Lobbying Affiliate: MML&K Government Solutions

Expanding Substance Abuse Treatment, but Restricting Physicians, Kentuckydoc, April/May 2014


Kentuckydoc, April/May 2014

In November of 2013, the Obama Administration announced that insurers would be required to cover mental health and substance abuse disorders in the same manner as physical conditions. Though the Mental Health Parity and Addiction Equity Act was signed into law by President George W. Bush in 2008, the Obama Administration's announcement served as the first big push for enforcement since the law's passage. By making treatment for mental health and substance abuse an "essential benefit" under the Affordable Care Act, exchange plans marketed to individuals and small groups must now include this service. Secretary of Health and Human Services Kathleen Sebelius called the change the "largest expansion of behavioral health coverage in a generation." Are Kentucky physicians prepared for it?

When it comes to the treatment of substance abuse, physicians in this state already have their work cut out for them. Kentucky has long been known for its prescription drug abuse epidemic. Physicians have worked hard in recent years to combat the problem. In 2013, the number of Kentucky deaths from controlled substances actually fell for the first time in a decade.[1] Despite these efforts, the intersection of new and existing law is making it more difficult for physicians to help this at-risk population.

First, more patients will actively seek help for their substance abuse disorders, creating a greater demand for these services. Governor Steve Beshear's decision to expand Medicaid eligibility in Kentucky to 138% of the Federal Poverty Line means that some Kentuckians will be able to receive professional treatment as part of their Medicaid coverage for the first time.

Second, stringent federal regulations make it impossible for physicians to simultaneously care for a large number of patients in their fight against substance abuse. Physicians often treat prescription drug addicts with Suboxone, an effective narcotic medication for the treatment of opioid addiction; however, the Drug Abuse Treatment Act of 2000 prevents a physician from treating more than 100 patients at a time with this medication. This patient cap not only makes it economically difficult for a physician to operate an addiction-only practice, but could also lead to the disparaging result of turning away individuals who need help.

Not only are physicians restricted as to the amount of patients they see, but the current fee schedule makes it economically unfeasible to treat Medicaid patients' substance abuse issues. A large number of substance abusers have lost their financial footing in the wake of their addiction, thereby qualifying them for Medicaid. The Kentucky Department of Medicaid pays merely $21.53 for most substance abuse treatments. Physicians literally cannot afford to see these patients, much less provide them with other services such as counseling and treatment plan development, which are crucial to recovery.

Because Medicaid reimbursement is low in this area, some physicians might consider providing only non-Medicaid addiction recovery services (thereby generating necessary income) in conjunction with their full-time Medicaid practice. There is significant risk, however, in wearing these two hats, as Medicaid and non-Medicaid providers' responsibilities differ in many ways.

The establishment of substance abuse treatment as an essential health benefit, paired with the expansion of Kentucky's Medicaid eligibility, should benefit Kentuckians struggling with addiction, but who is going to help the physicians? With patient caps, unreasonably low reimbursement rates, and the cost of compliance, physicians may soon decide to forego providing recovery services. Unfortunately, substance abuse coverage may not translate to substance abuse services for many Kentuckians.

This article is intended as a summary of federal and state law and does not constitute legal advice.

[1] KY Office of Drug Control Policy and KY Agency for Substance Abuse Policy, 2013 Combined Annual Report, February 2014.

Lexington, KYLouisville, KYFrankfort, KY: MML&K Government SolutionsWashington, D.C.