Former US Representative Patrick Kennedy

In this hard hitting, no holes barred interview, former Rhode Island congressman Patrick Kennedy discusses what it will take to successfully combat and reverse our generation’s biggest public health crisis, the opioid epidemic. Does the US have the will for success?

Steve Defossez: What do you think it will it take for this country to develop the political will necessary to actually stem the tide of the opioid crisis?

Patrick Kennedy: Not to sound like a downer but …we couldn’t wrap our arms around the invisible wounds of war for our citizen soldiers the way we need to do to address suicide; (acknowledging the obvious tragedy of 23 soldiers dying a day, in many cases for totally preventable suicides). If we couldn’t get a significant tranche of money for the opioid crisis given the epidemic that’s ongoing, it’s really hard for me to know what it is going to take to spur that kind of political will.

Steve Defossez: Once an effective treatment for HIV-AIDS was discovered, the death rate from HIV-AIDS started coming down right away. Yet similarly effective medication assisted therapies were developed for opioid use disorder years ago, and they have not been widely deployed; hence the death rate from opioid overdose continued to increase.

Patrick Kennedy: The comparisons are that during the HIV-AIDS epidemic, we were spending $24 billion a year to save these patients. And that made a big dent changing the whole fatal nature of HIV-AIDS. Today, we’re spending less than half $1 billion, on the opioid epidemic when we were spending $24 billion on the HIV-AIDS epidemic.

(It should be noted after this interview, Congress passed and the president signed the recent bipartisan spending bill which does include 4 billion dollars to combat the opioid epidemic. This is not allocated solely to fund treatment, however. It also funds opioid prevention, research and law enforcement.)

Steve Defossez: We need to open up people’s eyes to the fact that the genetic predisposition to addiction, like karma, is written indelibly into our genes at the moment of conception. Opioid addiction is as much of a “physical disease” as appendicitis is.

Many patients really want to feel normal again, to get out of the cycle of withdrawal symptoms and use, but they don’t see an alternative to avoid withdrawal besides the use of heroin.

I was told by a hospital CEO in the US Southwest that, when a patient without medical insurance presents to their emergency department with an opioid overdose, they are resuscitated and then immediately discharged back into the community, with no hope of accessing medication assisted therapy, because medication is simply unavailable to patients without insurance in her county. It’s stunning that in a country as rich as ours, which spends 20% of its GDP on healthcare, there is no treatment for these patients.

“And the persistence of this problem is so inexcusable.”

Patrick Kennedy: What’s also stunning is that the hospital CEO wouldn’t follow-up that statement by saying, “and I have therefore made a directive that as hospital CEO, my staff and my doctors will provide that medication assisted treatment, and we are going to work with our local community college to get the necessary peer support specialists etc. We will do that right here on the campus of our hospital.” That’s the appropriate follow-up line. Everyone thinks it needs to be someone else’s job, you know, send them somewhere else. And if they are rich, they can fly to some other part of the country. When in reality, they need to go to their hospital right down the street, where they go for everything else; they need to go there for this care too.

Steve Defossez: And today there isn’t parity. If that patient was pregnant and in labor, they wouldn’t say “oh, you don’t have insurance, leave the hospital.” But for patients suffering from opioid substance use disorder, they do say that.

“Bottom line; hospitals and doctors need to offer medication assisted therapy, as part of their moral responsibility…”

Patrick Kennedy: And the persistence of this problem is so inexcusable. Because as I said the template is pretty simple. They’re going to have an injectable medication. There are several companies coming up with different forms of injectable buprenorphine (medication). All of the insurance companies said they’re going to be reimbursing for this. CMS (Centers for Medicare & Medicaid Services) could easily do a bump up in opioid use disorder reimbursement payment. I’ve talked to them about doing this and they may well be on the track to doing that.

Patrick Kennedy: Bottom line; hospitals and doctors need to offer medication assisted therapy, as part of their moral responsibility, as the chief healthcare provider in the community. It’s hospitals that need to do this, it’s doctors that need to do this.

