Almost 90% of Medicare Part D insurance companies covered at least one buprenorphine product without restriction back in 2007—but in 2018, only 35% did so.
Yet prescription opioids are covered—with no restrictions—in 93% to 100% of recently surveyed plans.
The culprit appears to be controls insurance companies impose to hold down costs, such as prior authorization or step therapy.
Does this make sense? Why restrict access to medication to treat opioid use disorder, in the face of an opioid epidemic? An epidemic that during those ten years—2007 to 2017 (final data for 2018 are not yet in)—saw overdose deaths for all opioids, including heroin and prescription opioids, soar from 18,515 to 47,600?
The graph shows the number of U.S. overdose deaths involving prescription opioids, methadone, and synthetic narcotics, including heroin and fentanyl. Adapted from CDC Wonder.
The data cited above are from a research letter published February 12 in JAMA. The letter assesses prior authorization requirements for buprenorphine products in Medicare Part D prescription drug plans.
Insurance companies commonly use preauthorization rules to manage or limit access to certain drugs, Daniel Hartung, PharmD, MPH, lead author of the study, explained in an Oregon Health & Science University (OHSU) news release. Dr. Hartung is an associate professor at the OHSU/Oregon State University College of Pharmacy.
A coauthor on the paper, Todd Korthuis, MD, MPH, professor of medicine and public health, chief of the addiction medicine section at OHSU, commented in the same news release: “Medicare insurance companies are making it increasingly difficult to prescribe buprenorphine, while making it easy to prescribe the opioid pain medications that contributed to the opioid epidemic.”
Fulfilling a preauthorization requirement doesn’t sound arduous, but in fact it’s “so cumbersome that many doctors choose not to prescribe” the medications at all, Brian Barnett, MD, an addiction specialist at Harvard Medical School, commented in a Washington Post article last year. Each prior authorization request takes 30 to 60 minutes to complete, and afterwards he’s usually told, “a decision will be rendered in several days.”
While he waits for approval, his patient is “at high risk of relapse due to the horrific effects of opioid withdrawal”—when one relapse can mean death.
In short, Dr. Barnett said, insurers are “conducting a war of attrition against the addiction treatment community, to reduce their short-term costs.”
Could the hassle involved in getting prior authorizations explain why many practitioners fail to prescribe buprenorphine, after undergoing the trouble and expense of training and qualifying for a waiver?
Previous Calls for Reform
In 2017, the AMA and 16 other health care organizations called for reforms in prior authorization requirements. An AMA survey had found that the average physician received a total of 29 prior authorizations (for prescriptions and medical services) per doctor per week, requiring an average of 14.6 hours—two working days—per week of the physician’s and office staff’s time. And 79% reported they had to repeat the procedure—even for stable patients on a previously approved regimen.
Opioid Crisis Triggers a Massive Call for Reform: The SUPPORT Act
Last fall, President Donald Trump signed into law the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT for Patients and Communities Act), a massive piece of legislation—250 pages.
Starting in 2020, the Act will broaden Medicare coverage to include methadone treatment through opioid treatment programs. A provision within the Act mandates—by January 1, 2021—the use of electronic prior authorization for drugs covered under Medicare Part D. Details vary by state. (See Electronic Prior Authorization Bill for Medicare Part D, under References, below.)
Will the SUPPORT Act Have an Impact?
We wondered if the Act would help reduce the prior authorization problem.
We asked an expert, Barbara Andraka-Christou, JD, PhD, an assistant professor in the department of health management and informatics at the University of Central Florida.
She agreed with our idea that prior authorizations are a primary reason buprenorphine isn’t prescribed more often. But she added that under-prescribing isn’t limited to buprenorphine; it’s a problem with medications for OUD in general. And, from her research, she had some idea why this was happening.
Three Problems Underlying Prior Authorizations
Dr. Andraka-Christou’s research has uncovered three problems underlying prior authorizations
of OUD medications:
1. They are time-consuming. Dr. Andraka-Christou said that this is the only problem of the three that the SUPPORT Act addresses, and it does so only indirectly, “by requiring the government to create standards for electronic submission of prior authorizations.”
