Anthem to change opioid treatment policy under deal with NY regulators

Anthem, the nation's second-largest insurance company, has ended its policy of pre-authorizations for drugs to treat opioid use disorder following an agreement with New York Attorney General Eric Schneiderman, his office said Thursday.

The agreement, which affects Anthem plans across the United States and Empire Blue Cross Blue Shield customers in New York, followed an investigation into Empire's practices in New York.

A similar deal was reached between the attorney general's office and the insurer Cigna in October.

“We’re facing an opioid crisis in New York and around the country — and we should be doing whatever we can to make lifesaving treatments accessible to those suffering from addiction,” Schneiderman said.

Anthem announced Wednesday that it is working with its affiliated health plans to double the number of consumers who receive behavioral health services as part of medication-assisted therapy (MAT) for opioid addiction. Anthem also said it hopes to reduce the amount of opioids given to members by 30% from their peak levels by the end of 2019.

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As for the NY investigation, Anthem spokeswoman Lori McLaughlin says it was "one of several factors, including internal and external research," that prompted the company to change its prior authorization approach.

"This decision was just one component of Anthem’s overall strategy in the fight against opioid abuse," she said in an email. "We appreciate the Attorney General’s attention to this critical issue."

MAT drugs usually contain buprenorphine and naloxone and can be prescribed and given to patients in doctors’ offices as long as the physician has the appropriate certification and federal license.

While methadone and buprenorphine both reduce cravings and stabilize the brain so the person can think clearly and benefit better from counseling, methadone has to be administered in highly-structured clinics.

Psychosocial therapy and medical treatment are also recommended for patients receiving MAT.

Anthem required doctors to submit prior approval forms to request coverage for MAT to answer "numerous questions about the patient’s current treatment and medication history," according to Schneiderman's office. The doctors had already gotten specific training regarding MAT and had federal authorization to prescribe drugs.

Doctors and advocates say often time-consuming pre-authorizations for MAT increase the risks of overdose and death. Schneiderman’s office noted Anthem didn’t require patients to go through the time consuming pre-authorization process for highly addictive pain medications including fentanyl or oxycodone.

The company also doesn't require prior authorizations for most of the drugs it covers for medical conditions. New York and federal mental health parity laws require health plans to cover mental health and substance use disorder treatment the same way they cover treatment for physical conditions.

The investigation also found Empire BCBS denied nearly 8% of overall requests for MAT coverage in 2015 and the first half of 2016. This led to significant delays in patients obtaining treatment for addiction if they received it at all, the office said.

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Physician Teresa Koeller, St. Elizabeth Healthcare medical director of addiction medicine in Northern Kentucky, called the announcement "huge."

“We need to get prior-authorizations for everybody," she said. "This will definitely help."

New patients may not realize they have to call the doctor’s office for a new prior-authorization, she says.

“Patients in early recovery don’t have the ability to juggle their lives," Koeller said. "They may lack the basic life skills.”

Even later, when patients are working on multiple issues, such as education, job-hunting and paying debts, calling the doctor’s office is put off, Koeller said, which can lead to dangerous delays.

Anthem was actually often more receptive than many insurance companies when it comes to medication assisted treatment, said Mina “Mike” Kalfas, a doctor and certified addiction specialist in Northern Kentucky for Christ Hospital outpatient services.

A few years ago, Kalfas said, Anthem required opioid disorder patients to start with the pill form of a medication that blocks the effects of heroin and opioids called naltrexone.

That presents problems: those who are prescribed the pills often stop taking them, which puts them at risk for overdose, he says. Kalfas was prescribing injectable naltrexone, which is given in a shot once a month. That keeps the patients safer for a longer period and allows for accurate dosage, he said.

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Anthem said it determined in the last year that only about 16 to 19% of its members taking MAT medications for opioid use disorder also were getting the recommended in-person counseling. Last year three Anthem-affiliated health plans in the northeast began working on improvements to its medical coding and reimbursement for psychiatrists and non-psychiatrist medical doctors who are certified to support MAT treatment.  Anthem is also working to attract more doctors who aren't psychiatrists to help ensure members get counseling while receiving their drug therapy.

"While we’ve made progress, there are too many still suffering," said Schneiderman, "We’re committed to continue working with health insurers across the country to eliminate barriers to lifesaving opioid addiction treatments.”

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