Heroin, opiate addicts’ parents: Insurance companies bank on children’s failures

As Wisconsin heroin and opiate painkiller overdoses have hit epidemic levels, desperate parents say the current insurance system, which they are depending on to help them save their addicted children’s lives, is banking on their children’s failure.

“These stories are just heart-wrenching. Too many families are crying,” said Ellen Taylor-Powell, with the Parent Addiction Network of Dane County. “The treatment of the disease does not match the current insurance coverage.”

That disease, addiction to heroin, usually starts with opiate prescription abuse. Medicine once prescribed for pain hijacks and forever changes the brain’s chemistry, and it is only satisfied until the next hit.

If it was not for the opiate antidote Narcan, Dane County Sheriff Dave Mahoney said as many as six people, most of them 18 to 25 years old, would be dying on Dane County streets every week.

“It’s a lot. It’s a lot countywide that we’re experiencing,” Mahoney said. “Not a day goes by that I don’t hear the dispatch tones go off because of an unresponsive individual; usually a young person.”

One of the hardest questions John Nygren said he gets nearly a decade into his 26-year-old daughter Cassie’s opiate addiction battle — including a heroin overdose and jail time — is how she is doing.

“Thankfully Cassie’s alive. She’s getting a chance to turn her life around,” Nygren said. “She’s doing good today. But I also know once you’re an addict, you’re an addict for life.”

And now as a state representative, Nygren has heard from many other recovering addicts’ parents with similar stories about trying, and failing, to get what they view as proper insurance help.

“But often times what happens is they (insurance companies) go to the least costly,” Nygren said. “They have to fail first before you find what’s most effective for your child.”

SYSTEM BASED ON FAILURE

An insurance system based on addicts failing is something Madison addiction psychiatrist Dr. David Pierce said he constantly deals with when trying to get his patients Vivitrol shots, which block the brain’s opiate receptors.

“They’ll insist someone quote ‘fails’ on the pills. And that’s a real Catch-22, because if you fail on the pills what that means is you’ve relapsed,” Pierce said. “And what the insurance company restriction relates to, and ‘we’ll only pay for this if your life is in imminent danger.'”

In the same way, Taylor-Powell said parents discover a system based on failure as they try to get their insurance to help them pay for residential treatment longer than the typical 20-30 days.

“No insurance company will cover that. It’s just what they won’t cover,” Taylor-Powell said. “And then when someone has 30 days clean and comes out, and goes right back to the old habit, and then overdoses, maybe a fatal overdose.”

Today the websites recovering addicts turn to for resources show the country’s most famous recovery facilities can cost between $28,000 and $45,000 for one month’s care. It is hard to find care in most cases for less than $10,000.

In the letter Conrad’s mom wrote she details her other son, an EMT, saving the 22-year-old, who battled mental illness for years, after his heroin overdose in June.

“Since he worked long hours I agreed to call our insurance to get their help,” Conrad’s mom writes. “I was transferred to the mental health department. I told them I was looking for a provider for my son to see. I explained he has had mental health issues and had overdosed on heroin. They asked about a drug and alcohol assessment which was humorous since he clearly had a problem since he overdosed.”

Her letter details her insurance company, Unity, denying help five or six times, once they discovered Conrad was waiting on a court-ordered drug assessment. Conrad had planned to make the next call.

“We lost my son July 17 to a heroin overdose,” his mom writes. “The night before he died, we even spoke about the need for treatment. He told me he knew he needed it and he would try to get off work early the next day and we would make the calls together. Eight hours later my husband and I found him dead in his room. A beautiful mind is gone now because the system did not feel he was worth saving.”

While Unity spokesperson Jennifer Dinehart would not comment on Conrad’s case, citing privacy laws, she said general outpatient mental health services, including substance abuse care, does not require prior authorization

“Anything beyond routine outpatient services like residential or inpatient or intensive outpatient services do require prior authorization,” Dinehart said. “Each request is evaluated for medical necessity to determine whether the level of service is appropriate and Unity follows established national criteria to make this determination.”

In court-ordered cases like Conrad’s, Dinehart said Unity would follow the same medical necessity rule.

“Regardless of whether the service was requested by the member or the provider or court-ordered,” Dinehart said. “If the services are determined to be medically necessary at the requested level care then the payment for services are authorized. Unity does look to see whether services can be provided by participating network providers, but if medically necessary services cannot be provided timely then we would allow for out-of-network services.”

However, that is not the insurance reality many families say becomes their common experiences after their child’s opiate overdose. The dozens of families Taylor-Powell represents say their chaos could be calmed by their insurance companies paying to help them instead of banking on the next failure.

“Just too many deaths, too many families in chaos,” Taylor-Powell said. “If we’re not getting the help and treatment that is required, if people aren’t taking something seriously, don’t you think it’s adding to the epidemic?”

