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Insurers Moving Toward Paying For Methadone Treatment
By Susan Gonsalves Sunday, February 22, 2015
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As of July 1, 17 leading health insurers will cover methadone treatment for opioid addiction.

The move adds another "tool in the toolbox" to address a growing statewide epidemic, said Lora Pellegrini, president and CEO of the Massachusetts Association of Health Plans (MAHP).

By expanding coverage, the organization's member plans are displaying their commitment to improve access to a form of treatment that has been proven clinically effective, but has not been largely available outside of state addiction programs and clinics, she said.

In the past, Medicaid Managed Care Organizations and some plans have covered inpatient and outpatient services as well as methadone and other medication-assisted treatment (MAT) such as Suboxone and Vivitrol. However, commercial plans have not typically extended coverage for maintenance care.

Dr. Joel Rubinstein, medical director for behavioral health at Harvard Pilgrim HealthCare, noted that the insurer covered Methadone in the past as part of inpatient detox treatment.

However, outpatient Methadone maintenance has historically been delivered as part of a publicly funded program through public clinics, he said.

"But as part of dealing with this crisis, we want to do our part for our members who are struggling to overcome opiate addiction," he said.

Dr. Michael Hirsh, medical director in Worcester's division of public health, said that the expansion of coverage is "certainly great news," for the addicted population as well as the physicians attempting to care for them.

The state and region has long been cognizant of the growing number of people addicted to opioids — which include heroin and prescription drugs like oxycodone, codeine, methadone and fentanyl.

According to the Massachusetts Department of Health, between 2000 to 2012, the number of unintentional fatal opioid overdoses increased by 90 percent — to 668 deaths.

Data from the DPH's Bureau of Substance Abuse Services shows that nearly half of all people receiving treatment in the publicly funded system reported opioids as their primary or secondary drug of choice in FY13.

Additionally, nearly 40 percent of the individuals served in the BSAS system were ages 13 to 29.

Closer to home, a "rash of awareness," occurred last August, when the city experienced nine overdose deaths in one week, the medical director said.

Dr. Hirsh said his department has worked hard training first responders like EMS, police and fire personnel in the distribution of Narcan, an opioid antidote that reverses overdoses.

Worcester has not had any overdose fatalities since last fall, he added.

The issue is also a high priority on the Community Health Improvement Plan (CHIP) that takes a multi-pronged approach — aiming for improved access, education, first responder training and more.

"This access (to coverage for Methadone) is very important for Worcester," Dr. Hirsh said. "At Spectrum Health, 1,500 people a day get MAT for addictions. And those people should be applauded for trying to use those techniques to stay in recovery."

Dr. Sarika Aggarwal, chief medical officer at Fallon Heath noted, "Fallon remains committed to finding solutions for the ongoing opioid crisis, which is both economically and physically debilitating for the person struggling, their loved ones and the community."

According to a MAHP spokesperson, patients who could not get access to methadone through addiction clinics were responsible for co-payments or out-of-pocket costs.

Sharon Torgerson, director of public relations at Blue Cross Blue Shield Massachusetts, not a member of the MAHP, said that the insurer has provided Methadone coverage for the past decade and works with providers to make the option accessible to patients.

She referred to Blue Cross Blue Shield's current policy for methadone treatment and detoxification that notes that methadone maintenance is processed as a medical benefit, and therapy consists of detoxification up to 180 days, followed by maintenance therapy, and then detoxification from maintenance.

The policy further states that BCBS covers only direct patient treatment. Take-home dosing is not covered unless the methadone dosing facility has a pharmacy contract (such as at a hospital).

Ms. Torgeson described the results of BCBS's pain medication safety program, designed to reduce the risk of prescription painkiller addiction.

The health plan's initial review showed that more than 30,000 members received prescriptions for painkillers lasting for more than 30 days — which increases the risk for addiction. Additionally, the review found that thousands of members were receiving combination prescriptions containing acetaminophen at potentially harmful levels.

After 18 months of safeguards, claims for long-acting opioids such as OxyContin decreased by 50 percent, as providers switched to short-acting medications and an estimated 6.6 million fewer doses were prescribed.

"Addiction to narcotics and other substances is insidious and that's why we need to remain laser focused on preventing addiction before it happens," said Dr. John A. Fallon, BCBS Massachusetts senior vice president and chief physician executive in a written statement.

A focus on preventative measures is also key at Tufts Health Plan, said Dr. Thomas Amoroso, a medical director. Tufts, a member of MAHP, has covered methadone in the past and will continue to do so, he said, emphasizing that controls are in place to provide coverage "while mitigating misuse and abuse."

Acknowledging that methadone has a good track record of success, Dr. Amoroso said that prevention is a necessary complement to treatment.

"There needs to be a better model (of treatment) for pain so that we treat pain appropriately while at the same time not inadvertently creating more addicts," he said.

He added that it's important to create better opiate "diversion tools," to determine who is getting them at pharmacies and identify patterns of abuse and develop ways to intervene when necessary.

Dr. Amoroso referred to Tufts' Prescription Monitoring Program as a tool for their prescribers and said they'd advocate efforts to connect monitoring programs across state lines, and allow health plans access to the program "on a limited and authorized basis" to help identify members who may need intervention from physicians and benefit from substance abuse treatment.

"Basic prevention saves all the trouble and heartache caused by addiction, not to mention the expense of treatment," he said.





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