Looks like major changes are coming for those seeking treatment for drug and/or alcohol treatment.
Looks like some of these changes will significantly affect Alcoholics Anonymous.
Insurers Pushing For Changes In Substance Abuse Battle
By Mara Lee
July 11, 2016
Hartford- Facing a surge in substance abuse claims partly because more 19- to 26-year-olds have insurance major insurers are trying to use their leverage to make dramatic changes in the nation's substance abuse treatment system.
Insurance companies are pushing reforms that include encouraging suboxone-assisted recovery rather than abstinence, limiting pain-pill prescriptions and evaluating treatment programs based on their own outcomes.
While alcohol remains the biggest substance-abuse problem, the proportion of claims that include opioids is climbing steadily, particularly among young adults and teenagers.
Cigna reports that opioid claims went from 20 percent of substance-abuse cases five years ago to 25 to 30 percent today. At Aetna over the last four years, the share of claims for treating drug and alcohol abuse has gone from 15 percent of mental health spending (outside of prescriptions) to 30 percent.
The jump in claims has led, in part, to closer scrutiny by insurers of treatment methods and outcomes.
"The current approach to substance-use disorder treatment is based largely on the Alcoholics Anonymous 12-step model, which doesn't take into account that 40 percent to 60 percent of substance abuse is attributable to a person's genetic makeup," Cigna CEO David Cordani wrote recently in an online essay when he called for comprehensive treatment, including medication, therapy and family support.
Instead, research shows, suboxone, methadone and vivitrol which reduces cravings for alcohol have all been proven to do more to curb substance abuse than aiming for abstinence through counseling, though relapses do still happen with all three.The insurers point to evidence that shows the benefits of combining medication with more traditional treatments. For example, the federal government's Office of Drug Policy says that starting treatment with a detox period is dangerous, because those programs "are closely associated with relapse," and with lower tolerance, the next dose of narcotics can result in a deadly overdose.
"The scientific literature is very clear on this that medication-assisted treatment is much more successful short term and long term than not using medication,'' said Dr. Mark Friedlander, Aetna's Chief Medical Officer for Behavioral Health for commercial plans.Suboxone is a medication that blocks the euphoric effects of heroin or narcotic painkillers while preventing withdrawal symptoms. It is similar to methadone, but can be taken at home, rather than in a clinic.
Medication Assisted Treatment
About eight years ago, Cigna began to question why so few addicts were being treated with methadone, suboxone or vivitrol.
"Even within Cigna, those patients who had been maintained on suboxone had a very significant decrease in the number of hospitalizations and having to re-enter treatment," said Dr. Doug Nemecek, Cigna's Chief Medical Officer for Behavioral Health. The company found "a negligible rate of re-admissions for people had been treated with suboxone over six months, versus those who had no medicine."
Recently, Cigna and Aetna supported a successful campaign that convinced the federal government to lift a cap on the number of suboxone prescriptions a psychiatrist is allowed to write. Doctors who have been subscribing suboxone for at least a year had been limited to treating 100 recovering opioid addicts. The government announced Wednesday that the cap will be raised to 275.
At Aetna, Friedlander, said the cap was one factor making it hard to get patients into treatment. But, he said, "part of it is these guys [psychiatrists treating addicts] prefer not to join the network." He said many psychiatrists "establish a cash practice on the side" for the drug.
Cigna has the same problem with suboxone prescribers refusing to submit claims. Reimbursement from insurers typically is lower than what the prescribers can charge. "To some degree it's getting better, but still is a major problem in some markets," Nemecek said.
Friedlander said suboxone is popular because "you're going to your doctor's office. It's not a methadone clinic, which, unfortunately, tend not to be in the best part of town."
The insurers also found that some counselors are opposed to medication-assisted rehabilitation, which is one of the reasons methadone and suboxone aren't used in the majority of cases, despite evidence of their effectiveness.
Nemecek said some addiction counselors are former substance abusers who quit without medication, and so they think their clients can do it, too. He described this attitude as urging addicts "to just take control and just beat this condition, rather than looking it as truly a medical condition."
Friedlander agreed. "One of the frustrations for me, as a health plan medical director, is seeing facilities that have great reputations that have a philosophical barrier to evidence-based medicine almost a faith-based approach."
But Aetna will pay the bills at a treatment center that does not incorporate vivitrol, methadone or suboxone. Friedlander said the company's goal is to create "Institutes of Quality" in this area so that Aetna policy holders will have lower co-pays if they go to a place that incorporates maintenance medicine.