CHANGING THE SYSTEM

Taylor-Powell said stories like Conrad’s often happen because insurance companies do not approach addiction as a disease.

“There is a deep frustration things are moving too slowly,” Taylor-Powell said.

Attorney General Brad Schimel said while he does not have the legal authority to make insurance companies pay for treating an estimated 163,000 Wisconsin opiate addicts, he is on a mission to also use his pill-stopping “Dose of Reality” campaign to make sure insurance companies realize addiction is a disease that needs to be treated.

“That the insurance industry hears this message,” Schimel said. “No one would suggest to someone with lung cancer you smoked your whole life, so you deserve cancer and I’m not going to do anything to help you. Individuals become addicted. They’re suffering from a disease. And I think we need a better focus on getting them help.”

Nygren, who is in the process of leading the charge to change state heroin prevention and treatment laws, also said he wants Wisconsin insurance companies to change their model.

“We’re having conversations with the health insurance industry in Wisconsin,” Nygren said. “Often times what happens is they go to the least costly. Then you have to fail first before you find what’s most effective for your child.”

Nygren hopes to form agreements with the insurance companies without law changes, believing once insurance companies are educated they will look at treatment differently, and change the way they pay out benefits.

“It starts with discussion, then comes to ideas,” Nygren said. “And potentially at the end, an agreement where we won’t necessarily be looking for failure first.”

FAILURE LEADING TO INCARCERATION

Mahoney said the lack of people being able to pay for care means his Dane County Jail cells are full of young opiate addicts who can only afford to detox at taxpayer rehab.

“The people who are in jail are predominantly challenged economically, the vast majority,” Mahoney said. “Some of those individuals, when they come into jail, are detoxing from heroin. That’s why we have full-time medical staff, so they can monitor our ability to care for them in our facility.”

Utilizing a greater emphasis on drug court, Mahoney is proud of the lives jail treatment is saving, like a 23-year-old Sun Prairie woman who overdosed on an opiate in a town of Windsor gas station parking lot.

“In those cases, when we can, we charge people with possession of an opiate,” Mahoney said. “They enter the criminal justice system. And through that process, (we) can determine if they’re a good risk for the drug court in hopes of trying to get them into a treatment program.”

One day, Mahoney hopes the four or five people detoxing every week will not do that in solitary confinement.

“It borders on inhumane treatment. I would never hope a member of my family, if they were addicted, and needed to detox, would do so in a solitary confinement cell in this jail,” Mahoney said. “It should be a medical bed. It should be more calming and more welcoming.”

Today in Dane County, jail is where many insured parents, unable in the end to afford to help save their children, are glad to see they end up.

“If you’re concerned about the safety of your child, maybe that’s a safe place,” Taylor-Powell said.

THE INSURANCE RESPONSE

Even under the Affordable Care Act, JP Wieske, public information officer for the Wisconsin insurance commissioner, said federal and state laws exempt large businesses from covering addiction treatment.

In fact, Wieske said most of those businesses pay for employees’ health care instead of buying them insurance plans.

“Basically, policies offered by large businesses do not have to cover essential health benefits,” Wieske said. “However, if any benefits are covered, they cannot impose daily or annual dollar limits.”

Wieske said that usually involves the insurer reviewing the diagnosis along with treatment notes and coverage plans.

“Most insurers use national standards as a basis, and may have their own treatment protocols, like x number of days of inpatient, then outpatient etc.,” Wieske said.

Wieske said based on the Wisconsin insurance commissioner only receiving 14 complaints this year, those covered by insurance may not realize they have the right to an independent review.

“Typically, an insured person can appeal if the treatment plan is not approved,” Wieske said. “Also, all insurers are required to offer independent external review by state and federal law. If there is a dispute over a medical issue, it can be reviewed by an independent doctor i.e. not affiliated with the insurer, the patient, or the patient’s medical team.”

Wisconsin’s largest insurance lobbyist, The Alliance of Health Insurers, whose members cover about 70 percent of the state, did not answer the question about the premise their system is based on failure. Instead, spokesperson RJ Pirlot said treatment must be tailored to the person’s needs.

“It’s not correct that there should be a set amount of time for someone to spend in residential treatment and there is no evidence to suggest such programs are more effective if they are 28 days,” Pirlot said.

Pirlot said while 28-day programs work for some people, seven-day programs are more appropriate for recovering addicts.

“This depends on someone’s previous treatment, their motivation, their external supports, comorbid psychiatric difficulties, their cognitive skills, etc.,” Pirlot said in a statement. “As for withdrawal, symptoms can be as short as 2 or 3 days, or as long as 10 days.”

Wisconsin’s largest insurer, United Health Care, did not offer comment for this story.

Taylor-Powell urges parents needing help to contact The Parent Addiction Network of Dane County.