These practices can reduce unnecessary hurdles, but may lead to overtreatment without fixing the root of the problem.
Certain insurance requirements may restrict patients’ access to the medications and treatment they need to help them with their addiction. New Mandate Laws are aimed at limiting the power of these requirements so that patients can access treatment.
Several states have enacted these laws, including Massachusetts, New Jersey, Pennsylvania, and Texas. While these Mandate Laws can help ensure that treatment is accessible, the other effects of the laws have not yet been examined, and may impact the quality and cost of care for patients. More research is needed to understand these impacts, and how Mandate Laws can, or should, be effectively put in place.
Alyssa lives in New Jersey, and has been grappling with her opioid addiction for many years. Recently she’s chosen to seek treatment. For Alyssa, this means a medication-assisted treatment, in the form of buprenorphine, also known by the brand name Suboxone. Alyssa knows that Suboxone would help support her recovery, and that because her primary care provider prescribes it, she can go to her regular doctor’s office for treatment.
Under her insurance plan, before Alyssa can receive her Suboxone, her insurance must give prior authorization – meaning that her doctor must complete a form explaining why Alyssa needs to receive the medication, and the insurance company must approve it, all before she can receive the prescription. This requirement is meant to prevent insurance fraud, and ensure patients are receiving the proper medication. However, for many like Alyssa suffering with opioid addiction or other substance use disorders (SUDs), the main thing prior authorization means is waiting – for up to 72 hours – to receive life-saving medication. During this time, Alyssa is at high risk of relapsing, and of an overdose. Many families have experienced the pain of a loved one passing away during this waiting period.
Alyssa’s insurance would ordinarily require her to wait for prior authorization before being able to receive her Suboxone prescription. However, under her state’s new Mandate Law, her insurance company cannot require prior authorization on this prescription until 180 days of treatment have passed. This means that as soon as Alyssa’s provider submits her prescription, the pharmacy can process the order and she can receive her medication. Rather than potentially waiting several days, during which time she could relapse or otherwise be harmed, Alyssa can receive her medication the same day and start on her path of recovery.
Alyssa approaches her provider about getting treatment for her addiction. While Suboxone would likely be the appropriate treatment for Alyssa’s addiction at this point, because no prior authorization is needed for the first 180 days of treatment, after talking, both she and her doctor are now leaning towards residential treatment. Alyssa may have originally been considering Suboxone, but with the Mandate Law in place, she knows that she could instead go to residential treatment, which she thinks may be more effective. Similarly, Alyssa’s doctor wants her to go to residential treatment because he knows he does not need to fill out any paperwork to justify this choice, and he wants to avoid the possibility of Alyssa or her family suing him for not giving her enough treatment. With her state’s Mandate Law in place, Alyssa chooses to go to residential treatment and starts right away, even though this is likely to be more expensive and less effective for Alyssa.
These scenarios represent some of the possible impacts of a Mandate Law. It’s important to keep in mind that these laws differ by state, and may have similar, or different, regulations and effects, including on the cost and quality of patient care. As the scenarios demonstrate, while Mandate Laws represent an important opportunity for people to get the treatment they need, these laws may also have unintended consequences. As more Mandate Laws are put in place, it will be important to evaluate the effects of these laws, and how they can be improved to best help patients and families.
For more technical information on Mandate Laws in Massachusetts, New Jersey, Pennsylvania, and Texas, read the Mandate Law brief.