By Brian Skinner, Esq.
As the opioid-related overdose epidemic continues to escalate in West Virginia and the nation, timely access to Food & Drug Administration (FDA)-approved medications for the treatment for opioid use disorder (OUD) is more important than ever. Evidence shows that medication-assisted treatment (MAT) for OUD saves lives and helps people maintain recovery. But it also saves money and reduces crime.
Studies show treatment that includes buprenorphine or methadone reduces mortality among individuals with OUD by up to 50% and is associated with reduced rates of other opioid use, HIV diagnosis and hepatitis C virus infection. Unfortunately, in 2018, less than 35% of adults with OUD received treatment for their disease, and experts agree that FDA-approved medications are “severely underused” in the health care sector.
Despite this evidence of MAT success, complex prior authorization rules often get in the way of patients trying to access MAT.
In theory, prior authorization should ensure that patients who truly need a drug have access to it but encourage those who can recover using less costly interventions to utilize those options. However, in reality, prior authorization delays access to crucial treatments. Time is of the essence when treating OUD, but payers commonly impose prior-authorization requirements that patients and physicians must meet before medications are available for treatment. Eliminating prior authorization requirements would help patients connect with necessary treatment faster and more efficiently.
The has strongly recommended removing barriers that stand between patients and MAT for opioid-use disorder. The Task Force asserts that prior authorization for MAT has potentially dangerous consequences for patients who are forced to delay care or are denied treatment because of administrative barriers.
Requiring health plans and Medicaid programs to limit prior authorization requirements for SUD benefits is an effective way to increase coverage. Unfortunately, in the absence of federal or state requirements, prior authorization requirements persist.
According to the Legal Action Center, as of April 20, 2020, 21 states and the District of Columbia have enacted laws limiting public and/or private insurers from imposing prior authorization requirements on a SUD service or medication. Delaware, Illinois, Maine and Washington are the only states with laws that limit prior authorization for SUD services and medications in both Medicaid and commercial plans.
Since January 2019, 14 states and the District of Columbia enacted legislation limiting the use of prior authorization for SUD services and/or medications.
- Eleven states have laws that apply to both Medicaid and commercial plans; seven states have enacted laws applicable to commercial plans alone; and three states and the District of Columbia have enacted laws applicable to Medicaid alone.
- Twenty states and the District of Columbia limit the use of prior authorization for SUD medications, with nearly half of the state laws specific to medications OUD.
- Ten states limit prior authorization for SUD services, and three of those states specifically limit prior authorization for the services used in MAT, such as counseling and behavioral therapy.
In addition to laws prohibiting prior authorization requirements, policymakers have also used non-legislative action to reduce the use of prior authorization for SUD medications. State Attorneys General in California and Minnesota have urged insurers to remove prior authorization requirements for OUD medications. In settlement agreements with the New York Attorney General, national carriers agreed to stop imposing prior authorization for OUD medications. Pennsylvania and Rhode Island entered into agreements with commercial plans to remove prior authorization requirements for OUD medications.
In West Virginia, the legislature prohibited commercial plans from requiring prior authorization for outpatient prescription drugs to treat SUD in 2018, however, Medicaid continues to require prior authorization for SUD services.
Medicaid, which provides health coverage for an estimated 4 out of 10 non-elderly adults with opioid use disorders, plays a significant role in delivering effective OUD treatment and reducing barriers to FDA-approved medications.
States can remove prior authorization for medications in their Medicaid programs through informal regulatory actions. For example, removing prior authorization requirements on the fee-for-service preferred drug list or by issuing guidance. In 2018, the Centers for Medicare & Medicaid Services (CMS) issued guidance instructing Medicare prescription drug plans to limit utilization management, including prior authorization, for buprenorphine medications.
In the past, state policymakers have expressed concern over increased costs to publicly funded health programs from expanded access to MAT resulting in hesitation to remove prior authorization requirements. But a in the Journal of the American Medical Association finds that Medicare prescription drug plans that removed prior authorization for common opioid use disorder medications (i.e., buprenorphine-naloxone) saw an increase in the use of those medications as well as a decrease in hospitalizations and emergency department visits for all medical conditions.
Research conducted at RTI International, a nonprofit research institute, found that the cost of increased opioid medication usage was more than offset by savings from reduced hospitalizations and emergency department visits. The research team used claims data from Medicare beneficiaries with opioid use disorder who were enrolled in Medicare Part D plans between 2012–2017. Examining plan use of prior authorization over this period, the research revealed that patients their use of buprenorphine-naloxone when authorization requirements were removed and use of the medication when authorization requirements were added. This finding is consistent with previous research of the effect of prior authorization on other types of medications. The removal of prior authorization resulted in a 4% decrease in all non-drug health expenditures, including hospitalizations and ED visits for all health conditions. At the same time, the prescription drug expenditures for buprenorphine increased by only 1%.
These findings are entirely consistent with research on other chronic diseases that finds prior authorization requirements limit access to care and contribute to poor treatment.
As one of the states hardest hit by the opioid drug crisis, West Virginia has not only witnessed the devastation visited upon individuals and families, but has had to deal with barriers to effective treatment and recovery of SUD. West Virginia policymakers should re-examine the state’s Medicaid prior authorization requirements based on research that shows that reducing barriers to OUD medication improves health outcomes and results in cost-savings. Now is time for the state to take the next step in addressing obstacles to OUD treatment by removing Medicaid’s prior authorization requirement.
Brian is the former counsel to the West Virginia House of Delegates Judiciary Committee and counsel to the West Virginia Senate Minority Caucus. He was also general counsel to the West Virginia State Health Officer and Commissioner for the Bureau for Public Health. He has almost two-decades of experience as a strategic advisor and chief legal counsel to both executive and legislative branch public officials.