To curb prescription drug abuse, Kentucky started in July requiring people with long-term prescriptions for controlled substances to submit to urine testing. The tests determine if patients take their drugs, rather than sell them, and if other, unprescribed drugs are in their systems.
In Lexington, retired nurse Cynthia Burton grudgingly followed the rules Aug. 14 by urinating into a plastic cup so she could get a refill of her insomnia medicine. Her husband did the same for his anxiety medicine.
Last week, Burton's insurance company, Bluegrass Family Health, sent her a letter. The urine tests at LabCorp cost $533 each, and because they were not medically necessary, the insurer said, it won't pay for her husband's test. She's still waiting to hear if it will pay for hers, but she's not optimistic given that it was the same test for the same reason under the same plan.
"More than $1,000 is pretty damn big to us. We're both retired, so it's a lot of money," said Burton, 61, "What I don't like is that, under this law, we're considered guilty until proven innocent. We're having to prove our innocence at considerable expense."
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Gov. Steve Beshear, who enacted emergency regulations requiring urine tests as part of House Bill 1, the "pill mill bill," said this week that he understands the Burtons' financial burden.
Changes may come in January when the expiring emergency regulations are replaced with permanent rules, Beshear said. The Kentucky Medical Licensure Board is hearing complaints about costly urine tests and has extended a grace period for doctors until Nov. 1 so that "an isolated and simple failure to comply" with the regulations will not lead to professional discipline.
"We are aware of the concerns about the insurance coverage for these urine tests, and we recognize the costs of these tests can be prohibitive for patients," Beshear said in a prepared statement.
"We are working with the Kentucky Board of Medical Licensure to review options, including exploring whether other tests (blood, hair, etc.) could be as effective," the governor said. "We are also consulting with private insurance groups and managed care organizations about their policies regarding this standard of care, because some are covering the tests while others are not."
But critics say they warned last spring that HB 1 — intended to crack down on the illicit sale of prescription drugs — would treat everyone like a potential felon, including doctors and patients engaged in legitimate medical care.
"We anticipated this. Now we're starting to see third-party vendors denying payment for the tests, as we feared," said Cory Meadows, spokesman for the Kentucky Medical Association. "It's still early in the game, so concrete numbers are hard to come by at this point. But this certainly will be a significant issue."
Rep. Stan Lee, R-Lexington, who voted against HB 1 in April, is the Burtons' House member. He's been listening to their complaints.
"These were not unforeseen consequences," Lee said. "Some of us were not in favor of this bill for the primary reason that it punishes law-abiding citizens for the criminal acts of others. These problems were predicted and discussed in the legislature, but they obviously did not carry the day."
The General Assembly passed HB 1 to address the hundreds of deaths reported annually in Kentucky from prescription drug overdoses, as well as a scourge of crime by pill addicts desperate to feed their craving.
So far, most debate over the law has focused on how it affects doctors — requiring them to complete patients' medical histories, check photo identifications, conduct physical exams and consult a statewide prescription database before they issue prescriptions for controlled substances.
Relatively little attention has been paid to the impact on patients. But that may change shortly.
Under the emergency regulations, doctors must obtain a "baseline" urine sample from patients who have long-term controlled substance prescriptions, defined as greater than three months. When test results indicate that patients are likely to abuse or illegally sell drugs, doctors cannot issue a new prescription.
Doctors also must impose random urine tests — at least once a year if a patient is considered "low risk" for drug abuse and up to four times a year if the patient is considered "high risk." Additionally, patients must submit to urine tests if they show "aberrant behavior," such as multiple lost prescriptions, repeated requests for early refills and unauthorized dose escalation.
Nobody in Frankfort seems to know how many people will be giving urine samples under the rules, but it's likely to be in the tens of thousands.
In 2011, doctors and dentists in Kentucky requested 679,487 reports from the statewide prescription database before prescribing pills to address pain, anxiety, panic attacks, insomnia, seizures, muscle spasms and attention deficit disorder.
"I need to go into the drug-screening business," quipped Lee, the lawmaker.
This month, the first round of patients ordered to get a baseline urine test are receiving their "explanation of benefits" letter from their insurance companies announcing whether the tests are covered. Some insurance companies are paying for them and others aren't. The Kentucky Department of Insurance this week reported having received one consumer complaint and five consumer inquiries on the subject.
Medicaid is supposed to pay for the urine tests for its low-income clients, according to the Kentucky Cabinet for Health and Family Services.
"However, we are receiving anecdotal reports of some tests that have not been covered, and we are checking into whether there was an error or oversight or if the provider is billing for a full panel drug test when only a smaller drug screen panel is medically necessary," said cabinet spokeswoman Gwenda Bond.
There clearly is widespread confusion about the urine tests, said Rep. Linda Belcher, D-Shepherdsville, who co-sponsored HB 1.
Belcher said she recently heard from a woman whose son had to be urine tested for his prescription to treat attention deficit disorder. One doctor told her the urine test would cost $600. The mother consulted with a second doctor who said a $60 urine test would be adequate, Belcher said.
"I think there's a lot of misinformation going around, or at least, some people who don't understand what the requirements and costs are supposed to be," Belcher said.
Lloyd Vest, general counsel for the Kentucky Board of Medical Licensure, said some doctors apparently misunderstand the regulations to require a urine test with every visit by a patient who has a controlled substance prescription. As for the high price of urine tests, Vest said, "We don't really have any control over the costs."
The Burtons, the Lexington retirees billed $533 for urine tests, this week shared an explanation of benefits letter they received from Bluegrass Family Health. The letter identified three tests conducted on their urine — one to determine that the prescribed drug was in their systems and two to determine that unrelated painkillers were not present. Had the tests been medically necessary, the insurer said, it would have covered about two-thirds of the cost.
Jessica Kearney, director of regulatory compliance for Bluegrass Family Health, said she was aware of the Burtons' complaint but she could not discuss the company's policy on urine tests.
"This will be under investigation for us to look at," Kearney said. "There's no comment that I can provide at this point."
Cynthia Burton, who was a nurse at Central Baptist Hospital until she retired, said the law casts too wide a net.
"With the technology that we have, we can track the prescriptions that Cynthia Burton gets from however many physicians over 30 days or 60 days or whatever period of time," she said. "So let's take it from there. Let's track the patients where there are signs of abuse, where you've obviously got a problem with multiple prescriptions or multiple doctors, rather than testing everyone."