Roundtable Puts the Broken ‘Fail First’ Drug Treatment Policy Under a Microscope

The Legislative Gazette 

By Julio Olivencia

Barriers that have long prevented addicts from receiving the level of care they need may be finally coming to an end as the state struggles with a major heroin and opioid epidemic.

A major source of frustration for addicts and their families has been an insurance company policy that dependency advocates call “fail first.”

The “fail first” policy requires that an addict must fail at an outpatient program before getting admitted to an inpatient facility, even if a healthcare provider recommends an inpatient treatment. In some cases the patient must fail multiple outpatient programs before they can receive the level of care the healthcare provider originally recommended.

“They need to fail at outpatient and intensive outpatient first,” said John Coppola, of the New York Association of Alcohol and Substance Abuse Providers.”Before you know it you have someone who’s dead or in jail.”

Although, according to insurance experts, the insurance company criteria is normally based on federal and American Society of Addiction Medicine standards, the division between the criteria often times leaves the patient at a lower level of care than a health care provider recommends.

“The agency, some providers, and insurance companies are using different tools,” said Assemblyman Steven Cymbrowitz, D-Brighton Beach.

Assemblyman Cymbrowitz held a roundtable discussion in Albany last Monday to bring families, insurers, and health care providers together to identify barriers to treatment and come up with meaningful solutions. The discussion demonstrated the level of cooperation between both sides of the issue, but became adversarial at times as the sensitivity of the subject matter brought out emotions from family members of addicts, some of whom had overdosed while waiting for treatment.

The discussion highlighted an important point: help for those suffering is on the way in the form of changing attitudes in the insurance community and new legislation.

Legislation (A.07003-a/S.04623-a), sponsored by Assemblyman Michael Cusick D-Staten Island, and Sen. Kemp Hannon R-Garden City, chair of the Health Committee, aims to make it mandatory for insurance companies to cover rehabilitative treatment at a level recommended by a qualified health care provider. The law would essentially eliminate “fail first” practices and put the decision for the type and duration of treatment into the hands of an individual’s doctor.

In addition, a federal law, under the Affordable Care Act, will bridge the gap in cost between dependency treatment and more traditional medical and surgical treatment.

The Mental Health Parity and Addiction Equity Act requires plans that cover mental health and substance abuse treatments to do so in a fashion similar to medical and surgical conditions. The law is expected to reduce co-pays and out of pocket expenses, while increasing the number of days a patient can recieve inpatient and outpatient care.

“If the Department of Health and Department of Financial Services do a good job, [the parity law] will help,” Coppola said.

The law took effect January 14, and applies to plans beginning in July.

“The environment is changing,” Coppola added, “My sense is that insurance companies are starting to shift.”

The New York Association of Alcohol and Substance Abuse Providers, the state’s Office of Alcohol and Substance Abuse Services, and the New York Health Plan Association, which includes many major insurance companies like United Health and Aetna, have been working closely to find a common ground between patient and insurance company needs.

New York Health Plan Association spokeswoman, Leslie Moran, said her organization is committed to working together with advocates, families and lawmakers to “identify problems and find solutions,” while ensuring that no unintended consequences arise from over-legislation. Moran added that more and more plans are moving away from fail first policies.

“Plans need to re-evaluate fail first as a response,” Moran said.

There is also a push to unify the systems of criteria insurance companies and healthcare providers use.

“I’m working closely with OASAS and DFS to get us on the same platform,” Assemblyman Cymbrowitz said.

As the epidemic continues to intensify, it appears relief is finally coming to those who need it most and have largely felt they have been left behind.

“As this problem continues to evolve and grow we need to reevaluate where we are and where we are going,” Moran said.