"The difficulty for us, unlike like say some of the medical procedures, is that very few of these facilities accurately track outcomes," Friedlander said, such as how many people stay clean for a year.
Prevention
According to the federal Opioid Initiative, 80 percent of new heroin users started out by misusing opioid pills. Both the government and insurers have begun discouraging doctors from prescribing so many pain pills, especially at longer durations.
Connecticut just passed a law that requires doctors to document why there needs to be a refill after an initial seven-day prescription, unless the patient has chronic care, cancer, or is at the end of life.
The federal Centers for Disease Control and Prevention noted that one in 550 patients died from opioid-related overdose, with half dying within 2.6 years of their first opioid prescription. The CDC says that a combination of exercise and cognitive behavioral therapy is more effective for chronic pain than taking opioids for a year or more. But, the agency noted, "Multimodal therapies are not always available or reimbursed by insurance and can be time-consuming and costly for patients."
The CDC told doctors they should "be explicit and realistic [with patients] about expected benefits of opioids, explaining that while opioids can reduce pain during short-term use, there is no good evidence that opioids improve pain or function with long-term use, and that complete relief of pain is unlikely."
Aetna's Friedlander said that, in 2012, the insurer started talking to dentists about overprescribing pain pills, and now it has an initiative where it identifies doctors whose pain-pill prescribing patterns "are way above average." He said doctors are defensive when Aetna calls to tell them this. "They argue our data, they say 'your data's wrong. You don't understand.'" But months later, when analysts run the numbers again, they see those doctors are prescribing less.
Nemecek said Cigna is trying to work with primary care doctors to encourage them to steer patients that complain of pain into physical therapy, or cognitive behavioral therapy if appropriate.
"There's also a culture in our society we believe there are pills that will take care of everything that's wrong with us," he said.
Inpatient Denials
The insurers' desire to shift substance-abuse treatment spending to evidence-based programs also affects inpatient programs that typically have followed the detox route.
"Long-term, intensive recovery facilities have become the norm, even though there is very little evidence of their comparative effectiveness,'' Cigna's CEO Cordani wrote in his recent online essay. "Thirty-day inpatient programs can cost anywhere from $15,000 to $26,000, with some charging more than $100,000."
Connecticut Healthcare Advocate Demian Fontanella said last year there were 32 complaints about insurers denying longer stays for substance abuse, with the majority of the cases including opioid addiction. He said he thinks that doesn't capture the scope of the problem, because every time he does a talk, two or three people in the audience say they or a relative was denied longer inpatient treatment for opioid addiction.
Fontanella said that while the Office of the Healthcare Advocate tries to make sure that mental health treatment is treated the same as physical health, there's no direct parallel to make the case of what the right amount of inpatient or outpatient treatment is.
"I sincerely empathize with the folks at the carriers," Fontanella said. "I think they're doing what they can to help people stay in the right setting for the right amount of time."
Fontanella said about 80 percent of people who abuse alcohol or drugs have an underlying mental health condition like anxiety or depression, which makes treating the addiction more complex. Unless the person figures out a better way to deal with his feelings, it is very hard for him to avoid the numbing they sought in the first place through alcohol or drugs.
In the future, Cordani says insurers will make decisions based on what works and not merely past practice.
"Treatment for substance-use disorders will include only what is proved to be effective and efficient such as shorter-term outpatient programs, personalized care and education for individuals and their families,'' he wrote.
Looks like major changes are coming for those seeking treatment for drug and/or alcohol treatment.
Looks like some of these changes will significantly affect Alcoholics Anonymous.
Insurers Pushing For Changes In Substance Abuse Battle
By Mara Lee
July 11, 2016
Hartford- Facing a surge in substance abuse claims partly because more 19- to 26-year-olds have insurance major insurers are trying to use their leverage to make dramatic changes in the nation's substance abuse treatment system.
Insurance companies are pushing reforms that include encouraging suboxone-assisted recovery rather than abstinence, limiting pain-pill prescriptions and evaluating treatment programs based on their own outcomes.
While alcohol remains the biggest substance-abuse problem, the proportion of claims that include opioids is climbing steadily, particularly among young adults and teenagers.
Cigna reports that opioid claims went from 20 percent of substance-abuse cases five years ago to 25 to 30 percent today. At Aetna over the last four years, the share of claims for treating drug and alcohol abuse has gone from 15 percent of mental health spending (outside of prescriptions) to 30 percent.
The jump in claims has led, in part, to closer scrutiny by insurers of treatment methods and outcomes.
