Mental Health Parity and Addiction Equity Act of 2008 Edges Closer

I spoke by telephone 2 years ago with former senator Pete Domenici who currently serves as a Senior Fellow at the Bipartisan Policy Center.  He expressed regret that the bill he and Paul Wellstone drafted, pushed through committees, passed through congress and eventually saw signed into law by president Bush had languished through lack of policy definition by HHS.  After years of effort the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) is in effect.

Health and Human Services Secretary Kathleen Sebelius announced today “the largest behavioral health expansion in a generation”, with new requirements that health insurance companies treat mental illness and addiction the same as other illnesses.

Sebelius said the administration will post regulations Friday (11/8/13) requiring mental health parity. The new regulations will apply to both outpatient and residential treatment for mental health and addiction, which means patients would have the same deductible and co-payments applied to physical illnesses. Congress passed and President George W. Bush signed the the Mental Health Parity and Addiction Equity Act of 2008, which “requires group health plans and health insurance issuers to ensure that financial requirements such as co-pays, deductibles and treatment limitations, such as visit limits” are no more restrictive for mental health or addiction than for physical ailments. Continue reading

VICTORY!

In the posting at http://health.state.tn.us/Downloads/Pain_Clinic_FAQ.pdf the Department of Health clarified that “if and only if these drugs are used in accordance with their FDA indication solely in the context of a bona fide program for Medication-Assisted Treatment (MAT) for opioid dependence, this would not be considered pain management services and those patients should not be counted as such.”

letter to Commissioner

Dear Commissioner:

It has recently been brought to our attention that changes made in PC 430 this past session could be misinterpreted to require some addiction specialists who also treat pain patients secondarily to be required to register as pain clinics. The unintended consequence was created when the legislature, at our behest, eliminated the exclusion of suboxone from the list of opioids which would be counted toward the threshold for determining if a practice would need to register. For your information, when we brought the original legislation to the General Assembly in 2011 (PC 340), we, like other states that had decided that pain clinics needed tighter regulation, chose not to include suboxone in the calculation, believing that the drug is used to treat addiction and not pain management. Since we have learned that a number of practices have been prescribing suboxone for off-label uses such as pain management.

With the pending October 1, 2013 change in the definition of pain management clinics, we believe it is possible to interpret the revision in a way that far differed from the reason for the change. As such we would urge you to consider adopting the following policy statement that permits addiction specialists to continue to ply their needed trade in the state without the necessity of becoming registered as pain clinics:

Pharmaceutical products containing buprenorphine shall not be considered, and are specifically exempted from consideration, in the determination of whether a facility is designated as a pain clinic requiring registration as such with the state, if and only if the buprenorphine product is used in accordance with its FDA indication for the treatment of opioid dependency and in the context of an opioid dependence treatment program.  Use of buprenorphine products solely to treat pain, whether transdermal (e.g. Butrans) or sublingual (e.g. Suboxone), shall constitute the use of an opiate for purposes of pain management and shall count toward determination of a facility being designated as a pain clinic requiring registration as such with the state.

We greatly appreciate your consideration of this request and are prepared to respond to any questions or concerns you may have.

Sincerely,

Yarnell Beatty, JD
Vice President, Advocacy

cc:          The Honorable Ken Yager

The Honorable Bill Dunn

David Reagan, MD

Mitch Mutter, MD

PC clarification

Andrea,
Here is the tweaked and improved version, and the conversation thread.

“Pharmaceutical products containing buprenorphine shall not be considered, and are specifically exempted from consideration, in the determination of whether a facility is designated as a pain clinic requiring registration as such with the state, if and only if the buprenorphine product is used in accordance with its FDA indication for the treatment of opioid dependency and in the context of an opioid dependence treatment program.  Use of buprenorphine products solely to treat pain, whether transdermal (e.g. Butrans) or sublingual (e.g. Suboxone), shall constitute the use of an opiate for purposes of pain management and shall count toward determination of a facility being designated as a pain clinic requiring registration as such with the state.”