Patrick Kennedy: The AMA needs to step up. We know it takes eight hours of training to become certified to utilize these medications to treat substance use disorder. Physician organizations should just say you know what? We are going to incentivize that training. We’re going to make payment increases for substance use disorder a top priority. In addition, we are working with the National Council Of Behavioral Health to provide wraparound services. So doctors, you don’t need to do anything but write a prescription for the buprenorphine. Let the community mental health activists and those in the community recovery movement take it from there.

“It’s disappointing that there is so much lack of imagination in the space.”

Patrick Kennedy: This can be put together. I’ve run campaigns, not only for my own case, but for many others, for a long time. We know what the essential elements are for a good campaign. We know how to do it. The playbook is roughly the same. You make some small changes depending on where you are. This is not complicated stuff. It’s not a heavy lift to do. And I guarantee you that a lot of insurance companies would like to do this, because they don’t like the increased costs foisted on the system by undertreatment of opioid addiction.

Patrick Kennedy: With alternative payment models, such as Accountable Care Organizations (ACOs), hospitals and providers are increasingly taking on insurance risk, and are responsible for the total cost of care. They do better financially when they deliver high quality care, utilizing the fewest resources. In an ACO model, hospitals could negotiate increased reimbursement rates for providing mental health treatment and treatment for opioid addiction with these insurers. The rationale would be that we are going to treat the whole person, and be rewarded with lower overall healthcare costs and healthier patients. There are experts who can show that if we treat opioid addiction appropriately, we can easily expect to achieve over a four times lower cost of “physical healthcare” costs. This is the real result of putting somebody into a chronic care management program for addiction.

Patrick Kennedy: There is no rational way to explain why this isn’t already being done. It’s not because we don’t know what to do. It’s not as if we don’t have the reimbursement mechanisms that can be devised to make this a value proposition, especially in this new era of value-based payments. It’s disappointing that there is so much lack of imagination in the space.

“It would be my bet that perhaps one of the single biggest returns on investment in healthcare that we could expect today is to improve the quality of our mental health delivery system, as part of our healthcare system.”

Steve Defossez: Do you think integrated care is the future of mental health and addiction service delivery? What needs to happen to increase its uptake?

Patrick Kennedy: We need to align the financial incentives for optimal outcomes across the entire mental health – physical health spectrum. The optimal outcome is the reduction in the reoccurrence of illness, complications to illnesses and unwanted conditions such as readmissions to the hospital. If mental health issues factors into that, then pay for mental health treatment, at least to the degree that mental health factors into reducing those bad outcomes. It would be my bet that the current lack of mental health treatment factors into contributing to bad health outcomes in a big way.

Patrick Kennedy: In fact, it would be my bet that perhaps one of the single biggest returns on investment in healthcare that we could expect today is to improve the quality of our mental health delivery system, as part of our healthcare system. This is because of how much it’s going to do for the rest of healthcare. I think that unfortunately, the value proposition to cancer will be depression treatment. The value to diabetes could be alcohol treatment. The value to all kinds of intellectual and developmental disabilities will be prenatal care. There are five times as many babies born today with alcohol and drug related complications than there are kids born with autism. The bottom line is, it is integration, integration, integration. Mental health in each and every one of those areas of medicine can be the decisive factor in changing the health of our population.

Steve Defossez: That’s right. 5% of the US public consumes 50% of our healthcare. When you talk to people who work in emergency rooms, there are patients who come into the emergency room several times a week, because of anxiety issues or homelessness and because they don’t have access to more appropriate and less expensive care.

Steve Defossez: A friend of mine is a healthcare CFO in California who noticed one of their patients (who was not particularly ill) was spending $200,000 a year on unnecessary emergency room visits. The patient was checking into the emergency room every two or three days with one complaint or another. When the CFO evaluated the root cause of this behavior, he discovered it was because the patient was homeless. So this CFO somehow arranged to get this patient a stable apartment. The following year, what you think the insurance company spent on his healthcare? The answer is the patient stopped visiting the emergency room altogether. The insurance company didn’t spend one penny on this individual’s health care the following year.

