The Mental Health Parity and Addiction Equity Act, passed in 2008, was intended to balance the scales of insurance coverage for mental and physical illness. Despite that federal law, though, some healthcare insiders say that mental illnesses are still being dealt with relatively unfairly by insurance companies.
For example, the use of prior authorizations.
Sam Muszynski, director of health care systems and financing at the American Psychiatric Association, describes prior authorizations as a means for health insurers to restrict what they’ll pay for, and he claims that insurers require them more often with mental health and addiction treatments than with other medical care.
Are prior authorizations in opioid treatment too-steep hurdles at the worst time?
When it comes to addiction treatment for opioid use disorder, prescription medications like Suboxone are shown to have promising results (along with counseling). However, some insurance companies enforce requirements that make obtaining the drug, or staying on it long-term, challenging. Because prior authorizations can take days or even weeks to procure, patients may experience an initial wait to get the medication after it’s prescribed. Those early days of opioid withdrawal are often physically and mentally excruciating; without the benefit of the prescribed drug, the odds of relapse are heightened.
“You may lose that opportunity right then and there,” Muszynski notes of the patients who know they will not receive Suboxone or will be forced to wait for it. “They may never come back.”
And some insurers require a new prior authorization to be obtained just a few months after the initial one. This puts the patient at risk of running out of the medication during the treatment, and without Suboxone, the symptoms of withdrawal would set in.
To further underscore the disparity between coverage for mental and physical conditions: some insurance plans do not require prior authorizations for insulin treatments for diabetes, but do for Suboxone.
“It’s just totally unfair,” Muszynski says. “There’s a continuing pattern of discrimination, which results in reduced access to people who need opioid addiction treatment.”
Medicaid enforcing prior authorization in almost every state
According to Muszynski and policy analysts with the federal Substance Abuse and Mental Health Services Administration (SAMHSA), the prior-authorization requirement for addiction medication is used extensively in this country. Indeed, the 2013 data shows that Medicaid required prior authorizations for the active ingredient in Suboxone (buprenorphine) in a total of 48 states. Chris Carroll, director of healthcare financing at SAMHSA, doubts that that number has improved in the three years since the data was collected. He describes prior authorizations and similar limitations on addiction treatment as “the dark shadows of the insurance industry.”
Clare Krusing is press secretary with America’s Health Insurance Plans, a trade association representing the health insurance community. She states that prior authorizations are intended to help patients get appropriate care and, despite prevailing assumptions, are not intended to restrict treatment for opioid addiction.
“Prior authorization is not just arbitrarily applied,” she says. “Plans look at what the clinical guidelines are. A plan is going to make sure that before a drug is prescribed, the patient meets those guidelines.”
Addressing the parity law, she points out the prior authorizations required for buprenorphine are in keeping with the parity law in light of the fact that underlying treatment plans for addiction and other chronic illnesses (like diabetes) vary in the first place.
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