CareTalk Podcast – Patrick Kennedy: From Addict to Advocate

John and David confer about the causes behind the uncontrollable spike in COVID cases in both India and Brazil.

David Williams:

Welcome to CareTalk, your weekly home for incisive debate about healthcare business and policy. I’m David Williams, president of Health Business Group.

John Driscoll:

And I’m John Driscoll, the CEO of CareCentrix.

David Williams:

Well, John, we have a repeat guest. And I’m a little confused because this is Patrick Kennedy, and last time we talked about mental health parity and how everything is going to be fixed, I thought it was all fixed by now [inaudible 00:00:19] got nothing left to talk about, but let’s see if there is anything.

John Driscoll:

Welcome, Patrick.

Patrick Kennedy:

Thank you, John, and thank you, Dave. It’s good to be back with both of you. And congratulations on the success of this podcast. And let me just say how much I appreciate how successful you’ve been in trying to get a message out that’s important, especially around mental health and addiction. I’m happy to be one of those you talk to who can give you a little bit of an update.

I wish I could’ve said even after the bill passed that I had a chance to author about 13 years ago, the Mental Health Parity and Addiction Equity Act, that after the administration pushed rules through implementing it that it was all done. Here we are over a decade later, and the GAO just a week ago came out with a scathing assessment of payers’ accountability to the mental health parity law. I mean, it was particularly galling given the fact that over the course of the pandemic, when mental health crisis really ran parallel to the COVID crisis because they’re one and the same, the denials continued. And that’s got to change, especially coming out of this pandemic when we can focus full time on the mental health aftermath of it.

John Driscoll:

A threat as well as a promise, Patrick. What’s that going to mean?

Patrick Kennedy:

No, no. Well, the Congress just last cycle in the Consolidated Appropriations Act, which is part of the COVID relief, passed real amendments to the parity law now requiring health plans to have on file, at a moment’s notice their detailed analytics for how they’ve applied the law across medical, surgical, and mental health. That was not required under the previous guidance. That’s brand new, and that was a result of a legislative initiative that got put in the last appropriations bill.

Even Secretary Acosta, who’s the Republican labor secretary who preceded Secretary Walsh, really found that payers were not doing what they were supposed to do. And he had a different take from a Democrat. He said that he just didn’t like how private payers were shifting the cost of these patients onto the taxpayer. And as a Republican, he didn’t like the fact taxpayers were essentially subsidizing private insurance, which I thought was a pretty interesting angle. That’s an angle Republicans can make. Senator Cassidy also joined him in that initiative, so we have bipartisan support.

John Driscoll:

What does that practically mean in a pandemic for somebody who wants to get mental health, doesn’t quite know how to … This has been a brutal time for so many families and individuals. I mean, cutting through the clutter of the healthcare system, how does that affect access?

Patrick Kennedy:

It’s all about access. We need access and we need quality, but we need access almost first while we’re trying to improve the system. And of course, we’re catching up from years of neglect when insurers basically carved out mental health, left it to the side, put a small capitated reimbursement on it, and then didn’t think twice about it. Now, major employers in this country are demanding that their third-party administrators give them adequate networks because they’re worried, to your point, that employees who need mental health for themselves or their family cannot spend six weeks waiting for their first appointment because there aren’t an adequate number of mental health providers in network.

We have a violation, essentially, of parity when an insurer has an inadequate or phantom network of providers in mental health because, essentially, that’s forcing people to go outside in network and pay higher out-of-pocket copays for their out-of-network care, which they would not have to pay if they were trying to get diabetes care or cardiovascular disease or oncology or whatever it is.

That’s where parity, which means equal, it really falls on its face because this is part of a historic anemic reimbursement of providers, which of course, as you know because you’ve really led the way, John, CareCentrix, about addressing this just huge disparity in salaries amongst CEOs and staff. Mental health providers are lowest end of the rung, and no wonder there aren’t many of them. And that is, there’s not much of an incentive for people to go into mental health as a career.

John Driscoll:

This is basically legislation and regulation that would mean insurance would ensure access. I mean, that’s really what this … to real care. I mean, that’s really what we’re talking about.

Patrick Kennedy:

That’s what we’re talking about. And even more importantly, enforcement. So we wrote the law that said you had to eliminate the higher copays, higher deductibles, higher premiums, and lower lifetime caps. I blew through my mental health and addiction treatment cap when I was 22 years old already. What we have in this country is we address the quantitative treatment limits, those ones I just spoke about, but we have not fully implemented the non-quantitative treatment limits, which are pre-authorization, concurrent review, retroactive review, medical necessity determination, essentially.