Steve Defossez: I’m not a constitutional scholar but we all know cruel and unusual punishment is banned by the US Constitution. I’m pretty sure if we addicted prisoners of war to opioids and then forced them to go through withdrawal, this would be considered torture. Yet that’s just what we do in the criminal justice system. If someone goes into jail with diabetes, no one thinks twice about giving them insulin. But I understand almost nobody gets medication assisted therapy for opioid use disorder while incarcerated. Hence they’re forced to go through withdrawal and suffer cravings. Particularly with the long acting injectable medications you discussed, proponents of this unconstitutional policy can’t use the argument that these medications might be used illicitly within the prison. Am I wrong that failure to provide medication assisted therapy is a violation of the US Constitution, and a violation of the Parity Act which you spearheaded in Congress?

Patrick Kennedy: That’s right, and then you have the very real incarceration of people with these illnesses and also people with full-blown psychosis, banging their heads against the jailhouse doors. I’ve seen that going into these prisons. We are in a bad place in this country regarding the treatment of people with mental illness including those with addiction.

Steve Defossez: The United States is an outlier in that we incarcerate more people on a percentage basis than any other nation. Part of this is that we incarcerate more people with mental illness than we hospitalize.

Patrick Kennedy: That sounds about right. That’s what we ended up doing, shifting them from the “asylums” to the new asylums which are obviously our jails and prisons.

Steve Defossez: Where you think the future of opioid substance use disorder is headed, including the concept of supervised injection facilities (SIFs)?

Patrick Kennedy: We have long acting buprenorphine in phase 2 trials. Indivior just gained FDA approval for a monthly injection of buprenorphine this past November

Some of the existing long-acting medications come with a catch in that they were administered through a large-bore painful needle. But now they are developing these new long acting injectable medications which can be injected through a tiny needle, like your flu shot. You’d only have to adjust a little bit of titration down from the use of heroin, prior to starting treatment with these medications. These injectables satisfy cravings and protect a person from overdose.

Steve Defossez: Yes, I understand these new long acting buprenorphine medications do not require patients to go through withdrawal or detox before use.

Patrick Kennedy: So it seems to me our first urgency ought to be to get these types of products out, because to your earlier point, people are looking for a way to stop that cycle of in – out, in – out. Substance use followed by detox, followed by substance use then detox. If you can stop the cravings and use, you can prevent them from overdosing. Why isn’t this treatment more widespread? Because it’s out there, it’s not fantasy.

Patrick Kennedy: I understand the harm reduction of supervised injection facilities SIFs, but it’s kind of like what you do when you have no other options. My point is we have these other options, let’s double down on our options, and put these injectables in every doctors’ office in the country, like we do with our flu shots. I know they’ve had success with SIFs in Canada. I’m on my way to Philadelphia now, so I should learn more about SIFs soon.

Steve Defossez: The safe injection facility concept is that people bring in the stuff from the street because they don’t want to stop today but they do want to not die. So they bring it in from the street and this does allow the employees to take microscopic samples of the heroin to see what’s out on the street, whether it’s fentanyl, elephant fentanyl etc. If the person overdoses in the building, they can be resuscitated so they won’t die. And of course because it’s a medical facility, there are staff there who can teach the patient how to inject in a sterile fashion so they don’t get bacterial heart infections, HIV-AIDS, hepatitis etc. While there, patients also have access to first-aid for superficial infections, a warm shower and food. Every encounter is a touch point where someone explains to the patients that when they are ready to choose recovery, we can offer that too.

Patrick Kennedy: I like that. I was very much for safe needles exchange 20 years ago in Providence when I was first a state representative there. And God, it was so hard to get it passed and now, you know, it’s obvious these days.

Conclusion: Every American should awaken to this simple fact: if this scourge has not yet found you or your family, without bold action by everyone, it soon will. I ask you to support cost-effective and life-saving medication assisted therapy by emailing your elected state and federal senators and representative and express your support for adequate funding for and widespread dissemination of this life saving therapy.

As we learned with racial segregation, separate is not equal. Insurance plans should cover all diseases equally. In America, perhaps due to stigma or prejudice, insurance plans have historically paid more generous benefits to what they called “physical health” as opposed to “mental health” and substance use disorder (addiction) treatment. In medicine, it is often said that behavioral health care is paid the lowest fees, and within behavioral health, the very lowest fees are paid to treat substance use disorder.

