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How copays are contributing to the opioid epidemic in Colorado

A copay could be the tipping point for someone to become addicted to opioids based on insurance. Now Colorado state lawmakers are trying to change that.

DENVER — A copay could be the tipping point for someone to become addicted to opioids, depending on a patient's health insurance, according to Dr. Jonathan Clapp, a pain specialist with Porter Adventist Hospital. He said he's seen this problem first-hand.

"Say a patient comes into my office, and they have a knee problem that could be addressed with physical therapy. If we could work on strengthening and flexibility, we could fix the problem," he said. "But because it can sometimes cost $80 out-of-pocket for every physical therapy session, it's really hard for someone to afford that."

That's when doctors get caught between trying to treat pain and not bankrupting their patients, according to Clapp.

"Before we can get other things approved, and wait two or three days in a best-case scenario to get the right medicine, we still had to expose them to these medications, and it may have just ruined their life," Clapp said. "It's very hard for us to live with."

For two years, Clapp reached out to lawmakers to change this, and in the process, he began working with State Rep. Chris Kennedy (D-Lakewood) to work on a potential new law that would change insurance policies in Colorado that are regulated by the state.

Kennedy said one prong of the proposal would work on making non-opioid medication and less-addictive opioid medications more affordable. 

"Oxycodone would probably still be cheaper, but the hope is we are closing the gap," Kennedy said.

The second prong would include giving the Colorado Division of Insurance the authority to identify other treatments like physical therapy, occupational therapy and acupuncture as good alternatives for pain that might otherwise lead to an opioid prescription. 

The goal, according to Kennedy, is to require insurance companies to make these kinds of treatments more affordable, including limiting out-of-pocket costs and insurance deductibles.

Kennedy said physical therapy is considered an essential health benefit under the Affordable Care Act, so it's offered in every Colorado insurance plan right now. but the concern is the cost.

He also said it's a mixed bag when it comes to which insurance companies cover acupuncture and whether employers select plans that do include it. 

This idea for changing insurance policies has been sitting on the back burner ever since Colorado's Opioid and Other Substance Use Disorders Study Committee first met in summer 2017. It was a provision in a bill that was eventually taken out in order to move the bill forward.

Kennedy said legislators realized there wouldn't be enough support from his colleagues in the legislature to push it forward. However, this time around, Kennedy said the Democratic trifecta at the state capitol might change the outcome.

"We needed the politics to be right where we had majorities in both the House and the Senate who were not afraid to take on the insurance companies to do something to change the status quo," he said. "We’re really hopeful now with Democratic leadership in the senate that we are going to have willingness to challenge the status quo when it comes to insurance policies."

Kennedy was clear to point out that this proposed legislation is part of a bigger package of laws focused on opioid abuse prevention that has bipartisan support. Clapp said there's also been collaboration along the way with lawmakers, medical experts and insurance companies. 

"It's nice to see the coming-together of people who didn't get along for a really long time," Clapp said.

This legislation comes on top of previous work to address the opioid epidemic, as well as doctors working to change culture when it comes to writing out prescriptions. 

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Clapp did clarify that there are some patients who do need opioid medications. 

"Absolutely there are chronic patients that do really well on these medications and are able to work. They are able to live their lives, take care of their families," he said. "We try to add things in there to see if we can limit the opioids, but typically, they do well on opioids when we have tried everything else. Sometimes it's the only answer for a lot of patients."

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Clapp said legislation like this can help keep more people away from opioids, and therefore, reduce the risk of addiction and reduce the number of pills in homes that other people could access.

If the bill passes and prices go down for patients, the cost doesn't disappear. Often, insurance companies will absorb that cost. Kennedy said representatives from the insurance industry asked to meet and brought up the concern that this could increase premiums. 

At this point, lawmakers are still working on how much this bill would cost. It needs to pass out of the opioid committee and be approved by the legislative council before it can be introduced in January. 

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