AMA: Eliminate Prior Authorization for Opioid Abuse Treatment

February 08, 2017 - The American Medical Association (AMA) recently called on attorney generals across the nation to follow in New York’s footsteps with reforming prior authorization requirements for medication-assisted treatment for opioid abuse.

New York’s Attorney General Eric Schneiderman reached settlements with two major healthcare payers, Cigna in October 2016 and Anthem in January, to eliminate lengthy prior authorization processes to ensure opioid use disorder patients receive timely treatment.

“When a patient seeking care for an opioid use disorder is forced to delay or interrupt ongoing treatment due to a health plan utilization management coverage restriction, such as prior authorization, there often is a negative impact on their care and health,” wrote the healthcare industry group. “With respect to opioid use disorders, that could mean relapse or death from overdose.”

Over 33,000 individuals died from an opioid-related overdose in 2015, the letter stated. And more than two million individuals had a substance use disorder involving opioids and another 600,000 with a substance use disorder involving heroin.

Medication-assisted treatments, however, have been proven to prevent overdoses and help patients recover from opioid use disorders, the AMA continued. Unlike methadone treatments, medication-assisted treatments can be prescribed and performed at a physician’s office, making it cost-effective and convenient.

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But many payers require providers to submit prior authorizations, repeat step therapy processes, and retry failed treatments from other health plans.

For example, Anthem and Cigna used to require providers to complete lengthy prior approval forms for medication-assisted treatment requests even for providers who underwent specific training and federal authorization for prescribing the drugs, the New York Attorney General reported.

The New York Attorney General’s office also revealed that Empire Blue Cross Blue Shield (BCBS), which was included in the settlement with Anthem, denied almost 8 percent of medication-assisted treatment coverage requests in 2015 and the first half of 2016.

Some payers also maintained seemingly contradictory healthcare utilization management policies with opioid and opioid abuse treatments. In New York, Empire BCBS required prior authorization for medication-assisted treatments for opioid use disorders, but the payers did not require prior authorizations for some opioid prescriptions, such as fentanyl, morphine, tramadol, and oxycodone.

For those reasons, the AMA urged attorney generals to work with payers in their states to eliminate healthcare utilization management barriers to medication-assisted treatments.

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“The very manual, time-consuming processes used in these policies interrupts care for patients and causes providers (physician practices, pharmacies and hospitals) to divert valuable resources away from direct patient care,” the industry group wrote.

A recent AMA survey revealed that 90 percent of physicians experienced care access delays because of prior authorizations. Almost 60 percent also stated that care was postponed for at least a day because of the healthcare utilization management requirement.

Another recent study also found that prior authorizations usually take up to 20 minutes for manual transactions and 6 minutes for electronic transactions. But most providers are on the higher end for time because electronic prior authorization adoption was only at 18 percent among payers in 2015.

To prevent care access problems and reduce administrative burdens on providers, attorney generals should devise similar agreements to those signed in New York. The two settlements in New York included eliminating prior authorization requirements and educating providers on medication-assisted treatments.

Empire BCBS specifically agreed to develop an initiative to boost medication-assisted treatment access. The initiative will also include provider education on treatment benefits and certification processes for buprenorphine and buprenorphine/naloxone treatments.

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While the AMA called for healthcare utilization management changes for opioid use disorder treatments, the industry group also recently joined 16 other organizations to urge health plans to reform prior authorizations in general.

The coalition of industry groups offered 21 prior authorization reforms to health plans. The list of reforms included ways to ensure prior authorization requirements demonstrate clinical validity and not just cost-containment goals as well as strategies for making healthcare utilization management programs support care continuity.

The groups also called for increased healthcare transparency in utilization management programs, more timely access to care and administrative efficiency, and additional prior authorization exemptions, such as allowing providers with appropriate resource use patterns to forego prior authorization requirements.

“Strict or bureaucratic oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited healthcare resources and antagonized patients and physicians alike,” Andrew W. Gurman, MD, AMA President, stated in January.

“The AMA joins the other coalition organizations in urging health insurers and others to apply the reform principles and streamline requirements, lengthy assessments and inconsistent rules in current prior authorization programs.”