Jul 22, 2014

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.

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

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