New ASAM Policy Statements Support the Role of Physicians in Addiction Treatment

In April, the ASAM Board of Directors approved two new public policy statements that address the role of physicians in the treatment of addiction. The Public Policy Statements on Patient Review and Restriction (PRR) Programs and the Inclusion of Addiction Specialist Physicians in Managed Behavioral Health Care Organization In-Network Provider Panels support the direct input of an addiction specialist in the treatment of a patient’s addiction when faced with insurance and regulatory barriers. These new policy statements will guide ASAM’s advocacy efforts with federal and state regulators and commercial insurers. 

Public Policy Statement on Patient Review and Restriction Programs
The first statement addresses a practice that State Medicaid programs and commercial insurers have been using to combat prescription drug misuse. Patient Review and Restriction (PRR) programs, also known as pharmacy “lock-in” programs allow payers to restrict a patient to a single designated provider, pharmacy or both if their claims indicate they may be at risk of prescription drug misuse. The federal regulation that authorizes Medicaid to establish these programs gives broad discretion to states to determine whether and how they are implemented, and there is wide variability in how the programs are structured among the states and payers that use them. 

The PPC decided that it was necessary for ASAM to take a position on the use of these programs because of the potential unintended consequences and little evidence of their effectiveness. While the public policy statement provides recommendations for policymakers and payers in the case that they proceed with implementing PRR programs, the PPC was adamant that ASAM urge extreme caution towards their use for the protection of the patient. “The implementation of a PRR program without physician input relinquishes professional judgement regarding a patient’s health in favor of a bureaucratic, one-size-fits-all approach,” says Dr. Yngvild Olsen, Chair of the PPC. “The potential for unintended consequences to the patient’s health is high if the circumstances of each unique patient’s clinical needs are not assessed by a trained professional.” The statement advocates for alternative, evidence-based practices that keep the care of the patient in the physician’s hands, such as increased use of state Prescription Drug Monitoring Programs, improved FDA regulations and monitoring, increased access to addiction treatment, ready access to naloxone and increased education on the disease for prescribers.

Public Policy Statement on Inclusion of Addiction Specialist Physicians in Managed Behavioral Health Care Organization In-Network Provider Panels
The second statement approved addresses the inclusion of addiction specialists in managed behavioral health care networks. Many insurers carve out coverage for mental health and addiction to a separate behavioral health managed care organization (MBHCO) that specializes in managing patients with mental health conditions and addiction. Many addiction specialists can’t contract with the mental health insurer to be part of the network because the rules for joining that network are too restrictive; often only psychiatrists and non-physician mental health providers can be in-network. These rules limit the number and type of in-network providers, making it difficult to see someone like an addiction medicine specialist who specializes in pain and addiction or an obstetrician who can oversee addiction treatment for a pregnant patient. It can also increase out-of-pocket costs for a patient by making them go out of network for addiction treatment, which usually has a higher cost-sharing requirement or no coverage at all. 

Additionally, MBHCOs often restrict the services that can be billed to therapy and medication management. Most addiction specialists use evaluation and management (E/M) codes to bill for a patient encounter, not therapy or medication management codes. Even if a provider can join a network, they won’t be able to receive payment if they can’t bill for the services they are providing. As a result, non-psychiatrist addiction medicine physicians are often excluded from participating in MBHCOs. 

This public policy statement supports changes to insurance rules that limit access to board-certified addiction specialist physicians. If certified physicians can be part of the MBHCO provider network, then more patients can access addiction treatment, thus saving lives and reducing overall health care costs. Dr. Jamie Redwing, an ASAM Fellow, is an addiction medicine physician who practices at a Pennsylvania hospital. Dr. Redwing has firsthand experience with the negative consequences caused by the exclusion of addiction specialist physicians from MBHCOs. “I exclusively see patients with addiction as I’m board certified with a primary specialty in addiction medicine and a secondary specialty in pain medicine, but I am blocked by many insurers because I am not a state authorized “mental health provider” despite the fact that I have taught addiction medicine and pain medicine at the medical school where I was a fellow,” says Dr. Redwing. “If I were to be included in MBHCO in-network provider panels, I would be able to see even more patients suffering from addiction and be able to bill for my services rather than be confined to the very few work environments where I can be paid indirectly through my employer. This is a serious matter in the face of the multitudes of patients needing skilled physicians, the well-known plight of veterans like myself and the scarcity of physicians who are cross-trained in addiction and pain at the fellowship level. The patients I currently see have to pay higher co-pays or have to pay in full for my services before they hit a deductible. By addressing this consequence we can increase access to addiction treatment by no longer forcing patients to go out of network for treatment, thus decreasing overall health care costs.”

These statements will be helpful tools as ASAM advocates for patient access to high-quality addiction treatment, and we urge members to use them in your own advocacy with State Medicaid programs and commercial insurers as well. You can find all of ASAM’s public policy statements using our Find a Policy Statement search engine on our website. If you have an interest in learning about the work of the PPC or would like to join the committee, please contact Brad Bachman at 301-547-4107 or bbachman@asam.org.