Favorable Court Rulings, Regulatory Reforms, New Legislation Offer Hope for Patients and Providers
The $572 million that an Oklahoma judge ordered Johnson and Johnson to pay to the state of Oklahoma for the company’s role in the opioid crisis is the first court ruling among hundreds more to be handed down by state and local courts throughout the country. Such sizable awards earmarked for prevention and treatment will help health providers and public health officials arrest this soaring epidemic. And while state and county officials battle the issue out in court, including New York’s own attorney general, regulators and lawmakers grapple with the complex web of rules and regulations that govern the provision of substance use and mental health treatment. With the majority of substance abusers also suffering from a mental health disorder, it’s critically important these two behavioral health issues are addressed in tandem.
In our state, the Office of Alcoholism and Substance Abuse Services (OASAS) oversees addiction and chemical dependency treatment, and the Office of Mental Health (OMH) oversees treatment related to emotional and psychiatric disorders. The two offices have historically operated in silos making it difficult for providers, especially hospitals, to care for patients with a dual diagnosis. That has led to frustrated patients, family members, and even treatment providers.
The Suburban Hospital Alliance of New York State places behavioral health reform, including regulatory changes, enhanced reimbursement, and workforce needs, at the top of its advocacy agenda each year. Successful treatment for a substance abuse and/or mental health issue is heavily dependent upon the right services being offered in the right setting at the right time. This requires coordination among various health and social services providers, insurers, and regulatory agencies.
Rules and Regs
Different programs require different levels and types of certifications from the respective oversight agencies and insurers often impose even more rules and regulations upon patients and providers. However, there has been some relief in the area of insurance denials. Providers across the state voiced concerns about the rising number of claims denials for behavioral health services. The state reviewed claims for a handful of services from December 2017 – May 2018 and found high rates of inappropriate denials among the services. Psychiatric emergency room visits were one of the services with the highest rate of denials. The state is now holding managed care organizations – insurers – accountable for inappropriately denied claims and requiring the organizations to reach a payment agreement with providers.
Prior authorization for certain types of treatment is another roadblock in the management of behavioral health. Medication Assisted Treatment (MAT) is an evidence-based and proven approach to treating opioid addiction. It combines counseling and behavioral therapies with approved medications. Yet, until this most recent New York State legislative session, commercial insurers and Medicaid managed care plans could require prior authorization for coverage of these highly successful medications. We are hopeful the governor will sign the legislation.
Buprenorphine is one of the more successful MATs. It treats opioid addiction by reducing cravings and blocking painful withdrawal symptoms. Yet, federal prescribing restrictions on the drug limit who can prescribe and how much they can prescribe. This is often seen as a barrier to care. Physicians must complete 8 hours of training and complete a waiver in order to prescribe buprenorphine and can only treat up to 100 patients a year. Another waiver is needed to exceed this cap. However, the Support Act (2018) extends the privilege of prescribing buprenorphine in office-based settings to clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives until October 1, 2023. The behavioral health field continues to experience workforce shortages, especially among psychiatrists, and legislation like this will increase access to MAT. But longer term solutions are needed. The Opioid Workforce Act of 2019 is one. It would incentivize the training of physicians who specialize in treating substance abuse disorders and pain management by supporting additional residency slots.
According to the Centers for Disease Control and Prevention, on average, 130 Americans die every day from opioid overdose. New York State’s 2018 Opioid Annual Report shows that, among New York State residents, the number of overdose deaths involving any opioid increased from 1,074 in 2010 to 3,009 in 2016. The age-adjusted rate of deaths involving all opioids in New York State approximately tripled between 2010 and 2016, from 5.4 to 15.1 deaths per 100,000 population. The state’s quarterly reports on the opioid crisis provide county-level data. The most recent report was published April 2019.
In Suffolk County on Long Island and in Dutchess County in the Hudson Valley, an innovative treatment model in the form of a triage-type, free-standing facility is showing promise for those suffering from any range of behavioral health issues. Suffolk County’s Diagnostic and Stabilization Hub (DASH) and Dutchess County’s Stabilization Center are open 24/7 and both offer mobile crisis intervention. They are an alternative to the hospital emergency room, which is often not the best place of care for someone suffering from a mental illness and/or substance use disorder. Preliminary data show a dip in behavioral-based emergency room visits since the facilities opened. The new models of care are embraced by area hospitals because they are so highly specialized and focused on mental health care, and they are easing the strain on overcrowded emergency rooms. In fact, the MidHudson Regional Hospital of Westchester Medical Center is one of the Dutchess County center’s partners.
Cost to Society
The emotional toll of behavioral health issues on patients, families, and society is incalculable. However, the financial impact in terms of lost productivity, healthcare costs, and missed opportunity is measurable. The Fiscal Policy Institute recently released a report that specifically looked at the economic impact of the opioid crisis on Long Island, one of the regions hardest hit by the epidemic. It found that the opioid crisis caused Long Island $8.2 billion in economic damage in 2017 – 4.5 percent of Long Island’s gross domestic product. Such a report underscores the fact that mental illness and addiction touches everyone, and we are all responsible in some way for solving this public health crisis.
That is the crux of the 2,000 plus lawsuits advanced by states and local counties who believe drug manufacturers, retailers, and distributors have put profits over people and ignited the opioid epidemic. While Johnson and Johnson said it will appeal the Oklahoma court ruling and any payout could take years, Purdue Pharma, owned by the Sackler family, was denied the family’s request to dismiss New York State’s lawsuit against the pharmaceutical giant. The ruling was issued by a state judge at Supreme Court in Suffolk County, Long Island. Meanwhile Purdue Pharma is in talks with the United States Department of Justice to reach a settlement regarding civil and criminal accusations against the company’s role in the opioid epidemic. The deal is complicated by Purdue Pharma’s many local lawsuits with states and counties.
Treatment of mental illness and substance use disorders is difficult enough without the interference of many of the barriers outlined in this blog. We are, however, making progress. Hospitals are pushing on all fronts to ensure that those affected by any behavioral health issue get the right care in the right place and at the right time, despite the complexities of our healthcare and legal systems.