Saying that Pennsylvania cannot arrest its way out of the opioid epidemic, Attorney General Josh Shapiro this week laid out a 10-point plan that pushes for changes in health-insurance coverage for addiction treatment.
Shapiro's arguments — from expanding the number of treatment days covered to reimbursing organizations that hire certified recovery specialists to work with drug users — will likely be welcomed by families that have been frustrated in getting coverage for substance-abuse treatment.
His authority over the issue is somewhat limited, however. Shapiro has direct oversight of nonprofits, whose charitable missions are defined by law; about a quarter of residents with commercial insurance are enrolled in nonprofit plans, a state insurance department spokeswoman said. The agency can also refer egregious violations by any insurer for prosecution by the Attorney General's Office. And, as Shapiro pointed out, in his new position as the state's chief law enforcement officer, he has a bully pulpit.
"This is our No. 1 public safety challenge in Pennsylvania, bar none," Shapiro said in a short speech before a panel on opioids Tuesday that was sponsored by the Independence Blue Cross Foundation.
Many of Shapiro's arguments reflect mainstream thinking on the opioid crisis, but families have complained for years about the problems he seeks to address, and change has been slow. Treatment providers say insurance companies put up roadblocks to coverage, both intentional and not.
"They do crazy things like call in and say, 'Your patient has been in detox for a day. Has he improved?' " said Deb Beck, president of the Drug and Alcohol Service Providers Organization of Pennsylvania, pointing out that inpatient detox can take between three and 15 days, depending on the severity of addiction and how many drugs were involved.
Shapiro's plan is to:
Increase the number of plans covering substance-use disorder treatment.
Expand the days of treatment covered.
Increase mental-health coverage by enforcing parity requirements.
Remove preauthorization for addiction treatment.
Add preauthorization for opioid prescriptions.
Write initial opioid prescriptions for briefer periods.
Cover all medication-assisted treatments (the maintenance medicines methadone and Suboxone and the opioid-blocker Vivitrol).
Increase access to alternative pain treatments such as chiropractic, acupuncture, and treatment-related massage.
Encourage doctors to become certified to prescribe Suboxone.
Reimburse certified recovery specialists.
Beck applauded the list but said nuances are important. She worried, for example, about more physicians prescribing the treatment medication Suboxone, which is intended to work alongside behavioral therapy, but is often given alone and can be abused. And just maintaining the current level of coverage is in question, with President Trump and the Republican-controlled Congress pushing to roll back the Affordable Care Act as well as Medicaid entitlements, both of which have paid for significant amounts of addiction treatment.
"I am happy to see the AG recognize that the best way to treat addiction is to prevent it," said Samuel Marshall, president and CEO of the Insurance Federation of Pennsylvania, which represents insurers other than the nonprofit Blues. He suggested that "special consideration be given to opioid abuse in workers compensation," where "opioid prescriptions are uniquely high."
Richard Snyder, chief medical officer at Independence Blue Cross, said he generally agreed with Shapiro's recommendations, some of which are consistent with changes IBC has been making. Beginning July 1, for example, initial opioid prescriptions will be limited to five days — a duration chosen in part to coincide with a New Jersey law that Gov. Christie signed in February – and require preauthorization. Commercial insurance historically has not covered methadone treatment despite its availability as a cheap generic, Snyder said, but IBC expects to start on Aug. 1.
Both Snyder and Shapiro served on Mayor Kenney's opioids task force, although a surrogate represented the attorney general at meetings. The panel's final report, issued last week, contained some of the same recommendations, but also called for exploring supervised injection sites for heroin users. Shapiro did not address that issue on Tuesday, and a spokesman said later that he does not support them.