WASHINGTON — Requiring prior authorization, the inclusion of psychosocial supports, or duration limits can disrupt and delay access to evidence-based treatment for opioid use disorder, said experts during a Medicaid and CHIP Payment Access Commission (MACPAC) meeting Friday.
Beyond these potential hurdles, panelists also noted that simply finding prescribers who take Medicaid as payment for treating opioid use disorder can be a challenge in some states.
Commissioners invited policy experts from the government, academia, and the private sector to discuss how utilization management policies can impact clinically appropriate use of medication-assisted treatment (MAT) — FDA-approved options of which include buprenorphine (sometimes in combination with naloxone), methadone, and naltrexone (Vivitrol).
Under the SUPPORT for Patients and Communities Act of 2018, MACPAC has been charged with studying the matter and issuing a report by October 2019.
Prior Authorization
In 2016, Maryland’s Medicaid program restricted its formulary to steer use toward one form of buprenorphine, requiring prior authorization for all other buprenorphine formulations, said Anika Alvanzo, MD, medical director at the Johns Hopkins Substance Use Disorders Consultation Service.
That many patients were forced to switch to the agency’s preferred formulation despite being stable on another evidence-based therapy was “clinically disruptive,” Alvanzo said.
Maryland’s prior authorization request caused other headaches. For example, forcing clinicians and other medical staff to spend hours on paperwork rather than patient care, with some offices hiring staff solely to process these requests, she said.
And while proponents of prior authorizations have argued that it can limit diversion, Alvanzo disagreed.
“The use of prior authorization for medications to treat opioid use disorder is not the best way to manage diversion,” she said. To the contrary, by delaying access to evidence-based treatment, prior authorization can actually exacerbate diversion, because the longer a patient waits, the more likely he or she will seek an “alternative pathway.”
Maryland scrapped its MAT prior authorization requirement in 2017, Alvanzo said.
Mario San Bartolome, MD, medical director for substance use disorders at Molina Healthcare, agreed that such tools can lead to dangerous delays in care.
While he noted the example was “extreme,” he described a hypothetical in which a pregnant woman with a heroin use problem seeks out medical help on a Friday.
“You have to wait for a prior authorization, and tell that person to continue shooting up over the weekend and maybe through the week, until they get something approved,” San Bartolome said. “That’s gone away,” he said, noting that Molina also eliminated prior authorization for MAT.
Kristin Hoover, PharmD, a clinical pharmacy manager in the Office of Medical Assistance Programs for Pennsylvania’s Department of Human Services, explained that the commonwealth issued a letter to all of the state’s insurers in 2018 — following an opioid summit the year prior — recommending that prior authorization be implemented for opioids and removed for most MAT, with certain exceptions. These include when buprenorphine is prescribed without naloxone, when it’s prescribed in combination with benzodiazepines or another central nervous system depressant, and when a prescription exceeds daily dose limits.
All of the Medicaid fee-for-service insurers in the state and Medicaid Managed Care Organizations were required to comply with the recommendation. And by October 2018, all of the insurers in Pennsylvania had also agreed to the state’s recommendations.
Duration Limits, Psychosocial Support
Another challenge related to utilization management is “duration limits” for MAT. Given that opioid use disorder is considered a chronic disease and that relapse is common, Alvanzo panned such policies and also rejected requirements for documentation to show that a patient has been referred to counseling.
“If a patient needs behavioral health services then they should absolutely receive them without delay,” Alvanzo said, referring to supports like cognitive behavioral therapy, motivational enhancement, and skills training.
However, some patients can be managed effectively in an office-based setting using only MAT, she stressed.
San Bartolome agreed. On the subject of initiating buprenorphine treatment, he said that in the past there had been “a little bit of heavy-handedness” in terms of managing how providers handled patients, which drove him “crazy.”
“Providers have much more training than the people doing the utilization managment reviews,” San Bartolome said.
Issues like withholding buprenorphine until an insurer sees documentation of counseling are particularly frustrating to him, he said. It’s like visiting the dentist and admitting you haven’t flossed, he said. “And they say, ‘Well, then you’re not getting your toothbrush,” said San Bartolome, who added that while Molina Healthcare encourages counseling, it isn’t required.
Cash Clinics
Even after the removal of most prior authorization requirements for MAT in Pennsylvania, Hoover noted that “access to prescribers is the biggest issue.”
In some cases, the data-waived physicians who do accept Medicaid don’t have any openings because of patient caps defined in the waiver.
Her department tries to help patients locate providers who accept Medicaid as full payment for receiving buprenorphine services, but it’s a struggle.
“Stigma still bubbles to the top,” she said, regarding why more physicians aren’t prescribing MAT or accepting Medicaid.
Commissioners Respond
“Prior authorization, in the past, a lot of the time has been used as a hammer … and I think we got good information [today] that what we really need is a scalpel,” said Commissioner Kisha Davis, MD, MPH, a family physician at CHI Health Care in Rockville, Maryland, and a program manager at the Center for Applied Research in Philadelphia. “We have big data and we have better ways now to identify who the bad actors are that we didn’t have before … looking more specifically at quantity limits and dosing and numbers of prescriptions and things like that.”
While most commission members agreed that prior authorization, specifically, presents a hurdle to the treatment of opioid use disorder, Commissioner Kit Gorton, MD, former president of public plans at Tufts Health Plans, said the commission should not state its opposition to using prior authorization outright in recommendations.
“Fundamentally, prior authorization is a level of control and, fundamentally, human beings don’t want to be controlled,” he said, adding that while it may not be the ideal tool, “if all you have is a hammer, you have to use a hammer to get it done.”
The Commission anticipates completing a draft of its report sometime later this Spring.
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Source: MedicalNewsToday.com
