Barriers associated with prior authorization and drug distribution get in the way of Medicaid patient access to opioid treatment, GAO found.
Certain state and federal policies impede patient access to opioid treatment, including medication-assisted treatment (MAT), a problem that the Government Accountability Office says warrants further investigation from CMS.
Nearly 70,000 individuals died from drug overdoses in 2018, GAO stated in a recent report, with about 69 percent of those deaths involving opioids. MAT, which combines behavioral health therapy and the use of key medications such as buprenorphine, has proven highly effective at treating opioid use disorder and preventing future overdose deaths.
Federal healthcare agencies have identified MAT as the gold standard in opioid treatment, and even made calls for expanding patient access to the therapy.
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But this recent analysis from GAO has found that expanded access is left wanting, especially in the Medicaid program, which is responsible for treating the poorest and sickest patients.
Medicaid represents one of the largest resources for receiving coverage for opioid use disorder treatment, but issues with MAT medication coverage, prior authorizations, distribution methods, and authorizations for providers prescribing MAT medications all keep patients from accessing the treatment.
The GAO analysis, which looked at MAT policies in various states and compared them to federal regulations out of the Centers for Medicare & Medicaid Services, found that coverage for the medications included in MAT is limited.
That is to say, patients covered under 40 percent of state Medicaid programs do not have insurance coverage for the injectable or implantable drugs used as a part of MAT. This runs counter to protocol out of CMS, although CMS does not yet have a method to look at the extent to which states do not comply.
Prior authorization requirements, which necessitate patients receive approval from Medicaid before they can receive coverage for a certain therapy, get in the way of timely access to MAT. These requirements are intended to cut healthcare spending, overutilization, and inappropriate payments, but in many cases just delay patient access to care.
This can have disastrous effects when treating a patient with opioid use disorder, an illness that can be extremely life-threatening and time-sensitive.
Three of the states GAO looked at, as well as the District of Columbia, have taken the first steps to get rid of prior authorization policies for MAT.
Distribution models, such as buy-and-bill, also limit patient access to MAT. In some states, like in Minnesota’s fee-for-service Medicaid plan, providers must purchase and store MAT medications in their practices.
This method is intended to facilitate immediate patient access to MAT medications, but it places an untenable financial risk on providers who may not use the medication before it expires. Providers may choose not to engage in MAT for these reasons.
Some states are working to get rid of buy-and-bill protocol.
Finally, regulations and authorizations for providers who administer MAT may be restrictive. Although the federal government allows providers to obtain waivers that allow them to prescribe and administer certain MAT medications, the training for receiving that certification is labor-intensive and acts as a deterrent for many providers.
Protocol for advance practice practitioners, such as nurse practitioners or physician assistants, can also be restrictive. Although many states allow APPs to receive prescribing waivers, those APPs must receive physician supervision while administering the drug. This, again, can be time and labor-intensive for both the APP and the supervising physician.
The issue of patient access to opioid treatment and MAT is not necessarily new. In June 2019, the Annals of Internal Medicine published a report finding that fewer than half of patients seeking opioid use disorder treatment cannot access buprenorphine.
Using a “secret shopper” research methodology, the researchers made two separate phone calls to various healthcare providers posing as a patient without insurance coverage and as a patient with Medicaid coverage. Researchers made calls to a total of 546 providers in regions in which the opioid crisis is especially pressing, including Massachusetts, New Hampshire, West Virginia, Ohio, and Washington DC.
Of the 1,092 total calls made, just over half – 54 percent and 62 percent for Medicaid and uninsured patients, respectively – resulted in an appointment. This means that a substantial proportion of patients – between 38 and 46 percent – were denied even an appointment to discuss buprenorphine prescribing.
This comes even as leading medical groups are calling for better patient access to MAT and other opioid treatments. In September 2019, the American Medical Association (AMA), in partnership with Manatt Health, issued a recommended national policy for opioid use disorder treatment.
“We are at a crossroads in our nation’s efforts to end the opioid epidemic,” AMA President Patrice A. Harris, MD, MA, said in the policy’s introduction. “It is time to end delays and barriers to medication-assisted treatment (MAT)—evidence-based care proven to save lives; time for payers, PBMs and pharmacy chains to reevaluate and revise policies that restrict opioid therapy to patients based on arbitrary thresholds; and time to commit to helping all patients access evidence-based care for pain and substance use disorders.”
Going forward, GAO recommended CMS look into the extent to which states are complying with Medicaid recommendations for opioid use disorder treatment access. This in large part should center on state efforts to connect patients with MAT.
Source: Patient Engagement Hit