And the Wit case in Northern California, UnitedHealthcare versus Wit, really was a model case on the violation of a payer’s fiduciary responsibility to their subscribers. Because remember when people buy insurance, they’re buying mental health as part of their insurance. So when the insurer denies equal coverage, they’re not following their obligation to provide that insurance that was already purchased.

John Driscoll:

I don’t want to go too deep on what’s going wrong until we’ve really established how big a challenge … This has got to be a much bigger challenge in the middle of a pandemic. I mean, there’s a huge unaddressed anxiety and depression based on all of the statistics, Patrick. I’ve got to think this is getting worse, not better from a patient perspective.

Patrick Kennedy:

There’s no doubt that we have an epidemic of mental health along with the pandemic. And I will say for the payers, they’re seeing the light now. They know that the people they work for, Fortune 500 companies and beyond, are not going to have them on managing their benefits unless they can fix this, which is good.

And the payers, to their credit, are really insisting that it’s quality care, which I really support. In fact, my former colleague Jim Ramstad, God rest his soul, Republican from Minnesota, both of us were as equally outraged by people buying mental health that didn’t get them better because it never followed the evidence-based protocols, like cognitive behavioral therapy, which we know really help people gain recovery.

So this is a moment where we need not only access, but we need quality. And I’m also proud, John, to make a pitch for Psych Hub, which I had a chance to co-found along with Marjorie Morrison. And that’s trying to help the payers make sure that all their providers follow the latest in evidence-based treatments for particular diagnoses. Because in the past it was a one-size-fits-all where a therapist would see someone with grief in the morning and eating disorder in the afternoon and addiction during the day. And of course, they all require different kind of skill sets.

David Williams:

Patrick, tell us a little bit about how you personally got into a system that doesn’t work for so many. What’s your personal story?

Patrick Kennedy:

Well, I am a person who is living in long-term recovery. For me, that means I haven’t had to drink or use drugs since February 22nd, 2011. I have been well-known for being a person in recovery. I mean, I was arrested several times at airports, in boats, and most notably when I tried to drive my car into the Capitol at 3:00 AM in the morning. So I pretty well established as a certified drug addict.

And yet when I went to my physician, and of course, he knew who I was, he had gotten the appointment … and he even asked me about my cousin Caroline, who was ambassador to Japan at the time. He then asked me all about my asthma and my cholesterol. Of course, I have a big scar on my back from an original surgery that really kicked off my opioid addiction.

And I told him at the beginning, I said, “My biggest health problem is that I have the disease of addiction.” And then by the end of the doctor’s appointment, I asked him to prescribe me some Percocets. Because I said, “You can imagine with the scar on my back, it flares up once in a while. And if I can’t get back to you in time, couldn’t you just give me something to hold me over?” Part of my old kind of rap I had perfected over years for procuring drugs before there was a prescription drug monitoring program in place.

And you know what, he broke out his prescription pad. It was within literally half an hour of me telling him I was someone who was in recovery. And it’s because he was so focused on his EMR Q sheet, which had him ask questions about my asthma. Which inhaler do you use? Do you have problems breathing? How many times do you use your inhaler? Do you use steroids? I mean, there’s nothing in his questions about addiction, and there’s nothing in his own training for him to know how to treat addiction.

So then I proceeded to, I think I might’ve told you guys this story last time I saw you, going into the emergency room not long thereafter when … By the way, it should’ve been in my EMR that I was an addict. And so they asked me, “What are you allergic to?” And I said, penicillin and opioids. And the nurse kind of laughed. She’d never heard that before. And of course, they sutured me up for this injury that I’d had.

And then of course, because it’s an ER, everyone’s running in different directions, a new nurse comes in and hands me a script for Percocet. And thankfully, my wife, Amy, had just walked into the emergency room and snapped it right out of my hands. Even though my addict brain said, “Oh, well I have a legitimate use for this. It’ll only be for a few days. Blah, blah, blah.”

Then fast forward just about two and a half, three years ago, my wife and I have had five children. So she said, “Enough already,” sent me to the urologist. I’m coming out of propofol, and they had already given me a couple of Percosets. And I had said the same thing before going into that procedure. I said, “I’m addicted to opioids.” And even with that, they still gave it to me.

And my addict brain was off to the races because I wanted to fill the script. I went and I filled the script. I’m now probably six years into recovery. I go to meetings all the time. But just shows you the power of this compulsion.

David Williams:

Patrick, the good thing is that all this is, of course, many years ago. And since we spoke at least over the last two years, all of this has been now cleared up, and if this happened to somebody else … This is not happening. You’re a unique case. And everybody now understands. The dentist isn’t giving out Percosets. The vet doesn’t leave them around. You don’t have too many and so on. So this is just you, right? And this is just like the history books.

