A little-publicized bill now in the state Senate's insurance committee would drastically expand treatment options for heroin and opioid pill addicts -- and potentially reshape the landscape of drug rehabilitation in New York, experts say.
Senate Bill S4623 would require insurers to cover drug and alcohol abuse and dependency treatment. Currently, insurance companies routinely refuse coverage for some rehabilitation treatment deemed necessary by doctors, according to treatment experts, doctors and families of addicts.
The legislation would also give decision-making authority for a patient's addiction treatment, including which type of care and for how long, to a medical professional. Supporters say that stipulation would put treatment strategies in the hands of qualified addiction professionals and take it out of the hands of insurance company officials.
"These insurers . . . require patients to 'fail' at outpatient treatment before paying for inpatient care, and then when they do pay for inpatient care, they'll limit the stays to seven days," said Dr. Jeffrey Reynolds, executive director of the Long Island Council on Alcoholism and Drug Dependence.
Legislating "based on anecdote" and mandating levels of treatment is "never a good idea, as it precludes the ability to use evidence-based experience and establish best practices in care," said Leslie Moran, senior vice president and spokeswoman for the New York Health Plan Association.
"There should be an assessment of needs to determine the appropriate level of care -- as well as the appropriate setting for delivering care -- for individual patients," Moran said. "Providers of inpatient services have an interest in increasing the use of inpatient care and often use emotional anecdotes to support their arguments for more coverage. The reality is that the whole health care system is moving to try and avoid inpatient treatment and do more outpatient services."
The bill's sponsor, Sen. Kemp Hannon (R-Garden City), said passage would be an important step in easing Long Island and the state's drug abuse epidemic.
"We are desirous of having coverage for substance abuse rehab services," Hannon said. "It's a large challenge for all of us, but it's a challenge that must be met."
Frustration with insurers
Debate over the legislation comes as cheap, powerful and abundant supplies of heroin flood Long Island and the Northeast, contributing to a surge in fatal overdoses, authorities said. More than 220 heroin deaths have been reported on Long Island over the past two years -- the most ever recorded.
Jamie Bogenschutz, executive director of the YES Counseling Center in Massapequa, said she has seen insurers routinely tell patients they must first attempt outpatient rehabilitation unsuccessfully before the company will pay for inpatient treatment.
"If the person is lucky, they'll get to get higher level of care," Bogenschutz said. "If they're not lucky, they'll start using again or they'll die. So it's very important that insurance companies not turn people away and pay for the care they need."
Linda Ventura, a Kings Park resident whose 21-year-old son Thomas died of a heroin overdose in March 2012, recently traveled to Albany to push legislators to support the bill.
"I know firsthand how badly we need this law, because I was told on several occasions my son had to fail at outpatient rehab before the insurance company would consider covering inpatient rehab," Ventura said. "Addiction is a disease and needs to be treated as such by the insurance companies. Why won't they pay for the care people need when these people have been paying them for years?"
It sometimes takes a prolonged battle with one's insurance company to attain any kind of coverage for drug treatment, experts said. Some families are hesitant to go to such lengths.
Moran said plans now cover both inpatient and outpatient services, and that there are appeals processes that can be used "when plans and providers disagree about coverage -- with providers able to initiate the appeals."
Hannon's spokesman would not speculate on the bill's chances for passage. A spokesman for Senate co-leader Dean Skelos (R-Rockville Centre) did not return calls seeking comment.
Statewide epidemic grows
New York has made strides toward curbing the epidemic of pain pill abuse, due in part to the creation of a statewide, real-time prescription tracking database called I-STOP, as well as the implementation of tamper-proof technology by some drugmakers, officials and treatment experts said.
But as the supply of pain pills has dwindled, opiate addicts have increasingly turned to heroin as a cheaper, easily available alternative, leading to a heroin epidemic, authorities said. Amid surging demand, Mexican and Colombian cartels have flooded the region with potent, cheap varieties of the drug, authorities said.
The epidemic comes as Long Island simultaneously faces a shrinking pool of treatment options and financing from state and local government, officials said.
"There are significant issues with bed/slot capacity," said Reynolds of the Long Island Council on Alcoholism and Drug Dependence, referring to available spots in hospitals and treatment centers for people in need of rehabilitation. "With reimbursement rates so low, hospitals are eliminating detox beds, outpatient facilities are struggling and anyone with a grasp on basic math quickly figures out that opening an inpatient facility requires a huge amount of start-up capital and a stomach for ongoing financial losses."
Supporters of the new legislation said it might represent the only chance government has this year to reverse the trend of fatal overdoses.
"I'm praying they do the right thing and pass this," Ventura said.
New York Senate Bill S4623
The proposed legislation, currently in the state Senate, would require insurers to cover drug and alcohol abuse and dependency treatment; it would also give decision-making authority for a patient's addiction treatment, including the type and duration of care, to a medical professional. Supporters say the bill puts treatment decisions in the hands of addiction professionals and takes them away from insurance companies.