insurers at least sometimes denied inpatient treatment.

More than 60 percent of responding providers reported that Medicaid MCOs sometimes/often/ always refused to cover the requested level of care and instead approved only a lower level of care [19 percent often, 5 percent always], while 54 percent of responding providers reported commercial insurers did the same [19 percent often, 8 percent always].

With Medicaid MCOs, nearly 65 percent of responding providers reported that they were told often or always that networks were simply closed. Nearly half of responding providers were told this often or always with commercial plans. The result: with mental health and addiction care providers unable to join plan networks, patients have more difficulty accessing care, due to the narrow network.

More than 90 percent of responding providers report that both Medicaid MCOs [24 percent often, 9 percent always] and commercial plans [21 percent often, 9 percent always] have refused to provide requested medical necessity criteria, despite clear legal requirements that plans do so.

“Sometimes” is most definitely “always” if this happens to you or a loved one. And the numbers for “often” and “always” are way too high on their own. But we need a more thorough, scientific study, particularly since the governor is drastically expanding MCOs for Medicaid. The opioid crisis is all too real and it won’t get any better if we’re not helping people who need it.

posted by Rich Miller
Thursday, Sep 21, 17 @ 10:34 am

Comments

This is the kind of thing that leads to legislation that mandates certain medical expenses be covered by insurance. It’s mind-boggling that insurance companies would act this way. Perhaps it is time for a legislative solution if the insurance companies won’t fix this problem themselves.

Comment by Demoralized Thursday, Sep 21, 17 @ 10:41 am
This probably is indicative of problems, but a survey of providers should always come with a grain of salt. They tend to get, frankly, hysterical about everything, and quite often don’t know or bother trying to know why something got rejected. I’m sure that’s going to sound condescending but it’s true, a lot of providers, especially smaller providers with less resources, just don’t bother following up on a lot of claims and fixing whatever was wrong with the claim. Sure some of that is just bureaucratic baloney from the insurer, where they likely are throwing up road needless roadblocks, but a lot of the time the fault legitimately lies with the provider for rejected claims. Like Rich said, you need a more objective and complete study to draw conclusions from.

Comment by Perrid Thursday, Sep 21, 17 @ 10:46 am
Opioids addicition and deaths are the biggest public health crisis, but the insurance industry wants nothing to do with it. They just want their 30% off the top.

Comment by wordslinger Thursday, Sep 21, 17 @ 10:53 am
With all respect, @Perrid - This is getting to be an old story and the facts have not been changing.

The problem is very real and the “facts” ( even if you consider them anecdotal and non-scientific ) fairly well speak for themselves.

This state, and this country, has a major crisis that has to be dealt with and NOW, not later after more studies.

Comment by illini Thursday, Sep 21, 17 @ 11:00 am
Too bad insurance doesn’t cover medical marijuana. That would help cut way back on use of opioids.

Comment by SAP Thursday, Sep 21, 17 @ 11:12 am
there are a lot of reasons not to like the Graham Cassidy bill, and coverage is key for mental health and addiction treatment. also, costs for insurance for those with prior existing conditions like cancer could skyrocket, and essentially be a death sentence. Troubling that care for addiction NO, dispensing drugs that cause addiction YES. insurance is a financial operation, not a healthcare operation. that needs to change.

Comment by Amalia Thursday, Sep 21, 17 @ 11:13 am
So much stigma, so much dogma, such dire consequences. There is excellent data that structured opioid substitution (best done with methadone) decreases deaths, increases employment, restores families, etc. But it is vastly underused.

Comment by Groundhog Day Thursday, Sep 21, 17 @ 11:23 am
The workers’ comp system is overprescribing opioids in this state, and it’s been proven over and over by the WCRI. Why the Illinois Policy Institute is the only group pointing this out is beyond me.

Comment by Anonymous Thursday, Sep 21, 17 @ 11:26 am
=Demoralized= it’s mind boggling? It is the business model.

Comment by NoGifts Thursday, Sep 21, 17 @ 11:28 am
We are making the transition from addiction as a moral failing to a medical condition much too slowly. This month’s National Geographic has an excellent article about current research on addiction. http://www.nationalgeographic.com/magazine/2017/09/the-addicted-brain/

Until we fully accept this as a medical condition, big gaps will remain in coverage.

Comment by Pot calling kettle Thursday, Sep 21, 17 @ 11:30 am
@illini, I agree with you, behavioral health issues are avoided like the plague for a lot of reasons. I can agree with the overall trend without agreeing with all of pieces of evidence that are put forth.

Comment by Perrid Thursday, Sep 21, 17 @ 11:45 am
=== “Sometimes” is most definitely “always” if this happens to you or a loved one. And the numbers for “often” and “always” are way too high on their own. ===

I’m confused Rich. Isn’t this a survey of the providers? They are the ones who are filing the claims and dealing with the insurers. They are actually in a pretty good position to judge whether opioid treatment claims are being denied frequestly, especially compared to other claims denial rates.

If the insurers want to dispute the numbers, they should just open their books and tell us how much they are paying out, how much they are denying.

Comment by Free Set of Steak Knives Thursday, Sep 21, 17 @ 12:14 pm
“I’m sure that’s going to sound condescending but it’s true, a lot of providers, especially smaller providers with less resources, just don’t bother following up on a lot of claims and fixing whatever was wrong with the claim.”

Can someone explain why providers would fail to follow-up and fix “a lot of claims” when those claims determine whether or not they get paid? Am I supposed to believe that low-resource providers would just choose not to be paid for the services they provided? Why?

While I’m willing to be convinced otherwise, Occams Razor (and business sense) would suggest that the payment problem originates with the insurance companies (payors) rather than the service providers (payees).

– MrJM

Comment by @MisterJayEm Thursday, Sep 21, 17 @ 12:45 pm
The response rates for the survey listed on page four of the report seem pretty low and that could amplify negative responses. For example, of1331 providers surveyed only 123 responded. It seems to me the 15% responding would very likely be made up of the providers having the most challenges and we don’t see what’s going on with the providers that may have seen this and felt they didn’t have any issues or the issues were not big enough to make time to do the survey.

To Mr JM I think the question is a good one but I think it’s not clear in the survey if they have issues billing and they get a few billing denials based on either their or the insurance company’s error would that constitute multiple denials even if the payment eventually got through and the patient actually received the care without ever seeing a barrier.

Comment by Anonymous Thursday, Sep 21, 17 @ 1:05 pm
There is some good news: behavior health treatment is on the cusp of innovation. Online treatment is becoming more common and is much less expensive. Teladoc believes that 78% of the 131 million behavioral health visits a year could be treated through telehealth. Teladoc has provided over 100 million patient visits since they were founded, with 95% member satisfaction and with NCQA certification.
In Illinois, Prevail Health Systems treats online thousands of vets with PTSD with efficacy that is peer-reviewed and published, and with prices that are a tenth of traditional therapy. Regroup Therapy arranges online sessions for its extensive network of behavioral health professionals.
(I have stock in Teladoc and occasionally provide advice to Prevail.)

Comment by Lurkin' MBA Thursday, Sep 21, 17 @ 2:15 pm
You want the insurance companies to pay for opioid addiction treatment? Start pushing cannabis legalization in earnest. Watch how fast they come around.

Comment by Neophyte Thursday, Sep 21, 17 @ 2:23 pm