Patrick Kennedy:

Yeah, I wish that was the case. I’m, frankly, as I said previously, for people who have legitimate medical pain to get those strong opioids, but clearly we still have a challenge.

John Driscoll:

Do you think it’s a cultural breakdown between the body and the mind that we still have these kind of arbitrary gates that we don’t go through. How do you explain the fact that after you’ve disclosed the fact that you’re an addict, you’re famous as an addict, that they would give you pills that would make you more … It’s insane to me.

Patrick Kennedy:

Well, equally insane during this pandemic, the rate of benzodiazepines that have been prescribed is off the charts, and the medical profession really under … Those are Xanax, Librium, tranquilizers, all of which can be very addictive and all of which are very difficult to detox from. I was also addicted to Xanax.

It’s a worrisome thing because the medical culture will throw a pill at you, and that’s your care route, is medication. It’s not therapy. And we have to make sure therapy gets in there. But as I’ve said at the beginning, we just have inadequate access to therapy because there are too few providing therapy, so medication is dispensed. 70% of all antipsychotics, antidepressants, anticonvulsants, all written by primary care docs who’ve had zero training, and they’re the frontline of mental health.

John, we just did this report, your friend John Sununu, Republican from New Hampshire, and I, from the Bipartisan Policy Committee. And it calls for much greater reimbursement for primary care practices to build out their network EMRs and to build out their access and reimbursement for collaborative care. We need to do that because we’re not going to be able to build a whole overnight, separate mental health addiction system, which is what most docs want to do, is just push it off to their mental health cousins. This has got to be done by every doc, every provider in the country.

John Driscoll:

It also sounds like every family member needs to be an advocate for any family member that might have a problem because the system is unsafe, either because of access or risk, it sounds like. So really, this is a call to arms not just politically but personally for families to protect the most vulnerable people in the family. Because it doesn’t sound like, without advocacy, people are going to get the care they deserve, even if they paid for it or can manage the risk, even though it’s disclosed.

David Williams:

And, Patrick, along those lines, you talk about medication is given out for everything, and yet there’s another medication, naloxone, that maybe is not used as much as it should be and may also be a form of advocacy.

Patrick Kennedy:

No question. We are going to have over a hundred thousand deaths due to opioids this year when all the numbers are out. We’re 92,000 now. We were 78 maybe four months ago, according to latest stats. And they’re all telling me it’s going to be over a hundred thousand.

So the question is, how could we stop those deaths? One simple answer: have an available equivalent of an EpiPen, a naloxone shot. Or they can give it a nasally as well. But the shot will be very important, particularly because most of the current opioid overdoses are driven by fentanyl, which is very potent and which really stays in the system. So the shot is really the best chance.

And they tell me, “Well, how do you know when to give the shot?” People who are fellow addicts like me may say you’ll wake up in a second if someone says you’re going to get a naloxone shot. That if they don’t wake up to that … because everybody knows it’s a terrible, dysphoric feeling that happens after you get the shot. When you sober up, so to speak. Then that’s the time to give them the shot.

And the amazing thing, to your point, John, is most family members treat addiction kind of like alcoholism. Let them sleep it off. Let them sleep it off. When that’s the worst thing to do when someone that you love is suffering from the disease of addiction. I just was out, in fact, three weeks ago distributing naloxone kits to sober homes in New Jersey, where I live now. If there is ever a place to have an naloxone kit, it’s in a sober house, and yet they don’t have that.

John Driscoll:

Explain for folks who don’t have family members or personally gone through it, what a sober house is and why it’s such a critical bridge for addicts.

Patrick Kennedy:

A sober house is for people who really don’t have access like I did to long, inpatient stay for my addiction. What they end up doing for most Medicaid plans are discharge you after immediate detox, and really not sufficient to helping you recover, but then they refer you to a sober house because that’s the most cost-effective way.

And sober houses, if they’re not properly … have the proper oversight are really opportunities for a lot of dysfunctional behavior to compound on itself. And they’re ripe, unfortunately, for a lot of people relapsing because they never got that strong foothold. And because, frankly, there are a lot of rehabs out there that still insist on a pure sobriety, old school definition as opposed to MAT, which is the evidence form of treatment for people with opioid use disorder. I myself had have titrated off Suboxone, but I was on it for a couple of years in order for me to manage my addiction to opioids. And if we provided people with Suboxone, it quiets the fire in their brain that says that they need to use.

John Driscoll:

The distinction you’re making is between kind of cold turkey sobriety, the kind of the Old Testament sort of perspective view of this, versus the medicine-assisted therapy where you combine the drugs that are targeted to dial down or basically tamp down those fires that are wired in the brain.

