Officials with the Kennedy Forum—a mental-health advocacy group that former Rep. Kennedy found in 2013—noted other challenges to the Parity Act in a December Health Affairs blog post they co-wrote. Such challenges include that coverage criteria for medical/surgical benefits are often considered proprietary, so comparisons with mental health treatments are impossible, and that benefit denials don’t contain enough information for consumers to submit an appeal.
“All of these issues are exacerbated by growing pains as regulators, health plans, providers, and patients work out their rights and responsibilities under the law,” they wrote.
Those conclusions dovetail with the key findings in the Addictions Solutions Campaign report, which include:
- Regulators cannot conduct an assessment of compliance by reviewing insurance forms because the forms lack required information.
- Consumers are not informed of their rights under the Parity Act, so they cannot determine if access-to-treatment standards are being met.
- Prescription drug formularies contain “wide discrepancies in the coverage of, and restrictions on, medications for the treatment of addiction.”
“What regulators can learn from form review regarding a plan’s compliance with the Parity Act is insufficient to ensure that consumers get the coverage they are entitled to under federal law,” the report states. And for patients who seek treatment for substance-use disorders, “the plan documents reviewed do not fully identify the services that are covered and all requirements that may affect admission into care.”
New approaches needed
The Addictions Solutions Campaign’s report recommends that:
- The burden of proof for compliance be placed on insurers.
- Regulatory agencies develop model contracts that describe substance-use and mental health benefits and inform consumers of their rights.
- Regulatory agencies enhance providers’ “to identify potential Parity Act violations and advocate for plan compliance in network adequacy and rate setting standards.”
“With better enforcement of the Parity Act, consumers will begin to receive the substance-use services that they are paying for in their insurance coverage,” the report concludes.
Dr. Harris called increased access to treatment “an essential component of reversing the nation’s opioid epidemic,” adding that she hopes the report will spur action by insurers and regulators.
“When a patient seeking care for an opioid-use disorder is forced to delay or interrupt ongoing treatment because of a health plan utilization management coverage restriction—such as prior authorization—that can be harmful to their care and health,” Dr. Harris said. “With respect to opioid-use disorders, that could mean relapse or death from overdose.”
Opioid prescribing down
Earlier this month, the Centers for Disease Control and Prevention (CDC) published data showing opioid prescribing rates fell by 13.1 percent between 2012 and 2015.
The CDC report reinforces the importance of doing “more to provide evidence-based, comprehensive treatment for pain and for substance use disorders,” Dr. Harris said. That could be accomplished, she said, “by implementing the National Pain Strategy and reducing barriers to all modalities for treating pain, as well as by narrowing the treatment gap for addiction so that all patients who need it can access medication-assisted treatment.”
Physicians also should keep leading in “efforts to reverse the epidemic by using prescription drug-monitoring programs, eliminating stigma, prescribing the overdose-reversal drug naloxone, and enhancing their education about safe opioid prescribing and effective pain management,” she said.
These are among the recommendations of the AMA Opioid Task Force, which earlier this year issued a progress report in these areas.
The AMA offers online CME to expand your understanding of the opioid epidemic. Explore educational content such as "A Primer on the Opioid Morbidity and Mortality Crisis: What Every Prescriber Should Know."