Amid the worst overdose epidemic in U.S. history, addiction medicine specialists say a bureaucratic hurdle is increasing the difficulty of getting people into treatment: an insurance industry tactic called “prior authorization.”
Detested by doctors of all stripesrequires healthcare providers to obtain permission from insurance companies before prescribing treatment. Addiction medicine doctors said the requirement is both unnecessarily burdensome and could cost lives.
“We have patients who overdose once a month because fentanyl is in the supply,” said Dr. Alain Litwin, clinical researcher and executive director of the Prisma Health Addiction Medicine Center in South Carolina. “This is the crisis of our time – the number of overdoses is increasing every year.”
In 2021, the most recent year for which data is available, roughly three-quarters of the 107,000 people who died of an overdose had an opioid in their system, about 80,000 people.
An approximate one 2.5 million Americans Those 18 years and older are considered to suffer from opioid use disorder, the clinical name for an addiction to opioids, whether illicit or prescribed. People with opioid use disorder suffer from this “alarmingly high” mortality rates and health problems, research shows.
That The risk of death can be halved using the gold standard therapies: drug treatment with buprenorphine, methadone or naltrexone. However, four in five Americans are addicted to opioids are still not being processed.
Prior authorization was mainly aimed at buprenorphine. Insurance companies may establish qualifying criteria that require patients seeking treatment for opioid use disorder to submit to urine drug testing, require pill counts, set dosage limits and mandate patient education or advice. It also requires doctors to fill it out long forms and waiting for approvals. All this, doctors say, makes patients feel stigmatized and delays treatment for an often limited period of time during which a person is willing to try addiction treatment.
Doctors like Dr. Paul Christine, an internist who treats addiction in Denver, Colorado, and works for the city’s safety net health system, said there is no “clinical or economic justification for requiring prior authorization for buprenorphine.”
Although private health insurers could theoretically require prior authorization for every medication and procedure, this tactic, within legal limits, is typically reserved for expensive or second-line therapies.
Buprenorphine is “a first-line medical therapy for opioid use disorder, a life-saving treatment and inexpensive,” Christine said. “A lot of this has to do with the stigma around the medication and around the disease itself.”
Furthermore, prior authorization requirements are not evenly distributed across the healthcare system. For-profit health plans and Republican-leaning states tend to require prior authorization more often, according to recent research by Dr. Christina Andrews, associate professor of health policy at the University of South Carolina. Andrews is researching prior consent and collecting data on how it affects access to buprenorphine.
“I have a whole team of graduate students who spend hours a week going through member handbooks and provider manuals for the Medicaid fee-for-service and managed care plans,” says Andrews. “Their rules and regulations are incredibly difficult and complex.”
In her analysis, Andrews said the use of prior authorization in red states suggests the tactic is driven more by cost-containment pressures and partisan concerns about criminal abuse of buprenorphine than by the science about the medication itself.
Prior authorization is especially harmful in one program: Medicaid. More than half of people receiving treatment for opioid use disorder in 2017 used the public health insurance program for the poor and disabled, according to the report. Kaiser Family Foundation.
Andrews’ team is involved in primary data collection – in other words, she and her colleagues discuss health plans and create their own data sets. Typically, researchers rely on existing data to make analyses. Andrews’ team has been working on prior authorization data for seven years and is now drawing conclusions about where and how prior authorization affects access to buprenorphine.
“If you have a situation where someone is in the ER or a specialty clinic, they say, ‘I’m willing to try this, I’m willing to get buprenorphine’ – that provider is in that critical window of opportunity,” said Andrew. “Prior consent forces the provider to say, ‘I need to contact you next week.’
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“It begs the question – if we know that prior authorization is such a barrier to care, and we have the deadliest drug epidemic, why in the world would we maintain a policy that would make it harder to get the treatment they need? need? Overdoses are now the leading cause of death for Americans under the age of 50.”
Started in 1965 as a joint program between states and the federal government, Medicaid has grown to cover approximately 21% of Americans. 68 million people. In recent years, states have turned to private companies to administer Medicaid. That, in turn, gives private insurers the reins to set prior authorization policies for the health insurance program.
However, the practice has not gone entirely unnoticed by lawmakers — at least 13 states prohibit Medicaid programs from imposing prior authorization requirements on substance abuse medications, according to the Legal Action Center. Medicare, which is run solely by the federal government and insures seniors and the disabled, dropped prior authorization for buprenorphine in most of its plans years ago.
The Biden administration has also focused on prior authorization. In January, regulators have drawn up new rules for companies that do business with Medicare and Medicaid and require prior authorization determinations to be made more quickly. Problematically, the new policy only affects procedures, not medications like buprenorphine.
The health insurance industry, through the trade group Ahip, or America’s Health Insurance Plans, supported the Biden administration’s regulations and has said in the past that prior approval can save money.
Addiction medicine specialists noted that even if all prior authorization requirements were lifted, this alone would not solve the opioid epidemic.
In a recent analysis in JAMA Health ForumChristine, the Denver internist, studied how revoking prior authorization affected prescribing in states that ended the practice. Because Christine himself considered prior authorization the “bane of our existence,” he expected an increase in prescribing. Counterintuitively, he didn’t, but that didn’t make him doubt the “pernicious” power of these barriers.
“The main barrier is that there is a lot of stigma and these patients, quote-unquote, are difficult,” says Christine. “Even if removing this doesn’t cause a large increase in prescribing, it does remove a little bit of the stigma from the medication.”
And in the age of fentanyl, Christine said not treating even one patient willing to take buprenorphine because of a prior authorization requirement is nothing short of “catastrophic.”