Patrick Kennedy:

Addiction is a physical illness, it’s a mental obsession, it’s a spiritual malady. We need to treat, through reimbursement by insurers, the medical illness. But then you need mental health afterwards to address the mental obsession. A lot of that happens through 12-step recovery, which is a form of cognitive behavioral therapy. In other words, instead of thinking your way into a new way of acting, you act your way into a new way of thinking. You do it with the support of your colleagues and peers in recovery.

And then, of course, the spiritual element is you want to be connected with people, which of course the pandemic didn’t allow you to do. Obviously, Zoom is good for some, but it misses that chemistry that’s so important for people to get, especially if they’re new in recovery and they don’t have those well-established personal connections in 12-step recovery.

So I would just say this is a particularly challenging time, and we need to be prepared to stop deaths. We know we can’t get everyone on the road to recovery, but we can stop them dying.

John Driscoll:

But we’ve got to be able to do better. I mean, at a hundred thousand deaths per year from opiates, that’s more than died in Vietnam. I mean, the numbers are insane. And I thought the numbers had gone down and then they started to go up again.

Patrick, is this a partisan issue? We talked a little bit about the politics and the policy. Is this a Democrat versus Republican? How would you think about the challenge here politically?

Patrick Kennedy:

Well, let me just say on a big picture basis, whether you’re a Democrat or Republican, we’re really not even scratched the surface of responding to this. Now, during HIV, for another comparison, we were losing 53,000 lives a year during the height of the AIDS crisis. We started appropriating $24 billion in the congressional budget for tackling the HIV/AIDS crisis. Up until three years ago, we were spending less than $3 billion. Now it’s going to be touching maybe 10, still well under half of what we spent on HIV/AIDS. And I might add, we’re losing twice as many people as HIV/AIDS.

So whether you’re a Democrat or Republican, the bottom line is we reflect the American public who has not made this a priority because, generally speaking, those of us who know someone with addiction are ourselves fed up, frustrated, intolerant, impatient, because these diseases do one thing: they alienate us from the people we love. And the people we love are alienated from us, and they prefer to keep it that way. And there’s no motivation for them to go to Congress or the state House, raise their hand and say, “I’m a family member of someone with addiction.”

John Driscoll:

So it’s not really a question of D versus R, but in the light versus in the darkness. I mean, really what we’re talking about is still that cultural challenge. How do we crack that?

Patrick Kennedy:

I think, like racism, and we’ve seen kind of the recognition once again that even despite the advances in the ’60s, civil rights laws, voting rights laws, fair housing, fair employment, you look at all the battles today in the last few years, and it’s very clear that those divides still plague this country. And yet it’s still against the law to discriminate, thank God. So you cannot eradicate bigotry from people’s hearts, but you can make it illegal for them to act on that bigotry.

What we’re not doing today is enforcing anti-discrimination laws like the parity law with payers when it comes to them discriminating against people’s treatment. And I might say that most people, while they may not love people with addiction, they don’t like the idea of the insurance system providers discriminating against people with these illnesses.

So we are making progress, and I would say it will take quite some time for us to culturally change our kind of unconscious bias against people with addiction and mental illness. I mean, we walk by them every day on the street.

John Driscoll:

[crosstalk 00:25:06] bias. I was going to say conscious and unconscious. I think there is a conscious bias because at some level … I don’t know, Patrick. Whether it’s threatening or fear-based. But one of the things that we love about having you on our podcast is you are fearless in embracing the difficult and the personal, because we have to, to hold the system. And it’s not just insurers. It’s insurers, providers, it’s families, it’s neighborhoods. We have to embrace these problems if we’re going to actually solve them. And I just think that for us, yours a very courageous path.

Patrick Kennedy:

I would just say, for people out there, we know how to solve this crisis. I just want to disabuse people of the notion that no one ever gets better. If we were intervening stage one, just like they do with cancer, we’d be making much better progress. Instead, as everyone knows who’s listening, we do not address people’s addictions or mental illness till they’re stage four. That’s a problem. That’s why our worldview is shaped by those people who, quote, “never get better.” And they’re the only ones we know. We can change that if we do things differently.

David Williams:

Well, Patrick Kennedy, thank you very much for being a return guest to CareTalk. We’re looking forward to sharing with listeners all the work you’re doing with The Kennedy Forum, including a couple of very important current webinars. The one you mentioned with Marty Walsh, and another one on the anniversary of George Floyd’s death, you will be doing, as well as David Satcher. Thank you very much.

I’m David Williams, president of Health Business Group.

John Driscoll:

And I’m John Driscoll, the CEO of CareCentrix. Thank you, Patrick, for giving us some courage and some hope on this difficult issue.