By KEVIN DAHILL //
The $572 million that an Oklahoma judge ordered Johnson & Johnson to pay to the State of Oklahoma for the company’s role in the opioid crisis is the first such court ruling – among hundreds of pending cases throughout the country.
Such sizable awards, earmarked for prevention and treatment, will help health providers and public health officials arrest this soaring epidemic. But even as state and county officials battle in court, including New York’s own attorney general, regulators and lawmakers must 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 New York, the Office of Alcoholism and Substance Abuse Services oversees addiction and chemical-dependency treatment, and the Office of Mental Health 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’s led to frustrated patients, family members and 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. Successful treatment of a substance-abuse and/or mental-health issue is heavily dependent on the right services being offered in the right settings at the right time, and this requires coordination among various health and social-services providers, insurers and regulatory agencies.
Different programs require different levels and types of certifications from oversight agencies. Insurers often impose more rules and regulations upon patients and providers. But there has been some relief in the area of insurance denials.
After providers across the state voiced concerns about the rising number of claims denials for behavioral-health services, NYS reviewed claims for a handful of services from December 2017 to May 2018 and found high rates of inappropriate denials. Psychiatric emergency-room visits were one of the services with the highest denial rates.
The state is now holding managed-care organizations (insurers) accountable for inappropriately denied claims and requiring them to reach payment agreements with providers.
Prior authorization for certain types of treatments is another roadblock in the management of behavioral health. Medication-Assisted Treatment is a proven, evidence-based approach to treating opioid addiction that combines counseling and behavioral therapies with approved medications. But 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. But federal prescribing restrictions on the drug limit who can prescribe it and how much they can prescribe – often seen as a barrier to care.
Physicians must complete eight hours of training and complete a waiver in order to prescribe buprenorphine, and can only prescribe it to 100 patients each year (another waiver is needed to exceed this cap).
However, the Support for Patients and Communities Act (2018) extends the privilege of prescribing buprenorphine in office-based settings to clinical nurse specialists, certified RN anesthetists and certified nurse midwives until October 2023. 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 NYS 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, to 15.1 deaths per 100,000 people.
In Suffolk and Dutchess counties, an innovative treatment model – featuring a triage-type, freestanding facility – is showing promise. The Family Service League’s Diagnostic and Stabilization Hub and the Dutchess County 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 for care for someone suffering from a mental illness and/or substance-use disorder. The new, highly focused models are embraced by area hospitals because they’re focused on mental health and they ease the strain on overcrowded ERs.
The emotional toll of behavioral-health issues on patients, families and society is incalculable. But the financial impact – in terms of lost productivity, healthcare costs and missed opportunities – 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 hardest-hit regions. It found that the opioid crisis caused Long Island $8.2 billion in economic damage in 2017 – 4.5 percent of the Island’s gross domestic product.
Such data underscores the fact that mental illness and addiction touch everyone, and we are all responsible in some way for solving this public health crisis.
That’s the crux of the 2,000-plus lawsuits advanced by states and local jurisdictions that believe drug manufacturers, retailers and distributors have put profits over people. Johnson & Johnson said it will appeal the Oklahoma ruling and any payout could take years – but a Supreme Court justice in Suffolk County has already denied Purdue Pharma’s request to dismiss New York’s pending lawsuit against the pharmaceutical giant, even as Purdue is in settlement talks with the U.S. Department of Justice regarding several opioid-based civil and criminal accusations.
Treatment of mental-illness and substance-use disorders is difficult enough without the barriers outlined here. But we’re 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 at the right time, despite the complexities of our healthcare and legal systems.
Kevin Dahill is the CEO of the Nassau-Suffolk Hospital Council and the Northern Metropolitan Hospital Association, both part of the Suburban Hospital Alliance of New York State. The 40-year health-policy veteran is also an adjunct professor of management at St. Peter’s University in New Jersey and St. Joseph’s College in Patchogue.