Paperwork, even when electronic, gets in the way of gathering information about health history and current treatment progress. An addiction medicine physician she’d interviewed hired a billing specialist whose sole task was to complete prior authorization paperwork. Dr. Andraka-Christou noted: “Not every physician has the luxury of hiring additional staff, especially when the physician serves low-income populations.”
2. They are dangerous when they delay the start or continuation of medication treatment
for OUDs. Delays can cause relapse, a potentially deadly response. At a minimum, they “can quash a patient’s motivation or feelings of self-efficacy.”
3. They are inequitable, and possibly violate federal parity laws—if applied to medications for OUD, but not to opioids to treat chronic pain. (See the adjoining short article in this issue.)
And whatever good will come from the SUPPORT Act is almost two years away.
In the news release mentioned earlier, Dr. Korthuis recommended: “Require Part D plans to eliminate coverage-related barriers, such as prior authorization.” This single step, he said, would immediately improve access to treatment for many Medicare beneficiaries.
We asked Dr. Andraka-Christou what steps she would like to see.
“In addition to standardization of prior authorization for all medications, I want to see federal legislation banning prior authorization requirements for typical dosages of evidence-based and cost-effective medications for OUD. Sure, insurance companies should continue to require prior authorizations for atypical dosages of evidence-based medications, for medications with a smaller or emerging evidence base, or for medications not yet shown to be cost-effective. But typical dosages of methadone, oral buprenorphine, and extended-release naltrexone do not meet these criteria.”
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“Real-time Benefit Check,” a tool for prescribers from covermymeds, provides information on prior authorization and patients’ out-of-pocket prescription costs. According to author Kim Diehl-Boyd, it may help physicians select medications that do not require prior authorization. For information: https://www.covermymeds.com/main/insights/rtbc-scorecard/.
“2019 ePA National Adoption Scorecard,” another electronic publication from covermymeds, explains and clarifies some key aspects of the prior authorization process. Go to https://www.covermymeds.com/main/insights/scorecard/ and click on the nine subheads on the right.
Hartung DM, Johnston K, Geddes J, Leichtling G, Priest KC, Korthuis PT. Buprenorphine coverage in the Medicare Part D Program for 2007 to 2018. Research Letter. JAMA. February 12, 2019;321:6:607-609. PMID:30747957. doi:10.1001/jama.2018.20391.
Opioids more accessible than addiction treatment. OHSU study finds opioids are easy to get, but medication-assisted addiction therapy is not. Erik Robinson. February 12, 2019 Portland, Oregon. Available at https://news.ohsu.edu/2019/02/12/insurance-rules-make-it-harder-to-treat-opioid-use-disorder. Accessed 4/4/19.
Barnett, Brian. Insurers are making it harder for me to treat my opioid-addicted patients.
The Washington Post. OpEd. April 25, 2018.
http://blog.petrieflom.law.harvard.edu/2018/04/25/insurers-are-making-it-harder-for-me-to-treat-my-opioid-addicted-patients/. Accessed 4/4/19.
Wilson, F. Perry. Docs Rebel Against Prior Authorization. Prior authorization gets terrible reviews from practicing doctors, in a wakeup call to the insurance industry. The Methods Man. Methods Man Blog. March 19, 2018. https://www.methodsman.com/blog/prior-authorization. Accessed 4/4/19.
Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, (the SUPPORT for Patients and Communities Act). https://www.congress.gov/115/bills/hr6/BILLS-115hr6enr.pdf. Accessed 4/4/19.
Diehl-Boyd, Kim. Electronic Prior Authorization Bill for Medicare Part D Passes in Senate:
Legislation Update. October 08, 2018. https://www.covermymeds.com/main/insights/articles/electronic-prior-authorization-bill-for-medicare-part-d-passes-in-senate/. Accessed 4/4/19.