First, Consider Medicaid: Report on State Opioid-Fighting Initiatives Touts Expansion

One word in 24 pages of text stands out most prominently in a newly issued report on successful state-level efforts to combat the opioid crisis: Medicaid.

The American Medical Association (AMA) and legal and policy consultant Manatt Health strongly suggest in their report that Medicaid rests on the front lines of this fight, and has often made more of a difference than private insurance in stemming opioid addiction and overdose.

In stating that case, the report's co-sponsors essentially are saying that two of the four states they focused on in their analysis (Pennsylvania and Colorado) are at an advantage in implementing solutions over the other two states they studied (North Carolina and Mississippi).

At a Sept. 9 press briefing held upon the report's release, Manatt Health managing director Jocelyn Guyer called Medicaid expansion “a key foundation” on which to build a state's response to the opioid crisis. “It can be a key step—without it, you can be missing an important tool,” Guyer said.

The report, National Roadmap on State-Level Efforts to End the Opioid Epidemic: Leading-Edge Practices and Next Steps, cites Medicaid's lead role as one of four major themes that emerged from the groups' analysis of state activity. The other themes are:

• States must be willing to use their oversight and enforcement authority. The report's authors observed that state regulators across the country vary considerably in the degree to which they have used their authority to help expand evidence-based treatment or to hold payers accountable for ensuring access to care.

• Grants are helpful, but long-term implementation needs long-term, sustainable funding. Life-saving programs will not be in place for the long haul unless reliable funding streams are identified, the report says.

• The process of evaluating what works is just starting. Comprehensive analysis of state efforts will be essential in order to direct resources toward successful initiatives.

Guyer explained during the press call that the four analyzed states were selected to reflect diversity, as well as the presence of significant activity at the state insurance regulatory agency and Medicaid agency levels in those jurisdictions. She added that the sponsors wanted to avoid looking at “usual suspects” such as Vermont, which became a pioneer in establishing a hub-and-spoke model for expanding access to evidence-based treatment for opioid addiction.

Recommended actions

The report offers six main recommendations for impactful action by state regulators, policy-makers and other stakeholders:

• Expand access to medication-assisted treatment (MAT) by removing barriers to MAT and enhancing affordability. “There is no medical or policy need that justifies delaying or denying access to MAT—particularly during an epidemic,” the report states. Last fall in Pennsylvania, state officials announced an agreement under which all major commercial insurers would cover at least one formulation of each of the three approved medication treatments for opioid dependence, with no prior authorization requirements for coverage and with placement of MAT on the lowest patient cost-sharing tier of the pharmacy benefit.

• Enforce mental health and substance use disorder parity laws. Patients cannot be expected to know whether the behavioral health services they are receiving are at parity with general health benefits, so this oversight responsibility falls on state regulators, Pennsylvania Insurance Commissioner Jessica Altman said at this week's briefing. “Parity is more than a law—it is almost a belief system,” Altman said. In Colorado, the state Division of Insurance rejected 11 market conduct examinations of insurance companies because they did not probe deep enough into the causes and effects of disparities in care, said Kate Harris, the insurance division's chief deputy commissioner. Colorado is now under a legislative mandate to ensure parity compliance as part of the insurance rate review process, Harris said.

• Enforce network adequacy requirements to ensure timely access to care. A provider network may appear adequate for treating enrollees with opioid use disorders, but states need to determine if these providers are accepting new patients. Several states have worked to build infrastructure to support MAT providers, such as in North Carolina where Project OBOT (Office-Based Opioid Treatment) involves collaborative community-based care with local physicians at the hub.

• Improve access to comprehensive pain care. Several states are working to improve access to non-opioid options for pain management. In Colorado, for example, the Medicaid program covers antiepileptics and other non-opioid pain relievers without prior authorization.

• Access to naloxone can help save lives from overdose. “The uptake of naloxone has been a public health success, but there is more that can be done,” the report states. Insurance regulators can work to ensure that the overdose reversal drug is not subject to prior authorization requirements or placed on high cost-sharing tiers of insurance benefits.

• Improve evaluation. The report suggests that while some states have taken initial steps toward broader evaluation of their opioid-fighting efforts, “...few states have initiated the kind of comprehensive policy evaluation warranted by this epidemic.”

AMA President Patrice Harris, MD, who also chairs the AMA's Opioid Task Force, stated during the briefing that while there are several evidence-based practices that are working at the state level, “There are no single magic wand solutions.”