In 2008, Former US Representative Patrick Kennedy was a chief sponsor of the Mental Health Parity and Addiction Equity Act (MHPAEA). This bill was signed into law under President George W. Bush, as part of the Troubled Asset Relief Program also know as TARP. Let’s hear what he has to say about parity today:

” When you think you’ve done it, check again. Historical biases and prejudices have a sneaky way of infiltrating our practices.”

Steve Defossez: What can hospitals and health systems do to make sure we finally see full implementation of the 2008 Mental Health Parity Act (the federal parity law)?

Patrick Kennedy: Well, we have to change our cultural predisposition towards these issues. Historically, we segregate mental health issues to the margins of healthcare. Why? because they were not seen as real healthcare issues. Unfortunately that’s the backdrop from which we come. So if I were to emphasize anything, it’s that when you think you’ve done it, check again. Historical biases and prejudices have a sneaky way of infiltrating our practices.

Patrick Kennedy: We don’t know what the future looks like in healthcare delivery because it hasn’t happened yet. We know academically that mental health is essential health and the brain mediates the health of the whole body. We know that you can’t properly treat any illness without treating the mental illness as well, which may underlie it. Mental illnesses often underlie physical diseases. Depression and anxiety are often co-occurring with all other major illnesses and physical disabilities. I would say that we need to start with the parity law because it’s very tangible and easy to wrap our arms around. Ask yourself, are we treating mental health and addiction the same way we treat physical and surgical diseases? Do patients with mental health issues have the same access to inpatient and outpatient care? Is this true for in-network providers and out-of-network providers? Do patients with mental illness have the same pharmacy benefits (coverage and deductibles) and the same ER benefits as patients with “physical disease?”

Patrick Kennedy: The parity law (which requires health insurance plans to pay for mental illness treatments just as it pays for physical illness treatment) is not just for payers. Hospitals are increasingly becoming part of these Accountable Care Organizations (ACOs) which are taking on insurance risk. This concept of bifurcating (separating) the payer from the provider; that obviously is quickly becoming a thing of the past.

“Lack of access to mental health care and addiction treatment… is driven by money and the lack of resources.”

Steve Defossez: How does the current system fail to treat behavioral health issues the same as so called, “physical health?”

Patrick Kennedy: One needs to really understand the practices of insurance plans to see the discrimination occurring today. Technical insurance procedures, including:

medical necessity determination, (where an insurer can determine that a procedure is not “medically necessary” and therefore not pay for it.)
retrospective review (where an insurer can fail to pay for a service which has already taken place)
prior authorization (a time consuming hoop physicians need to jump through, in order to get the insurer to approve a service. If the service is performed, even if medically necessary, the insurer will not pay for it unless prior authorization is obtained first.)

These insurance procedures, and others often result in inadequate payment of those who provide mental health services.

This, of course, has led to the historic lack of access to mental health and addiction treatment. By the way, every hospital system and every state is still suffering from lack of access in terms of the inability to really address this public health opioid epidemic. And there is lack of access just to address the day-to-day needs of every patient. All of that is driven by money and the lack of resources that have gone into paying for reimbursement for professionals in mental health. The lack of payment for providers and other ancillary services can actually increase cost and lead to worse outcomes.

Patrick Kennedy: For example, we know stable housing produces as big an impact on stable mental health as anything else you can do on the medical side. We need to do more to provide access to stable housing, and this will be cost effective, as it reduces healthcare costs. We know the science of mental health. It’s not always just biological in terms of its intervention. Social services can be as important as medications. So we need to treat the delivery of mental health services as scientific. If you do that, we can start to move away from this cultural bias among medical staffs and hospitals that this somehow is not what they do. In fact, in order to achieve better outcomes using fewer resources, ACOs need to be thinking about how they address the mental health component of all diseases, whether it’s oncology, cardiovascular disease, diabetes or what have you.

The time for healthcare parity is long overdo. Unless we make it known that our behavioral health benefits are not equal to our physical health benefits, nothing will change, If you experience second class treatment for a behavioral health issue, please contact your state’s insurance commissioner, US representative, US senator or me at Steve@DefoSays.com.

Please be on the lookout for the next and final installment (Part Two) of our two part interview with Former US Representative Patrick Kennedy, where we will address the US opioid crisis.

Prescription for the US opioid crisis: An interview with former congressman Patrick Kennedy (Part 2 of a two part series)