"The current approach to substance-use disorder treatment is based largely on the Alcoholics Anonymous 12-step model, which doesn't take into account that 40 percent to 60 percent of substance abuse is attributable to a person's genetic makeup," Cigna CEO David Cordani wrote recently in an online essay when he called for comprehensive treatment, including medication, therapy and family support.
Instead, research shows, suboxone, methadone and vivitrol which reduces cravings for alcohol have all been proven to do more to curb substance abuse than aiming for abstinence through counseling, though relapses do still happen with all three.The insurers point to evidence that shows the benefits of combining medication with more traditional treatments. For example, the federal government's Office of Drug Policy says that starting treatment with a detox period is dangerous, because those programs "are closely associated with relapse," and with lower tolerance, the next dose of narcotics can result in a deadly overdose.
"The scientific literature is very clear on this that medication-assisted treatment is much more successful short term and long term than not using medication,'' said Dr. Mark Friedlander, Aetna's Chief Medical Officer for Behavioral Health for commercial plans.Suboxone is a medication that blocks the euphoric effects of heroin or narcotic painkillers while preventing withdrawal symptoms. It is similar to methadone, but can be taken at home, rather than in a clinic.
Medication Assisted Treatment
About eight years ago, Cigna began to question why so few addicts were being treated with methadone, suboxone or vivitrol.
"Even within Cigna, those patients who had been maintained on suboxone had a very significant decrease in the number of hospitalizations and having to re-enter treatment," said Dr. Doug Nemecek, Cigna's Chief Medical Officer for Behavioral Health. The company found "a negligible rate of re-admissions for people had been treated with suboxone over six months, versus those who had no medicine."
Recently, Cigna and Aetna supported a successful campaign that convinced the federal government to lift a cap on the number of suboxone prescriptions a psychiatrist is allowed to write. Doctors who have been subscribing suboxone for at least a year had been limited to treating 100 recovering opioid addicts. The government announced Wednesday that the cap will be raised to 275.
At Aetna, Friedlander, said the cap was one factor making it hard to get patients into treatment. But, he said, "part of it is these guys [psychiatrists treating addicts] prefer not to join the network." He said many psychiatrists "establish a cash practice on the side" for the drug.
Cigna has the same problem with suboxone prescribers refusing to submit claims. Reimbursement from insurers typically is lower than what the prescribers can charge. "To some degree it's getting better, but still is a major problem in some markets," Nemecek said.
Friedlander said suboxone is popular because "you're going to your doctor's office. It's not a methadone clinic, which, unfortunately, tend not to be in the best part of town."
The insurers also found that some counselors are opposed to medication-assisted rehabilitation, which is one of the reasons methadone and suboxone aren't used in the majority of cases, despite evidence of their effectiveness.
Nemecek said some addiction counselors are former substance abusers who quit without medication, and so they think their clients can do it, too. He described this attitude as urging addicts "to just take control and just beat this condition, rather than looking it as truly a medical condition."
Friedlander agreed. "One of the frustrations for me, as a health plan medical director, is seeing facilities that have great reputations that have a philosophical barrier to evidence-based medicine almost a faith-based approach."
But Aetna will pay the bills at a treatment center that does not incorporate vivitrol, methadone or suboxone. Friedlander said the company's goal is to create "Institutes of Quality" in this area so that Aetna policy holders will have lower co-pays if they go to a place that incorporates maintenance medicine.
"The difficulty for us, unlike like say some of the medical procedures, is that very few of these facilities accurately track outcomes," Friedlander said, such as how many people stay clean for a year.
Prevention
According to the federal Opioid Initiative, 80 percent of new heroin users started out by misusing opioid pills. Both the government and insurers have begun discouraging doctors from prescribing so many pain pills, especially at longer durations.
Connecticut just passed a law that requires doctors to document why there needs to be a refill after an initial seven-day prescription, unless the patient has chronic care, cancer, or is at the end of life.
The federal Centers for Disease Control and Prevention noted that one in 550 patients died from opioid-related overdose, with half dying within 2.6 years of their first opioid prescription. The CDC says that a combination of exercise and cognitive behavioral therapy is more effective for chronic pain than taking opioids for a year or more. But, the agency noted, "Multimodal therapies are not always available or reimbursed by insurance and can be time-consuming and costly for patients."
The CDC told doctors they should "be explicit and realistic [with patients] about expected benefits of opioids, explaining that while opioids can reduce pain during short-term use, there is no good evidence that opioids improve pain or function with long-term use, and that complete relief of pain is unlikely."
