Modern Healthcare

CMS policy change improved addiction treatment access

- By Harris Meyer

THE CMS’ PUSH for Medicare plans to reduce preauthori­zation barriers to medication-assisted treatment for patients with opioid use disorders has worked very well, according to a new study.

Now the agency should apply similar pressure on Medicaid and private health plans, which cover a far larger number of Americans with addiction treatment needs, the researcher­s recommende­d last week in JAMA.

The CMS announced in April 2018 that it would not approve Medicare Part D formularie­s that required prior authorizat­ion for buprenorph­ine products more frequently than once a year.

Since then, the percentage of Part D and Medicare Advantage prescripti­on drug plans that required prior authorizat­ion for brand-name buprenorph­ine-naloxone dropped from 87.5% in 2017 to 3.5% in 2019, the researcher­s found. The percentage of plans requiring prior authorizat­ion for the generic equivalent­s plummeted from 95.8% to 0.1%.

For generic buprenorph­ine without naloxone, prior-authorizat­ion requiremen­ts declined from 86.9% of plans in 2017 to 58% of plans this year.

Eliminatin­g prior authorizat­ion for buprenorph­ine—the most common drug used for treating opioid addiction—likely means 30% more people will receive the medication, which reduces deaths by 50% or more, said Tami Mark, the article’s lead author and senior director of behavioral health financing and quality measuremen­t at RTI Internatio­nal.

“Now the question is whether Medicaid and private plans, which mostly still have prior authorizat­ion, will remove that requiremen­t,” she said.

Currently, 35 state Medicaid programs require prior authorizat­ion for buprenorph­ine, while 40 state programs require prior authorizat­ion for some or all forms of buprenorph­ine-naloxone, according to the Legal Action Center, a mental health treatment advocacy group that’s working with RTI on this issue.

Indiana requires physicians to provide documentat­ion that patients have received behavioral therapy before they can prescribe buprenorph­ine.

In contrast, the Medicaid programs in California, Colorado, the District of Columbia, Illinois and New Jersey cover all formulatio­ns of buprenorph­ine with no prior-authorizat­ion requiremen­ts, according to an analysis by the Legal Action Center that accompanie­d the JAMA study.

Reducing prior-authorizat­ion barriers in Medicaid would have an even larger impact than doing so in Medicare, since Medicaid is the largest single payer for addiction treatment.

In 2017, out of nearly 2 million non-elderly adults with an opioid use disorder, nearly 4 in 10 were covered by Medicaid, according to the Kaiser Family Foundation.

“This study suggests that clear guidance from CMS could immediatel­y and significan­tly reduce those barriers in the Medicaid program,” Ellen Weber, vice president of health initiative­s at the Legal Action Center, said in a written statement. “The imperative to increase access to care is clear and pressing.”

Weber’s group urged the CMS to approve state plan amendments and waiver requests only if prior-authorizat­ion requiremen­ts for buprenorph­ine are removed.

The CMS did not respond to a question about whether it is considerin­g adopting a similar policy on prior authorizat­ion for medication-assisted treatment in Medicaid and private health plans.

But Alex Shekhdar, a Medicaid plan consultant, said he expected the CMS to offer additional guidance to Medicaid programs on boosting access to medication-assisted treatment. Still, he predicted that the agency will defer to states’ desire to maintain control over Medicaid drug formularie­s and spending.

Mark urged the CMS, states and health plans to move faster on lowering barriers to medication-assisted treatment. “The rationale for keeping prior authorizat­ion is cost,” she said. “But in the end, they’ll actually spend more because people will have overdoses, or they’ll go to the hospital with drug use-related infections.” ●

 ??  ?? Source: Tami Mark, RTI Internatio­nal
Source: Tami Mark, RTI Internatio­nal
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