Today’s Managing Health Care Costs Number is $15,000
USA Today and the Cincinnati Enquirer have a heart-wrenching article on addiction this morning –and the trouble that many addicts have at getting their insurance plans to pay for drugs used to treat addiction. The article opens with a pregnant woman facing a second prior authorization in a month; additional anecdotes include a woman who lost her 22 year old son days to a heroin overdose days before an appointment on a new insurance plan that would have covered treatment, and a grateful father of twin five year old boys whose Medicaid plan covers methadone.
From the article:
Six years after the passage of the Affordable Care Act, no state covers all of the substance use disorder treatments required by the law without harmful treatment limitations, a report out this summer by the National Center on Addiction and Substance Abuse found.
This is a real problem. Addicts are often not nearly organized enough to navigate a complex bureaucratic system to get prior authorizations every month for drugs they may need for the rest of their lives. The drugs aren’t cheap, either. Suboxone costs over $5000 a year, and the new six month implantable version will cost almost $10,000 a year. Methadone is a bargain at under $100 a year, and Vivitrol, a monthly injection of a drug which causes withdrawal symptoms of addicts use narcotics, costs about $15,000 a year. 19 Americans die of a drug overdose each hour, and the states with the highest rates of drug addiction often have the lowest rate of public funding for substance abuse medications.
The answer posed by those interviewed, including former Representative Patrick Kennedy who coauthored the Mental Health Parity and Addiction Equity Act, is that insurance plans should fully cover all medications used to treat substance abuse.
I’m sympathetic to this – it’s lunacy to require patients to “fail” at one medication before trying the one recommended by their physician – especially when failure means going back to illicit narcotic use, with a high risk of overdose and death. The stakes are very high here.
There’s a flip side, though. There is little to counterbalance drug company imperatives to increase prices. Indeed, some of the organizations pushing for a requirement that all health plans cover all medications are likely to get substantial funding from the pharmaceutical industry. We need to figure out how to insure access to these life-saving drugs while not causing health care costs to continue to escalate. We could do this by purchasing these medications through public entities and removing this coverage from the private insurance markets, much as many states do with vaccines. The public health imperative is large and getting larger. But alone among developed countries we’ve been reluctant to have the government play a role in pharmaceutical pricing. We must think about ways to make these medications simultaneously affordable to both the system and to individuals in need.
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