Orlando Harmon
The opioid epidemic has ravaged communities across the United States, with over 42,000 opioid-related deaths in 2016 alone. Evidence suggests that insurers' prior authorization rules may be contributing to this crisis. Prior authorization is a process where a prescriber must obtain approval from an insurer before writing a prescription, and it has been identified as a significant barrier to accessing medication for opioid use disorder (MOUD). This delay in treatment can increase the risk of death for patients with opioid addiction, and there is also a lack of transparency and standardization in the prior authorization process. While some insurers have removed prior authorization requirements for MOUDs, many have not, leading to concerns about the legality of these restrictions and their impact on patient care.
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What You'll Learn
- Buprenorphine prescriptions increase when prior authorization is removed
- The risk of opioid overdose increases with prior authorization
- Insurers' prior authorization rules are a barrier to treatment
- Insurers' prior authorization rules may be fueling the opioid epidemic
- Some insurers are removing prior authorization requirements
Buprenorphine prescriptions increase when prior authorization is removed
Prior authorization is often reported as a key barrier to prescribing medications for opioid use disorder (MOUD). Insurers have traditionally required prior authorization for MOUD, but some states have passed laws prohibiting this. Research has found a large variation in coverage and prior authorization policies for MOUD across state Medicaid plans and programs. This variation can affect a patient’s access depending on where they live and what plan they have.
A study of two states, Illinois and California, found that buprenorphine prescribing for opioid use disorder (OUD) in the state Medicaid program of Illinois increased after removing prior authorization requirements. In contrast, a similar increase was not observed in California. Another study of 23 states from 2015 to 2019 showed that removing prior authorization for buprenorphine was associated with increased buprenorphine prescribing in states with low baseline buprenorphine prescribing but not in states with higher baseline prescribing.
The removal of prior authorization for buprenorphine has been found to decrease hospital and emergency department use and decrease overall healthcare costs. It also increases medication use and lowers healthcare spending. Additionally, removing prior authorization for buprenorphine-naloxone (the most common formulation for OUD) was associated with increased prescriptions and decreased OUD-related inpatient admissions and emergency department visits.
However, some studies have found that removing prior authorization for buprenorphine was not associated with consistent changes in buprenorphine prescriptions among Medicaid enrollees. For example, a study of California and Illinois found heterogeneity in the findings, with an increase in buprenorphine prescriptions in California but not in Illinois. These findings suggest that buprenorphine prescribing may depend on multiple factors, including pre-policy utilization trends and baseline buprenorphine prescribing rates.
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The risk of opioid overdose increases with prior authorization
Prior authorization is a tool used by insurers to manage costs and utilization. However, when it comes to opioid addiction treatment, it can have serious negative consequences. Requiring prior authorization for medications used to treat opioid use disorder (MOUD) can cause dangerous delays in treatment and increase the risk of overdose and death.
Research has shown that uninterrupted treatment with MOUDs such as methadone, buprenorphine, and naltrexone is associated with a significant reduction in overdose risk. However, prior authorization requirements can interrupt continuity of care, leading to an increased risk of overdose. For example, a patient with opioid use disorder may need to wait days for approval from their insurer before they can access their medication, during which time their risk of overdose remains high.
In addition, prior authorization can be a barrier to accessing treatment for opioid use disorder. Buprenorphine, for instance, is often subject to prior authorization requirements, and this has been shown to reduce access to this medication. Evidence suggests that removing prior authorization for buprenorphine increases the number of prescriptions filled and improves access to treatment. Furthermore, in states that removed prior authorization for buprenorphine, there was a decrease in hospital and emergency department use, as well as a reduction in overall healthcare costs.
The timeframes for prior authorization decisions vary among insurers and are often not transparent. This lack of clarity can cause significant delays in treatment. For example, BlueCross BlueShield of Tennessee, which holds 72% of the insurance market share in the state, stated that it could take up to 14 days to make a decision on prior authorizations. Such delays can be life-threatening for patients with opioid use disorder, as they are at high risk of relapse and overdose during this time.
The impact of prior authorization on opioid overdose risk is complex and influenced by various factors, including state laws, insurer practices, and the specific medication being prescribed. While some insurers have taken steps to remove prior authorization requirements for certain medications, many have not. As a result, patients with opioid use disorder continue to face barriers to accessing timely and potentially life-saving treatment.
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Insurers' prior authorization rules are a barrier to treatment
Prior authorization is one of the main tools used by insurers to manage costs and utilization. However, it is often reported as a significant barrier to treatment for opioid use disorder (OUD). Medications for OUD (MOUD) are the most effective treatments for opioid addiction, but historically, insurers have required prior authorization for these medications. This can cause dangerous delays in treatment, increasing the risk of relapse, overdose, and death.
