Kentucky Medicaid Plans Restrict Addiction Care

In Kentucky, efforts to combat widespread opiate addiction and heroin poisoning deaths are hitting limits built into Kentucky's newly-expanded Medicaid system. A big part of the answer to this epidemic is access to medication that helps stabilize patients while they receive treatment or wait for further care. Unfortunately, Kentucky's new Medicaid system is built on a health insurance infrastructure that can be fairly unfriendly to families with chronic care needs.

American healthcare has evolved into a gatekeeper-driven system. Insurers save money by rationing care and by putting barriers in the way of care. All of this is calculated. Companies know that when service becomes inconvenient, a certain number of people  will simply give up, and the company will never have to pay.  The extent to which a company puts self-interest ahead of patient interest is embodied in its published plan documents, regulatory filings, and customer service practices.

The preferred drug list or formulary is a list of medications a plan intends to pay for. The plan might eventually approve or pay for others on a case-by-case basis, but customers who need medicines that are not on these lists should expect to encounter obstacles. This is intentional. Companies know that drug formularies are interpreted as a reflection of company attitudes towards patients with various specific healthcare needs. Insurers manipulate formulary listings to discourage certain patients from enrolling in their plans. In public benefit situations like Medicaid or Medicare, insurers are paid for managing a certain population’s health risk – and the higher the risk of the patients they enroll, the lower the company's bottom line.

Here’s how these factors impact patient care for addiction in Kentucky. The three medications which are FDA approved for Medication Assisted Treatment for opiate and heroin addiction are Methadone, Suboxone, and Vivitrol.

Kentucky has five Medicaid Managed Care Organizations. I tracked down each company's online drug formularies/preferred drug lists, and discovered the following.

- One provider lists only Methadone.

- Another lists only Suboxone.

- Two providers list two of the three medications: Methadone and Suboxone.

- Only one lists all three: Methadone, Suboxone, and Vivitrol.

What I read from this is that only one of the companies seems willing to support all the available medication options. You can draw your own conclusions.

If you or your family's health depends on Kentucky Medicaid

You can start your own research journey at this link.

Companies update formularies periodically, so perhaps the situation will change. Kentucky requires managed care organizations to post their plan documents online, but as of today it does not offer plan-by-plan comparison tools. Medicaid representatives say customers who are denied services under any of the plans have appeal rights, but to me that's just another built-in obstacle. Folks at high risk need prompt care.

People who find out that they are stuck on the wrong managed care plan can switch from one plan to another, even after the open enrollment period ends, using a process described here.

More information about Kentucky Medicaid managed care enrollment is found here.

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Meet me August 6th to talk about what it will take to stop heroin deaths, at the Cincinnati SHARP Stop Heroin Meetup. Learn more.

My System Reform Wishlist

What might really improve behavioral health? The Ohio Mental Health and Addiction Service Department has a survey out, looking for input.

Here are the key survey questions, and what I wrote.

1. Briefly describe the top 5 issues (in rank order) that, if addressed, would have a significant impact on the lives of persons with substance abuse challenges in your community?   

1 Establish a clear path to safety and good health, and align system resources to support that path
2 Eliminate system-created barriers, delays and disincentives   
3 Foster population-level nonclinical social support and volunteer-delivered service networks   
4 De-emphasize pathology thinking (e.g. AA), emphasize personal strengths, learning, improved cognition, improved relationships, and safe environments   
5 Align justice system practices with the path to safety and good health   

2. Briefly describe the top 5 issues (in rank order) that, if addressed, would have a significant impact on the lives of persons with mental health challenges in your community?

1 Establish a clear path to safety and good health, and align system resources to support that path   
2 Eliminate system-created barriers, delays, and disincentives   
3 Establish population-level nonclinical social support and volunteer-delivered service networks   
4 De-emphasize pathology thinking (e.g. personal identity connected to clinical diagnosis), emphasize personal strengths, learning, improved cognition, improved relationships, and safe environments   
5 Align justice system practices with the path to safety and good health   

3. Do you have specific ideas about how to address the issues you mentioned in questions 1 & 2? Please explain:
For a variety of reasons, our systems pay lip service to the notion that behavioral health is biopsychosocial. We only invest in biological methods. We underfund the psychological, and ignore social support completely. This imbalance creates failure, because we are trying to solve population level problems with the most expensive techniques imaginable. Our system has developed a siege mentality. It is plain from reading community plans that system leaders mostly look inward, fretting over the little resources they have. The system must start facing outward, and figure out ways to serve the whole population effectively. This means that, instead of acting like 88 service fortresses in 88 service deserts, the system needs to act more like a network of service hubs. If the system can’t support funding a particular technique (e.g. medication assisted treatment for addiction), it should remove the service from the behavioral health carve-out, and find ways to collaborate with systems that can support the technique. There should always be a path to the least expensive, most accessible way to deliver what is needed when it is needed. People should feel safe and connected if they must wait for a more intensive service.

The relevant techniques for redesigning effective service systems are community organizing, appreciative inquiry, civic engagement, asset based community development, and the IDEO Human Design toolkit.

I developed NAMI Ohio’s court and jail training, worked on the Hamilton County SAMI team. I have developed crisis de-escalation training, and worked on tough issues in multiple service systems. I have been working and learning from Peter Block and other civic engagement experts about how to generate positive solutions to seemingly intractable problems. I do licensing and accreditation work for service delivery agencies. For the past several years I have focused on what ordinary people can do to support each other, and writing about how to change the experience of having mental illness. I have written a well-regarded book that embodies what I have learned. For the past year, I have also worked with anti-drug advocacy groups in Northern Kentucky about heroin poisoning issues. I have learned that it is possible to articulate a path to safety and good health that is practical, understandable, consensus based, and effective.

4. Who would you need to partner with in your community in order to effectively address the issues you mentioned in questions 1 & 2?
Behavioral health is a population-level issue. The whole community has a stake in it. Effective system reform will come from engaging business leaders, neighborhood groups, church groups, parent groups, service system users and political leaders. Today’s reforms are mostly about responsiveness and clarity, not about delivering a smidgen more of what the current system cannot deliver.

5. Briefly describe what the impact would be to your community if these issues were addressed?
People with substance abuse issues – particularly heroin – would move from having a life that is unsafe, at risk of harming others, and is essentially criminal, to a life of a person who is enrolled in a system, who has first aid available, who is safe from infection, whose life is managed, not criminal, less risky, positive, supported and safe. People with mental illness would retain economic and social capacity, move from social isolation and control by others to a life that is safe, socially supported, with access to care as needed, delivered in an ethical, collaborative fashion, and oriented to achieving the ordinary milestones of human development.

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Photo By Carin fuerst (Own work) [CC-BY-SA-3.0-at (http://creativecommons.org/licenses/by-sa/3.0/at/deed.en)], via Wikimedia Commons