CDC will fi­nal­ize opi­oid prescription guide­lines

Modern Healthcare - - THE WEEK AHEAD - —Shan­non Much­more

The clock is tick­ing on new guide­lines from the Cen­ters for Dis­ease Con­trol and Preven­tion to reg­u­late opi­oid pain­med­i­ca­tion pre­scrip­tions. The CDC has been re­ceiv­ing some harsh feed­back on its strat­egy as the coun­try faces a grow­ing num­ber of over­dose deaths.

The guide­lines sug­gest that doc­tors use the small­est pos­si­ble dose of quick­re­lease opi­oids and con­sider non-opi­oid treat­ment first. They also urge pre­scribers to use urine drug test­ing on pa­tients to de­ter­mine any other drug use. The om­nibus bud­get deal in­cluded a re­quire­ment that the U.S. Veter­ans Ad­min­is­tra­tion adopt the guide­lines. The agency had planned to an­nounce the guide­lines ear­lier but re­ceived crit­i­cism for not get­ting more physi­cian and pa­tient in­put.

Sev­eral mem­bers of the House Over­sight and Gov­ern­ment Re­form Com­mit­tee sent a let­ter to CDC Di­rec­tor Dr. Thomas Frieden seek­ing more in­for­ma­tion about the 17 peo­ple the agency con­sulted with to de­velop the guide­lines. Law­mak­ers said they wanted to see the plans re­spon­si­bly ad­dress chronic pain.

A few health of­fi­cials told the Na­tional In­sti­tutes of Health’s In­ter­a­gency Pain Re­search Co­or­di­nat­ing Com­mit­tee that the CDC plan was not backed by suf­fi­cient ev­i­dence.

Pres­i­den­tial can­di­dates have been vo­cal about the ad­dic­tion epi­demic, which is hit­ting hard in some early pri­mary states. At a re­cent Demo­cratic pri­mary de­bate, all three can­di­dates said doc­tors are over­pre­scrib­ing opi­oids.

“We can­not have this huge num­ber of opi­ates out there through­out this coun­try, where young peo­ple are tak­ing them, get­ting hooked and then go­ing to heroin,” said Ver­mont Sen. Bernie San­ders.

As opi­oid over­doses con­tinue to rise across the coun­try, providers are bat­tling large in­sur­ers and phar­macy ben­e­fit man­agers that ar­gue cov­er­age of treat­ments for peo­ple with opi­oid ad­dic­tions should be left up to the pay­ers’ dis­cre­tion.

More than 28,600 peo­ple died in 2014 as the re­sult of over­doses from prescription painkillers, heroin and other opi­oids, ac­cord­ing to a re­cent anal­y­sis from the Cen­ters for Dis­ease Con­trol and Preven­tion.

Nu­mer­ous hos­pi­tal as­so­ci­a­tions, psy­chi­a­trists, pri­mary-care physi­cians, ex­ec­u­tives at drug-abuse treat­ment cen­ters and re­cov­er­ing opi­oid ad­dicts re­cently sub­mit­ted com­ments to the CMS urg­ing that all health plans sold on the fed­eral ex­change cover med­i­ca­tions that help over­come sub­stance abuse.

The Af­ford­able Care Act re­quires health in­sur­ers to cover 10 es­sen­tial health ben­e­fits, in­clud­ing prescription drugs and sub­stance-use dis­or­der ser­vices. But it has been un­clear whether plans on the fed­eral mar­ket­place must cover the full range of med­i­ca­tionas­sisted treat­ment, or MAT. Many com­mer­cial in­sur­ers pay for MAT, a ther­apy in which peo­ple com­bine med­i­ca­tion with coun­sel­ing to re­duce their crav­ing for opi­oids.

The Sub­stance Abuse and Men­tal Health Ser­vices Ad­min­is­tra­tion and the Na­tional In­sti­tute on Drug Abuse have found MAT to be ef­fec­tive for peo­ple suf­fer­ing from opi­oid ad­dic­tion. The NIDA said MAT “in­creases pa­tient re­ten­tion and de­creases drug use, in­fec­tious-dis­ease trans­mis­sion and crim­i­nal ac­tiv­ity,” and it also saves money by keep­ing peo­ple out of hos­pi­tals and out­pa­tient cen­ters.

