Amid COVID-19 Crisis, ASAM Calls on Health Plans to Provide Fair, Complete Coverage and Payment for Addiction Treatment
Rockville, MD – In a new public policy statement released today, the American Society of Addiction Medicine (ASAM) calls on all health plans to provide robust and equitable coverage of addiction prevention and treatment services. Specifically, the statement calls for all public and private payers to 1) treat addiction care as an essential health benefit, 2) cover the entire continuum of clinically effective and appropriate services as defined by The ASAM Criteria or other nationally recognized clinical guidelines, 3) provide addiction treatment coverage at true parity with benefits that cover general medical illnesses, and 4) develop medical necessity criteria for addiction treatment that follow generally accepted standards of care.
The policy statement covers a wide range of recommendations – including those specific to private health insurance benefit design, pharmacy benefit management, and high deductible insurance plans – and comes as COVID-19 disproportionately impacts patients with substance use disorder (SUD) and magnifies existing coverage and payment problems in addiction care.
“COVID-19 has broadly exposed – and indeed, exacerbated – the significant structural weaknesses in America’s current addiction treatment system,” said Paul H. Earley, MD, DFASAM, president of ASAM. “Coverage and payment policies for addiction treatment were unjust and insufficient long before this pandemic, but the current crisis puts the situation at a dangerous tipping point. Patients are relapsing due to treatment delays and access issues. Families face the untenable choice of getting help for their loved ones or avoiding crushing medical debt. Addiction medicine doctors across the country are struggling to keep the lights on to serve their communities. The already precarious addiction treatment foundation is cracking, and reforms are desperately needed now.”
The historical separation of addiction and mental health treatment services from mainstream medical care has created a patchwork coverage and payment system that exists today despite recent legislative reforms, such as the Affordable Care Act, designed to improve coverage. Addiction treatment services are still frequently carved out of health insurance policies and managed by separate behavioral health plans, indicative of a prevailing stigma that perpetuates barriers to patient care.
Even with health insurance, access to affordable, evidence-based addiction treatment is not guaranteed. Too often, needed care is compromised by utilization management delays, high deductibles and copays, and narrow networks that do not include sufficient or geographically available addiction clinicians or programs.i
Plans that require high cost-sharing from beneficiaries, such as high deductible plans, can also be a major barrier to addiction treatment. The nature of addiction and the symptoms of the disease frequently result in patients having no available funds to pay for treatment when they accept the need for treatment. Failure to initiate treatment early may result in the exacerbation of symptoms as well as job and/or housing loss, family disruption, and additional medical complications including overdose and death.
Overall, even though alcohol and drug use and addiction are among the leading causes of death and disability in the United States,ii insurance plans spend 1% or less of total health expenditures on the treatment of addiction.
“We know what is needed: more utilization of evidence-based practices for addiction treatment, and third-party payer practices that foster – rather than inhibit – access to clinically appropriate care,” concluded Earley. “ASAM will continue to advocate for standardized care and equitable insurance coverage, because these are the systemic changes needed to save lives.”
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i Melek SP, Davenport S, and Gray TJ. Addiction and mental health vs. physical health: Widening disparities in network use and provider reimbursement. Milliman Research Report. November 19, 2019. Available at: http://www.milliman.com/bowman/ Accessed December 3, 2019
ii US Burden of Disease Collaborators, Mokdad AH, Ballestros K, et al. The State of US Health, 1990-2016: Burden of Diseases, Injuries, and Risk Factors Among US States. JAMA. 2018;319(14):1444–1472. doi:10.1001/jama.2018.0158