Research has found that requiring prior authorization for MOUD can negatively impact the continuity of care, which is critical in preventing overdoses and deaths. In one study, 94% of physicians reported care delays due to prior authorizations, and 80% reported that it could lead to treatment abandonment. The time frames for prior authorization decisions vary, and insurers often do not provide specific time frames, with some taking up to two weeks to make a decision. For patients with OUD, this wait time can be life-threatening.
Additionally, there is limited transparency in the prior authorization process, with variation in coverage and authorization policies across different state Medicaid plans and programs. This variation affects a patient's access to treatment depending on their location and insurance plan. The stigma and discrimination associated with addiction further compound the issue, as patients with addictions may face additional barriers and be less likely to seek treatment.
While some insurers have started removing prior authorization requirements for certain medications, many have not. The removal of prior authorization has been associated with increased access to treatment, reduced healthcare costs, and improved patient outcomes. It is essential to address the barriers created by prior authorization requirements to ensure timely and effective treatment for individuals struggling with opioid addiction.
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Insurers' prior authorization rules may be fueling the opioid epidemic
The study examined the application of "utilization management" strategies, including quantity limits, step therapy, and prior authorization. While quantity limits were commonly used for opioids, they often allowed for a 30-day supply, contrary to the CDC's recommendations for shorter durations. Additionally, step therapy, which involves starting with less risky painkillers, was rarely required for opioids in the plans studied.
Prior authorization, the focus of this discussion, was also found to be a barrier to accessing medication-assisted treatment (MAT) for opioid use disorder (OUD). Corey Waller, MD, an addiction and emergency medicine expert, emphasizes that any delay in treatment increases the risk of death for patients with addictions. The time taken by insurers to approve medications can lead to dangerous waiting periods, potentially resulting in treatment abandonment.
Furthermore, research has shown that removing prior authorization for buprenorphine, a medication used to treat opioid addiction, significantly increased access and reduced healthcare costs. Evidence also indicates that patients initiating MAT without prior authorization were 47% less likely to relapse. Despite these findings, many insurers continue to require prior authorization for MAT, contributing to the barriers faced by patients seeking treatment for OUD.
While some insurers have started to remove prior authorization requirements for buprenorphine and similar medications, many have not. This disparity in practices and the slow pace of change contribute to the challenges faced by individuals seeking treatment for opioid addiction and may fuel the opioid epidemic.
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Some insurers are removing prior authorization requirements
In 2017, Corey Waller, an addiction and emergency medicine physician, highlighted the deadly consequences of delaying treatment for opioid addiction. He likened it to the immediate treatment provided to heart attack patients, where no prior authorization is required for costly procedures. Since then, insurers such as Aetna, Anthem, and Cigna have removed prior authorization rules for buprenorphine products and medication-assisted therapies, respectively.
The removal of prior authorization for buprenorphine has resulted in increased access to this medication, leading to a significant decrease in hospital and emergency department visits and overall healthcare costs. Evidence also shows that patients initiating MAT without prior authorization were 47% less likely to relapse. Additionally, in state Medicaid programs that removed prior authorization for buprenorphine, there was a notable increase in filled prescriptions, improving access to necessary treatment.
While some insurers have taken the initiative to change their policies, many have not. As of 2019, fewer than a third of states had laws prohibiting MOUD prior authorization. This variation in state policies can affect a patient's access to treatment depending on their location and insurance plan. The removal of prior authorization requirements is a critical step in reducing barriers to treatment and improving patient outcomes.
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Frequently asked questions
Opioids are a class of drugs that include heroin, fentanyl, and prescription painkillers such as oxycodone and hydrocodone. They are highly addictive and have been linked to a growing epidemic of overdose deaths.
Prior authorization is a process where an insurer requires pre-approval for certain medical treatments or medications before they agree to cover the cost. For opioid addiction treatment, prior authorization often involves a delay of hours or days before patients can access medications like buprenorphine or methadone, which are used to treat opioid use disorder (OUD).
Insurers use prior authorization as a tool to manage costs and utilization. They argue that it helps ensure patients receive the most appropriate drugs and can prevent overuse or misuse of certain medications.
The delay caused by prior authorization can increase the risk of death or relapse for opioid addicts. It creates barriers to accessing life-saving treatments, and patients may not receive uninterrupted care, which is critical in preventing overdoses.
Some states have passed laws prohibiting MOUD prior authorization requirements. Additionally, insurers can implement other strategies such as "step therapy," which starts with less risky painkillers before progressing to opioids if necessary. Removing prior authorization has been associated with increased access to treatment, reduced healthcare costs, and a decrease in opioid overdoses.
