The Blues

 

This letter was published in the Raleigh News & Observer last week, about insurance coverage for treatment of opioid use disorder. It was written by Alex Gertner, an MD/PhD student at University of Chapel Hill’s School of Medicine and the Gillings School of Global Public Health.

I know Alex from his participation in UNC’s Project Echo, a program designed to connect new providers of office-based buprenorphine treatment with more experienced providers, for assistance and support. The goal of UNC ECHO is to get more primary care physicians and physician extenders to prescribe buprenorphine, so that people wanting treatment can get it more easily.

 

The opioid overdose epidemic continues to devastate North Carolina communities, even though effective treatments for opioid addiction exist that allow individuals to lead healthy, fulfilling lives. During this crisis, you might think that North Carolina’s largest private insurer would be helping as many people into treatment as possible, but that is unfortunately not the case.

As a medical student researching the opioid epidemic, I spend time in addiction clinics and talk with addiction providers from across the state. A complaint I hear from these providers is that Blue Cross and Blue Shield is making it harder for their patients to access treatment.

Buprenorphine is the main drug used to treat opioid addiction in office-based settings, like primary care offices. BCBS requires providers to request prior authorization to start buprenorphine. These prior authorizations can require days of back-and-forth discussions until approval, during which time a person seeking treatment is at risk of overdose. Sometimes authorizations are denied even after appeals from providers.

Part of the reason for these denials are BCBS’s criteria for approval, which conflict with evidence and best practices. As the criteria state, BCBS may deny a person buprenorphine if that person is using illicit drugs. But illicit opioid use is a symptom of addiction. That is like denying someone insulin because they have high blood sugar. The American Society of Addiction Medicine says that the use of addictive drugs only should not be a reason to suspend opioid addiction treatment.

BCBS will also deny buprenorphine if its thinks someone isn’t following a “psychosocial treatment plan,” such as counseling. Unfortunately, many communities across the state don’t have addiction counselors who take insurance. What’s more, evidence shows that counseling helps some people who get buprenorphine, but not others. Even if someone would benefit from counseling but isn’t getting it, that doesn’t justify withholding a medication that could save their life.

Office-based buprenorphine treatment doesn’t work for everyone. Some people need more specialized clinics known as opioid treatment programs. I called several of these programs and was told that BCBS rarely pays for this type of treatment. One provider told me people with BCBS seeking care at opioid treatment programs are better off being uninsured, because then they could access public funds to pay for treatment. Imagine if, at the height of the AIDS epidemic, insurers didn’t cover treatment at specialty HIV clinics. Drug overdoses are now claiming more lives than HIV at the height of the AIDS epidemic.

There are other ways in which BCBS is making it harder to get treatment, such as denying certain dosage formulations or charging high cost-sharing. Such actions may appear minor, but every disruption in treatment can lead to a potentially deadly relapse.

In contrast to BCBS, North Carolina’s Medicaid program covers treatment at opioid treatment programs and stopped requiring prior authorizations for the most common formulations of buprenorphine.

I wrote to BCBS to share these concerns. It said it follows CDC and FDA criteria for approving treatment. In fact, no CDC or FDA criteria recommend withholding buprenorphine because of illicit drug use or lack of psychosocial support. Federal recommendations stress the importance of access to opioid treatment programs.

The reason why BCBS applies such strict criteria may lie in a different part of BCBS’s response: “The street value of these products are high and these medications are used by addicts to maintain functionality between abuse, thus perpetuating the epidemic. A similar rationale is used for why we place prior authorization on extended release opiates.” It is true that buprenorphine has a street value, but that’s largely because it’s so hard to find treatment. Research shows that illicit buprenorphine use is mainly driven by attempts to self-treat addiction.

The use of the term “addict” in BCBS’s response is also troubling. The Office of National Drug Policy has stated that terms like “addict” can negatively affect perceptions of people suffering from addiction.

BCBS should end prior authorizations for commonly prescribed formulations of buprenorphine, align its approval criteria with best practices, and start covering opioid treatment programs. The opioid overdose epidemic is the public health challenge of our generation. How and whether North Carolina will emerge from this epidemic will depend in large part on BCBS’s response.

Read more here: http://www.newsobserver.com/opinion/article212771774.html#storylink=cpy

When I compare Alex’s vision and concern for such important health issues, I can’t help but to think of my days as a medical student. My concerns were narrow; I only cared about getting through medical school and into a good residency. But Alex is already working on an issue that’s so important to this country.

As you can tell from Alex’s letter to the editor, he understands the issues and eloquently advocates for Blue Cross/Blue Shield to deliver better assistance for patients with opioid use disorder. After I read his letter, the only thing I can say is “Amen!” All of the issues he listed have happened to my patients.

I pray Alex decides to work in the field of Addiction Medicine. We need him.

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6 responses to this post.

  1. Posted by Mary Anne Hughes on June 18, 2018 at 7:23 pm

    Wow! So well researched and written. I say we send an agent out to Alex right away to recruit him on for “our team”. He already sounds like a MVP candidate. Thank you both for putting this out for all to read!

    Reply

  2. Posted by Kelly Pfeifer on June 19, 2018 at 3:16 am

    Hello
    I am so glad you wrote about this issue.

    We fought pretty hard in California, and Blue Shield of California (and other plans) removed PA for buprenorphine a couple of years after our Medicaid program did.
    The California Society of Addiction Medicine wrote a paper on the negative effects of PA on access, in case it is useful to you.

    All my best
    Kelly

    Kelly Pfeifer, MD
    Director, High-Value Care
    California Health Care Foundation
    510 587-3133

    Reply

  3. Posted by Sean McKinnon on June 23, 2018 at 3:02 pm

    It’s heart breaking that people pay good money for insurance and then can’t access the most effective treatment for opioid use disorders.

    Luckily BCBS of Massachusetts covers my OTP care 100% no cost sharing, no referrals, no prior authorizations, no copays, no billing. Thank god they do!

    Reply

  4. Posted by Sara Koenig on June 24, 2018 at 5:08 pm

    So glad you posted this! And yes, we need Alex and more thoughtful people like him in the field 🙂

    Reply

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