Committed to working with health insurers to make effective addiction treatment more accessible to every American who needs it.

Overview

The Shatterproof Payer-Based Strategies Initiative was created to move the needle on insurance coverage of addiction treatment in order to make high quality, evidence-based care accessible to patients nationwide.

Insurance typically covers some aspects of addiction treatment, but not always the types of care that give patients the best chances of long-term recovery. Current research shows that insurance often covers things like short stays in detoxification or rehabilitation programs but not always evidence-based long-term care. This coverage generally tends to focus on paying for acute services rather than improving long-term patient outcomes. [1]

As part of our commitment to improve the addiction treatment system, Shatterproof is working to align financial incentives with best practices of addiction treatment, as encompassed in the Shatterproof National Principles of Care© for Substance Use Disorder Treatment.

This initiative is a multi-stakeholder collaboration between Shatterproof, the Leonard Davis Institute of Health Economics , and key insurance carriers.

The Issue

Substance use disorders (SUDs), or what we commonly call addiction, are chronic medical conditions. SUDs can be managed with the same effectiveness as other chronic diseases using evidence-based best practices, such as the ones outlined in the Shatterproof National Principles of Care© .

However, the addiction treatment system has developed largely outside of mainstream healthcare, resulting in fragmentation in both delivery and payment. Despite advancements in science, technology, and pharmacology, evidence-based addiction treatment services are largely unavailable in mainstream healthcare and even specialty addiction treatment programs. In fact, only about one third of specialty addiction treatment programs offer even one of the FDA-approved medications to treat opioid addiction—and less than 2% offer all three. [2]

Unlike other areas of healthcare, only 18% of addiction treatment is paid for by private health insurance. [3] Instead, large portions of funding for addiction treatment have historically come from state and federal grant programs. This has resulted in the financial, geographic, and cultural separation of addiction treatment from mainstream healthcare.

Some advancements have been made to close these gaps. The Mental Health Parity and Addiction Equity Act, for example, requires health insurance coverage of mental health and addiction services to be at par with other medical benefits. And the Affordable Care Act of 2010 further expanded coverage requirements for addiction treatment services. Still, barriers related to insurance coverage for addiction treatment remain.

One in four Americans needing but not receiving addiction treatment report lack of health care coverage and inability to afford care as the reason. [4]

Fortunately, organizations across the country are actively working to ensure addiction is covered like other chronic diseases.

In addition to expanding treatment access for patients, Shatterproof’s work in this space will also ease insurance-related barriers faced by providers. Current barriers reported by providers include delays in payment, complicated approval requirements, and high cost burdens. For many, these barriers outweigh incentives to offer evidence-based treatment, which may contribute to the lack of providers in the addiction treatment space. [5]

Insurers have an opportunity to reduce both patient and provider barriers and create incentives that will transform the addiction treatment system. Shatterproof is committed to working with public and private payers to ensure that barriers to care are reduced and that payment systems incentivize evidence-based care.

The Opportunity

Payers recognize the effectiveness of treatments for addiction, and the fact that the current treatment system is broken. In a historic 2017 announcement , 16 health insurance companies representing over 248 million lives showed their commitment to changing the addiction treatment system by agreeing to “identify, promote, and reward” care that aligns with Shatterproof’s National Principles of Care© . With this agreement, payers have stepped forward to begin working with our Substance Use Disorder Treatment Task Force . Together, we’ll implement strategies to financially incentivize and remove barriers to care that is of the highest quality.

Shatterproof is working with payers to understand the current landscape of insurance coverage for addiction treatment, and to develop and implement strategies that support delivery of care that aligns with the Principles.

Pilot Research: Payment for Opioid Use Disorder Treatment

To advance this work, Shatterproof is partnering with the University of Pennsylvania’s Leonard Davis Institute of Health Economics to conduct a six-month research project to assess health insurance coverage and payment policies related to evidence-based treatment for opioid addiction.

This research is examining both private insurance companies and state regulations around addiction treatment. The assessment will identify areas where insurance policies and payments can and should be modified, and ways to track this information across the industry. Results from this assessment will inform collaboration with payers to implement strategies that incentivize evidence-based care.

This pilot is made possible by the Laura and John Arnold Foundation . The Laura and John Arnold Foundation’s core objective is to improve the lives of individuals by strengthening our nation’s social, governmental, and economic systems. Its investments are focused on criminal justice, education, health care, and several other key areas.

Read the press release for the pilot research here.

Project Team

Daniel Polsky, PhD, MPP
Executive Director
Leonard Davis Institute of Health Economics

Samantha Arsenault, MA
Director
National Treatment Quality Initiatives
Shatterproof

Caroline Davidson, MPH
Research Associate
National Treatment Quality Initiatives
Shatterproof

[1] Reilly, Cynthia, and Samantha Arsenault. (2017). “Insurance Coverage for Substance Use Disorder Treatment Impedes Care.” PEW, The PEW Charitable Trusts, 29 Mar. www.pewtrusts.org/en/research-and-analysis/articles/2017/03/29/insurance-coverage-for-substance-use-disorder-treatment-impedes-care .
[2] Substance Abuse and Mental Health Services Administration. (2017). National Survey of Substance Abuse Treatment Services (N-SSATS): 2016. Data on Substance Abuse Treatment Facilities . BHSIS Series S-93, HHS Publication No. (SMA) 17-5039. Substance Abuse and Mental Health Services Administration, Rockville, MD. https://www.samhsa.gov/data/sites/default/files/2016_NSSATS.pdf .
[3] Substance Abuse and Mental Health Services Administration. (2016). Behavioral Health Spending and Use Accounts, 1986–2014 . HHS Publication No. SMA-16-4975. Substance Abuse and Mental Health Services Administration, Rockville, MD. https://store.samhsa.gov/shin/content/SMA16-4975/SMA16-4975.pdf .
[4] Center for Behavioral Health Statistics and Quality. (2017). 2016 National Survey on Drug Use and Health: Detailed Tables . Substance Abuse and Mental Health Services Administration, Rockville, MD. https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf .
[5] Volkow, N. D., Frieden, T. R., Hyde, P. S., & Cha, S. S. (2014). Medication-assisted therapies—tackling the opioid-overdose epidemic. New England Journal of Medicine, 370(22), 2063-2066. https://www.nejm.org/doi/full/10.1056/NEJMp1402780 .