Christie’s (Middle-Class) Anti-Addiction Efforts Get Closer to Realization

It looks as though governor could get most of what he wants, but plan specifically excludes Medicaid and FamilyCare recipients

Gov. Chris Christie
Lawmakers plan to vote Monday on a measure that would articulate several of Gov. Chris Christie’s latest proposals to address New Jersey’s epidemic of drug addiction.

Legislative staff continued to circulate draft language of a bill Thursday while lead sponsors consulted with healthcare providers, insurance companies, and other stakeholders to tease out fine details in advance of Monday’s committee hearings, when it is one of several anti-addiction proposals scheduled for debate. During his State of the State address earlier this month, Christie said he wanted new measures in place within 30 days.

And, based on elements of the proposal shared with NJ Spotlight, it appears Christie could get much of what he called for to help middle-class residents get quick access to six months of addiction treatment without battling insurance red tape, despite persistent concerns about the costs involved and who would be responsible. His promise to restrict first-time opioid prescriptions to only five days for acute pain patients also appears intact; it exempts those with chronic pain, including cancer patients and residents in hospice, but doctors have said those in pain will still suffer and termed it “cruel.”

But, when it comes to the insurance mandate, the draft doesn’t extend the same protections to the state’s most vulnerable residents — something experts have said would involve huge costs, all borne by state taxpayers — and its reach is limited to less than a third of the state’s policy holders, since most are covered by plans not regulated by state laws.

Even so, experts are still concerned about the current capacity of the state’s treatment centers to absorb what could be tens of thousand of new patients. New Jersey licenses nearly 4,000 inpatient beds, and more than 300 outpatient facilities, but some 28,000 drug users were treated here in 2015; wait lists for some facilities stretch nearly two months, experts said, and thousands of others give up before they get care.

“We have taken some admirable steps. We have made some progress,” Christie said in his State of the State address. “But it is clearly not enough. I can tell by reading the growing statistics. I can see it by watching the growing costs to our budgets. I can feel it by looking into the eyes of too many loved ones who have lost someone so close and so dear that you can see their hearts actually breaking.”

While the governor has focused more on anti-addiction efforts in recent years, he devoted most of his annual address to the cause and has continued that push with a series of recent public events during which he’s shown compassion to those in treatment and reiterated his commitment to get insurance companies and prescribers to do their part. Earlier this week, he added hospitals to the list, saying they needed to do more to address the lack of treatment beds.

Text for the legislation (S3/A3) had not been posted on the Legislature’s website, as of Thursday night. The text is likely to evolve, sources said, and it might not be officially introduced until Monday morning, when it would be available to the public. Stakeholders declined to comment publicly until the bill is completed; the measure is to be sponsored by Senate President Steve Sweeney (D-Gloucester), Sen. Joe Vitale (D-Middlesex), who leads the health committee, Sen. Tom Kean Jr. (R-Union), and Assembly Speaker Vincent Prieto (D-Hudson), Assemblyman Herb Conaway (D-Burlington), a physician and health committee chair, and Assemblyman Jon Bramnick (R-Union.)

According to sections of a draft bill — which is scheduled for review Monday in the Senate health and Assembly insurance committees — the measure would require all health insurance plans, including those sold after its passage to state and local government workers and teachers, to provide unlimited benefits for inpatient and outpatient treatment at facilities that were part of their network but not without some checks and balances. While up to six months could be approved at once, if considered medically necessary, insurance companies could review the treatment protocol every three weeks after the first month.

The mandate includes medication-assisted treatment, which involves prescription medicines to control an addict’s cravings, and it does not appear to limit patients to Garden State facilities, only those in-network with plans that are covered. Insurance companies could not discriminate against patients seeking addiction treatment who might have other medical conditions that also require care.

Data from insurance companies suggests that, as written, the proposal would apply to perhaps 30 percent of policyholders in New Jersey. The draft bill specifically exempts those covered by Medicaid or FamilyCare or other programs operated by the state Department of Human Services to protect the state’s most vulnerable residents; this group makes up about 20 percent of those with insurance. While federal law now seriously limits inpatient benefits for Medicaid patients, the program does cover most outpatient treatments at little cost to the patient. (In his State of the State, Christie said 14,000 Medicaid patients were receiving drug treatment last year.)

The remaining residents — roughly half of those insured— have self-funded policies that are popular with large companies or the federal government, but not subject to state regulation.

Under the proposed mandate, the insurance company would be required to cover treatment — inpatient, outpatient or a mix of the two — for the first six months of a calendar year without any review or other requirements in advance, as long it is considered medically necessary. If an in-network spot isn’t available, the company must find the patient room in an out-of-network facility within 24 hours. Patients would not be charged anything above their co-pay, deductible and other usual out-of-pocket expenses, for treatments during those 180 days.

After the first 28 days, the insurance company could challenge the medical necessity of continuing the treatment, but only at certain intervals and not without informing the patient of any reviews and providing them a simple appeal process that must be settled within 24 hours. Additional, external appeals are also possible, if coverage is denied, and the insurance review process must conform to an evidence-based standard that will be developed by state officials that oversee health and addiction issues.

The draft language also spells out Christie’s controversial proposal to limit prescription opioids. As he suggested earlier this month, a first-time acute-pain patient — or someone who hasn’t been prescribed the drugs in more than a year — would be limited to a five-day supply. If more medicine was required, after four days the doctor could write another prescription for up to 30-days. After that, the patient would be required to sign a “pain contract” with the doctor, who would need to review the course of treatment every few months and make “periodic” and “reasonable” efforts to shift to a less addictive option.

The mandate would require that, before prescribing the first time, the physician do a thorough examination, discuss the potential dangers of the drug with the patient, check the state’s Prescription Monitoring Database for signs of illicit behavior, and document the process in a chart to be created by state officials. Elements of this protocol would be repeated if the patient requested additional medications.

The proposal applies only to acute pain, which — whatever the cause — is not expected to last long. Patients with chronic pain, from cancer treatments or other conditions, or those in hospices, would not be subject to the limits. That said, a number of pain patients have raised concerns that misunderstandings or misinterpretations of this proposal could leave them suffering.

The draft calls for the insurance mandate sections of the law to take effect three months after approved; the elements related to the opioid limits would be immediate. In fact, the state Board of Medical Examiners is working on a regulation that would enact nearly identical restrictions starting immediately and lasting until the law took effect.

Other legislation up for consideration Monday in the Assembly Financial Institutions and Insurance committee includes a measure (A-1875) to establish a public awareness campaign about the dangers of opioid and heroin addiction — and the effective response. A resolution (ACR-225) would establish a joint legislative task force to explore addiction and prevention issues.