John B. Standridge, M.D., FAAFP, FASAM

President, Tennessee Society of Addiction Medicine
Personal Medicine LLC
2115 Stein Dr  Ste 304
Chattanooga TN  37421-7200

Gary,

Yes, thank you for your courteous and productive response to the issue of clarifying the definition of who must register as a pain clinic. Allow me to suggest wording that the Health Commissioner might issue as a policy statement until it can be added to Senate Bill No 676 in January.
“Pharmaceutical products containing buprenorphine shall not be considered, and are specifically exempted from consideration, in the determination of whether a facility is designated as a pain clinic requiring registration as such with the state, if and only if the buprenorphine product is used in accordance with its FDA indication for the treatment of opioid dependency.”
If you need additional clarification, consider, “Off-label use of buprenorphine products used to treat pain in the absence of an opioid dependence treatment program shall constitute the use of an opiate for purposes of pain management and shall count toward determination of a facility being designated as a pain clinic requiring registration as such with the state.”
Again thank you for your thoughtful deliberation in an effort to avoid the unintended consequences of hindering the efforts of addition specialists in Tennessee. I think these two sentences should satisfy everyone’s concerns.
Thanks again for your productive response.
John

SB reply

Dr. Standridge: thanks for taking the time to speak with me this morning about your concerns on suboxone being included in the threshold for determining if a practice needed to be registered as a pain clinic. As we discussed, I am proposing to draft a letter next week from TMA to the Health Commissioner explaining the concern of addiction specialists and asking if the department would be willing to develop a policy statement to address it, at least in the interim. As you know, we cannot change the statute, if needed, until the legislature returns in January, 2014.

Gary M. Zelizer

Director of Government Affairs

Tennessee Medical Association

2301 21st Avenue South

Nashville, TN 37212

 

Phone: 615-460-1641

Cell: 615-364-7555

Fax: 615-312-1898

Senate Bill No 676 letter

To the responsible TMA representative:
In a page 12 article featured in the September TMA journal, Tennessee Medicine, you stated, “Suboxone will be included in the type of prescriptions considered as part of determining whether a location meets the definition and should be registered with the state as a pain management clinic”.  This statement is precisely the opposite of all previous pronouncements on the topic. Everything I have read until this point in time states, “Suboxone will not be included in the type of prescriptions considered as part of determining whether a location meets the definition and should be registered with the state as a pain management clinic.” [italics offered for emphasis]. I do not believe you understand the dire ramifications of what I hope is shoddy journalism. If your statement is true — and I could find no second source for substantiation — then an entire specialty, that of Addiction Medicine, is crippled beyond repair in the state of Tennessee. Addiction professionals work passionately and hard in a difficult field treating America’s number one disease.  Few outside the field have a good understanding of the brain physiology, psychological forces, social ramifications and spiritual insights of this disease. Understand that Suboxone is not and never has been FDA-approved for the treatment of pain; it is for treatment of opioid dependence and for no other FDA-approved purpose.  If your statement were true, board-certified specialists in addiction medicine all over Tennessee would have to close the doors of their small practices, given the onerous burden of registering as a pain clinic, leaving thousands of patients without care or access to care. The Tennessee Society of Addiction Medicine would have no recourse but to sue to correct restraint of trade issues. If this is true, I need to know immediately what your sources are, in particular I need a copy of the legislative bill that has been passed to create this travesty. If it is not true, we need a vigorous and public retraction correcting the mindset and zeitgeist.
John B. Standridge, M.D.

President, Tennessee Society of Addiction Medicine
Personal Medicine LLC
2115 Stein Dr  Ste 304
Chattanooga TN  37421-7200

TnSAMers! Don’t Panic… yet.

We continue to have to engage in the political arena to maintain the privilege of practicing addiction medicine in accordance with established standards of care.  In a page 12 article featured in the September TMA journal, Tennessee Medicine, it was stated, “Suboxone will be included in the type of prescriptions considered as part of determining whether a location meets the definition and should be registered with the state as a pain management clinic”.  This statement was precisely the opposite of all previous pronouncements on the topic, but it turns out to be true regarding a fundamental change in the legislation enacted, Senate Bill No 676, unbeknownst to me or anyone else in the addiction community, on the advice of the TMA’s prescription guidelines committee.  Please continue to read. Continue reading

TnSAM Addiction Medicine Conference Was A Huge Success

It was risky for a tiny 60 person organization to organize and offer a regional conference. What if we spent all that money, time and trouble, and nobody came? We were hoping for 100 registrants: we got 130! ASAM was thrilled with the REMS course turn out. We bested the turn out generated by much larger state chapters. We were hoping for meaningful addiction education. We got outstanding speakers on important topics. The evaluations were glowingly positive. We were hoping to break even. We put several thousand dollars into the TnSAM coffers. Thanks to all who came. Thanks to all who made it happen. Shall we do it again next year?