Aetna's Friedlander said that, in 2012, the insurer started talking to dentists about overprescribing pain pills, and now it has an initiative where it identifies doctors whose pain-pill prescribing patterns "are way above average." He said doctors are defensive when Aetna calls to tell them this. "They argue our data, they say 'your data's wrong. You don't understand.'" But months later, when analysts run the numbers again, they see those doctors are prescribing less.
Nemecek said Cigna is trying to work with primary care doctors to encourage them to steer patients that complain of pain into physical therapy, or cognitive behavioral therapy if appropriate.
"There's also a culture in our society we believe there are pills that will take care of everything that's wrong with us," he said.
Inpatient Denials
The insurers' desire to shift substance-abuse treatment spending to evidence-based programs also affects inpatient programs that typically have followed the detox route.
"Long-term, intensive recovery facilities have become the norm, even though there is very little evidence of their comparative effectiveness,'' Cigna's CEO Cordani wrote in his recent online essay. "Thirty-day inpatient programs can cost anywhere from $15,000 to $26,000, with some charging more than $100,000."
Connecticut Healthcare Advocate Demian Fontanella said last year there were 32 complaints about insurers denying longer stays for substance abuse, with the majority of the cases including opioid addiction. He said he thinks that doesn't capture the scope of the problem, because every time he does a talk, two or three people in the audience say they or a relative was denied longer inpatient treatment for opioid addiction.
Fontanella said that while the Office of the Healthcare Advocate tries to make sure that mental health treatment is treated the same as physical health, there's no direct parallel to make the case of what the right amount of inpatient or outpatient treatment is.
"I sincerely empathize with the folks at the carriers," Fontanella said. "I think they're doing what they can to help people stay in the right setting for the right amount of time."
Fontanella said about 80 percent of people who abuse alcohol or drugs have an underlying mental health condition like anxiety or depression, which makes treating the addiction more complex. Unless the person figures out a better way to deal with his feelings, it is very hard for him to avoid the numbing they sought in the first place through alcohol or drugs.
In the future, Cordani says insurers will make decisions based on what works and not merely past practice.
"Treatment for substance-use disorders will include only what is proved to be effective and efficient such as shorter-term outpatient programs, personalized care and education for individuals and their families,'' he wrote.
I dunno. I can see how these ideas might have an effect on for-profit inpatient rehab facilities, but I don't see how any of this "threatens to affect AA".
AA has always been for people who have either tried everything else already and ran out of options, or the lucky ones who found it earlier, discovered that it worked for them, and didn't have to look further. I don't see how the changes described here would affect that.
This will not affect AA. It seems to be an article about narcotics, I know there are people with opiate problems which attend AA and maybe they are on suboxone or something similar, but if you can abstain without drugs I think you should try that way, otherwise you will be dependent on drugs your whole life. AA works for those who work it.
This will not affect AA. It seems to be an article about narcotics, I know there are people with opiate problems which attend AA and maybe they are on suboxone or something similar, but if you can abstain without drugs I think you should try that way, otherwise you will be dependent on drugs your whole life. AA works for those who work it.
It's about all substance abuse, Bunchie. Alcoholism treatment is the part most of us would be interested in. Alcoholism treatment is the biggest share of the substance abuse problem.
Looks like the main drivers for future change in treatment selection for alkies (and addicts) may be cost-related. That makes a ton of sense. It's much cheaper to give an alcoholic a detox, a monthly shot of Vivitrol and a suggested aftercare of a few AA meetings than to run him or her through a 28 day rehab.
The article is saying that will be more efficacious than what is being done now. That is probably correct, possibly even if future patients skip the AA meetings.
I smell money. I think I will buy some drug company shares. Real good business, repeat business. Look at the tobacco companies. Almost every medical solution has spawned its own 12 step fellowship. I even spotted antidepressants anonymous the other day.
I don't think these guys are being honest. They talk evidence based. The first rule of that is to establish the starting point, which is never done, except in AA. The first pioneers of AA were all medically diagnosed as hopeless. Now a more honest physician, and head of research in these matters states that there is a small percentage of alcohol use disorder sufferers at the severe end of the scale (that's me) for whom there is still no medical solution and for whom the only solution is some kind of conversion experience or what AA calls a spiritual experience. There has been no real progress in finding a medical solution for these people since about 1967. I don't smell money behind this information.
The stuff these insurers are talking about is harm (read cost) minimisation, a pretty second rate recovery at best. That would not be attractive for the likes of me, I hate pills anyway, But I would probably give it a try if I thought I could get a decent result without all the God stuff. And I would probably fail.
