Private insurers see surge in opioid-related claims

Private insurance claims related to heroin overdoses alone jumped 400 percent in one year.


New health insurance data puts to rest any notion that addiction to opioids like heroin primarily affects the poor.

In a single year, the number of private health insurance claims related to heroin overdoses in Dayton skyrocketed by more than 400 percent, underscoring the drug’s impact on the affluent and middle-income households that tend to have those policies.

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FAIR Health, a non-profit watchdog group that maintains a database of billions of claims billed to Medicare and private health insurers across the country, analyzed data specifically for the Dayton Daily News.

Its analysis confirms what is playing out in restrooms of fast-food restaurants, in cars parked in plain view on area streets and in the living rooms of city and suburban residents alike: Dayton is at the epicenter of the deadliest drug crisis in modern history.

From 2013 to 2014, claims related to heroin overdoses in Dayton jumped 422 percent, the analysis found, and were up more than 5,000 percent from 2007 to 2014. The epidemic has only worsened since 2014, and FAIR Health is currently working on an updated analysis through 2016.

RELATED: Task force seizes 66 pounds of heroin, fentanyl, marijuana in Montgomery County raids

The nonprofit tracked private insurance claims for emergency room visits, substance abuse treatment and other services related to opioid overdoses and addiction. The analysis included all ZIP Codes that begin with 454, which encompasses both urban and suburban addresses.

Claims associated with heroin overdoses occurred overwhelmingly among young adults — specifically 19- to 30-year-olds. Many of those young people are covered by their parents’ health policies under the Affordable Care Act (ACA), which allows children to stay on their parents’ health plans until age 26, said Robin Gelburd, FAIR Health’s president.

RELATED: Employers examine prescription drug claims for opioid abuse

“These claims are from people who are sitting in the cubicle next to you, or sitting next to you at the soccer field,” Gelburd said. “These are people who are employed or the dependents of those who are employed and have the means to buy insurance. That’s why I think our studies have captured the attention of some policymakers, because it’s a private insurance data set.”

The 454 ZIP Codes accounted for about 7 percent of the state’s opioid-related claims through private insurance from 2007 to 2014, even though the city represents a mere 1 percent of Ohio’s population.

RELATED: Dayton tops list of drugged-out cities

Dayton was also one of five cities in the state — Cincinnati, Cleveland, Columbus and Toledo were the others — that collectively accounted for 62 percent of all claims.

FAIR Health compiled the data to help health care providers, insurers and lawmakers better evaluate the need for treatment and addiction services and arrive at strategies to expand the range of health and social services available to those struggling with addiction, Gelburd said.

“The question is, how do you organize a health care system that responsibly meets the needs of this growing epidemic?” she said.

‘We do see the crisis’

While the latest drug crisis shows no socioeconomic bounds, low-income households are far from immune.

Downtown Dayton-based CareSource, the largest provider of Medicaid managed care services for Ohio’s low-income residents, recently began compiling its own database of opioid-related claims by tracking pharmacy claims, office visits, in-patient and emergency department claims in response to the growing epidemic.

The data will be used not only to identify the growing number of members receiving substance abuse services and treatment, but also members that CareSource may want to reach out to with medication-assisted treatment and counseling.

RELATED: Opioid crisis persists despite funding burst

“We recognize the opioid epidemic and crisis that the nation is facing, and that we are facing here in Ohio, and we do see the crisis in the member populations that we serve,” said Kelly Kopecky, director of behavioral health at CareSource, which has about 1.3 million Medicaid members in Ohio.

About 200,000 CareSource Medicaid members have already been identified as having drug problems or substance abuse disorders, said Kopecky, who noted the number increased exponentially with the expansion of Medicaid in Ohio in 2014 under the ACA.

About half of CareSource Medicaid members with drug problems joined CareSource under expansion, Kopecky said.

‘Rising premiums’

Medicaid expansion now covers more than 700,000 people in Ohio, and nearly a quarter-million Ohioans have gained coverage through the ACA’s Health Insurance Marketplace — the federally operated health insurance exchange for private health plans sold in Ohio under the ACA.

The growing number of opioid-related claims among the newly insured population touches everyone with insurance, not just those seeking treatment for opioid addiction, said FAIR Health’s Gelburd, who compared health insurance to an Aspen forest, which typically grow from a single seedling.

RELATED: No ground zero in opioid fight

“They look like individual trees, but under the ground all the roots are connected,” Gelburd said. “The health industry is connected in a similar way. If there is a surge in need for certain services or resources, that impacts every other part of the health care system as well. And it impacts the costs that have to be shared among all the other different stakeholders.”

The trend can already be seen in rising health insurance premiums for those with private coverage under the ACA. Because many people buying plans on the individual market were sicker and more costly to insure than expected, insurers were forced to raise premiums substantially to cover the unexpected costs.

The vast majority of consumers with ACA health plans were protected from the premium increases by federal tax-credit subsidies that were designed to cover most of the cost increase under the ACA. But those subsidies are at risk as Congress weighs changes to the Affordable Care Act. And people in employer-based group plans or those who bought coverage outside of the health insurance exchanges will face the cost consequences directly if opioid-related claims for addiction services and treatment continue to rise.

‘No end in sight’

The impact on insurance premiums is bound to continue because the opioid drug epidemic shows no signs of leveling off.

Ohio, which led the nation in opioid related overdose deaths in 2014 with 2,531, continued the lethal pace in 2015 with 3,050 overdose deaths, according to the Ohio Department of Health, which hasn’t released 2016 data yet.

RELATED: Stark number of ER visits show heroin’s local grip

While overdose deaths from prescription painkillers and other drugs have begun to wane, the vast majority of overdose deaths now are tied to fentanyl — a synthetic painkiller that the U.S. Drug Enforcement Administration says is up to 50 times more powerful than heroin, and is commonly found mixed with heroin and other drugs.

Locally, the Montgomery County Coroner’s Office said it investigated 145 overdose deaths in January, mostly tied to fentanyl, putting the region on pace to nearly double 2016’s record-setting 355 deaths.

“There’s no end in sight,” Montgomery County Coroner Dr. Kent Harshbarger said.



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