The Very Lastest Conference Information — AAFP Preferred CME Credits Have Been Approved

Dear Colleagues:

We have an abundance of new information regarding the 2013 TnSAM Addiction Medicine Conference, now being held in Chattanooga, Tennessee August 29th and 30th. Roughly 123 people have registered.

AAFP accreditation is approved.This Live activity, Tennessee Society of Addiction Medicine Conference (3rd), with a beginning date of 08/29/2013, has been reviewed and is acceptable for up to  12.00 Prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Family Medicine doctors, we paid the extra monies to get prescribed credit for you. You are very welcome.

NAADAC, the Association for Addiction Professionals, approved the 2013 TnSAM Addiction Medicine Conference for contact hours for attendees. NAADAC is the premier global organization of addiction focused professionals and we are honored that they will provide Continuing Education Credits for their 8,000 members who attend.  Thanks to TAADAS, Tennessee Association of Alcohol, Drug & other Addiction Services, for facilitating this valuable Continuing Education accreditation for counselors.

Specialists in the field of Pain Management will be happy to learn that attendance at the 2013 TnSAM Addiction Medicine Conference will count toward the requirements by the state for physicians working in pain management clinics.

The AMA and the TMA have proclaimed a desire to be on the forefront of the prescription drug abuse crisis issue, promoting access to addiction treatment and physician education. The American Society of Addiction Medicine and the Tennessee Society of Addiction Medicine have created a free three-hour risk evaluation mitigation strategy conference about opiate prescribing.  Titled ER/LA Opioid REMS: Achieving Safe Use While Improving Patient Care, this session is designed in association with the FDA and ASAM at no charge (Free CME!) thanks to a grant.

The 2013 TnSAM Addiction Medicine Conference is co-sponsored by the UT College of Medicine. The Tennessee Society of Addiction Medicine is now offering this conference to those in the field of education for the cost of the lunches. Registration is now open to medical students, nurse practitioner students, and UT faculty and residents for $20! This 2-day conference with full accreditation and internationally recognized speakers is that important.

The conference at a glance:

Thursday morning, 8/29/2013

ER/LA Opioid REMS: Achieving Safe Use While Improving Patient Care – Herbert L. Malinoff , M.D.

Thursday afternoon, 8/29/2013

Hooked But Not Hopeless – Sherry Hoppe, Ed.D and Sylvia Yates

Tennessee Department of Health and TMA Response to Tennessee’s Prescription Drug Abuse Epidemic – Mitch Mutter, M.D.

Dual Diagnoses: Management of co-occurring disorders in Addicted Patients – Terry Holmes, M.D.

Opiate Dependency in Pregnancy – Tom Cable, M.D.

Friday morning, 8/30/2013

Addiction Medicine Talking Points – John Standridge, M.D.

Evidenced-Based Behavioral Treatments for Addiction – James Finch, M.D.

The Neurobiology of Reward and Addiction – John Standridge, M.D.

Friday afternoon, 8/30/2013

Lunch and Learn with Faculty

Counseling Skills Workshop: Motivational Interviewing, Cognitive Behavioral Therapy, and Mindfulness – James Finch, M.D. and Jane Finch, L.C.S.W.

John Standridge, MD, FAAFP, FASAM

President, Tennessee Society of Addiction Medicine

Dr. Herbert Malinoff is scheduled to present the course on ER/LA Opioid REMS: Achieving Safe Use While Improving Patient Care

Dr. Malinoff is the president and founder of Pain Recovery Solutions, PC. He is certified in Internal Medicine, Medical Oncology, Pain Management, and Addiction Medicine. He specializes in treating patients with chronic pain syndromes, addiction as well as addressing their internal medicine needs. His understanding of the relationship between medical problems, pain, and addiction led to the establishment of a practice that provides services to patients that address multiple related problems using an integrated, comprehensive approach.

Dr. Malinoff lectures internationally on Chronic Pain and Addiction and is a member of the board of directors of the American Society of Addiction Medicine (ASAM). He is co-chairman of the ASAM annual course on pain and addiction. Continue reading