But some providers and pa­tient ad­vo­cates say in­sur­ers have in­sti­tuted high co­pays and other bar­ri­ers that re­sult in in­ad­e­quate cov­er­age and ac­cess to the treat­ment.

Methadone and buprenor­phine, the two most com­mon drugs used in MAT, could an­nu­ally cost some­one thou­sands of dol­lars out of pocket.

SAMHSA of­fi­cials also have ar­gued there are mis­con­cep­tions and stig­mas as­so­ci­ated with ad­dicts and MAT, which could make treat­ment harder to ac­cess.

Travis Simerly and his wife are MAT pa­tients who take methadone daily, ac­cord­ing to Simerly’s com­ments to the CMS. He wrote that his in­sur­ance com­pany, Blue Cross and Blue Shield of Ten­nessee, de­nied their claim be­cause the com­pany cov­ers only buprenor­phine for ad­dic­tion treat­ment. Simerly called the cov­er­age dis­crep­ancy a “farce” and said all MAT drugs should be held to the same ben­e­fits stan­dards. Blue Cross did not im­me­di­ately re­spond for com­ment.

“Our ad­dic­tion treat­ment is by far our largest med­i­cal ex­pense, and for it to not be cov­ered by the in­sur­ance that we are re­quired by law to have is noth­ing more than a prover­bial kick in the teeth,” Simerly wrote.

Dozens of in­di­vid­ual physi­cians sub­mit­ted let­ters ask­ing the CMS to man­date that all fed­eral health plans fully cover MAT as part of the es­sen­tial health ben­e­fits.

“There is clin­i­cal con­sen­sus that MAT is the most ef­fec­tive treat­ment for opi­oid ad­dic­tion,” said Dr. Shelly Green­field, a psy­chi­a­trist at Har­vard Med­i­cal School and McLean Hos­pi­tal in Bel­mont, Mass. “The use of med­i­ca­tions re­duces opi­oid use and over­dose rates, and helps re­tain peo­ple in treat­ment longer, which is as­so­ci­ated with bet­ter out­comes.”

But the coun­try’s largest health in­sur­ers, PBMs and lob­by­ing groups want the CMS to punt the pro­posal. Amer­ica’s Health In­sur­ance Plans, the Blue Cross and Blue Shield As­so­ci­a­tion, the Phar­ma­ceu­ti­cal Care Man­age­ment As­so­ci­a­tion, Ex­press Scripts Hold­ing Co., CVS Health Corp. and Unit­edHealth­care said they shared the fed­eral gov­ern­ment’s con­cern over the “dev­as­tat­ing ef­fect of opi­oid abuse,” but they ar­gued they should not be forced to pay for spe­cific treat­ments that could curb the prob­lem.

“We are con­cerned that by man­dat­ing spe­cific ben­e­fits within an (es­sen­tial health ben­e­fits) cat­e­gory, CMS may es­tab­lish a prece­dent of im­pos­ing es­sen­tial health ben­e­fit man­dates in the fu­ture,” Blue Cross and Blue Shield wrote. “Re­quir­ing plans to cover spe­cific drugs within a cat­e­gory and class would con­flict with this care­fully es­tab­lished bal­ance be­tween cov­er­age man­dates and af­ford­abil­ity, which in turn would lead to in­creases in pre­mi­ums at a time when CMS is seek­ing to en­sure that con­sumers have ac­cess to af­ford­able cov­er­age and that there is sta­bil­ity in the mar­ket.”

The com­pa­nies and groups said the gov­ern­ment should in­stead rely on in­di­vid­ual in­sur­ers and their phar­macy and ther­a­peu­tics com­mit­tees to de­ter­mine cov­er­age for spe­cific drugs.

How­ever, the As­so­ci­a­tion for Com­mu­nity Af­fil­i­ated Plans—the trade group that rep­re­sents small safety net health plans that cover many low­in­come peo­ple—dis­agreed with the large play­ers, say­ing the in­dus­try should be prod­ded to fully cover MAT.

“ACAP plans are cog­nizant of the opi­oid ad­dic­tion epi­demic and are in­vest­ing in ef­forts to ad­dress opi­oid abuse,” the or­ga­ni­za­tion said. “We are sup­port­ive of CMS adding MAT to the es­sen­tial health ben­e­fits.”

Buprenor­phine is used as part of a

ther­apy to help peo­ple re­duce their

crav­ing for opi­oids.

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