Removal of prior authorization for medication-assisted treatment: impact on opioid use and policy implications in a Medicare Advantage population

Abstract

BACKGROUND: More than 30% of Medicare beneficiaries and 40% of patients dually eligible for Medicare and Medicaid use opioids. With an estimated 8%-12% of patients developing an opioid use disorder (OUD) after initiating opioids, opioid misuse is a significant public health challenge, especially among high-risk Medicare populations. Medication-assisted treatment (MAT) is the use of medications for the treatment of OUD and to prevent relapse to opioid use. MAT is the most effective treatment for OUD. There are a variety of barriers to MAT therapy that may delay access to treatment. OBJECTIVE:To study the impact of the removal of prior authorization requirements for MAT medications on MAT utilization, opioid utilization, and clinical outcomes, including emergency department visits, inpatient admission, relapse rates, behavioral health services, and nonopioid pain medication utilization, among opioid-using individuals with Medicare Advantage Prescription Drug (MAPD) coverage. METHODS:This retrospective, cross-sectional study used administrative medical, pharmacy, and enrollment data to identify chronic opioid users and a subset cohort initiating MAT use in 2017, when prior authorization requirements were in effect, and 2018 after removal of prior authorization requirements. Opioid and MAT utilization and clinical outcomes from emergency department visits were also examined before and after prior authorization requirements. A logistic regression analysis was conducted to examine the impact of the policy change on relapse rates, comparing relapse rates in 2017 and 2018, after controlling for potentially confounding demographic and clinical factors.

Coverage and Prior Authorization Policies for Medications for Opioid Use Disorder in Medicaid Managed Care

“…Many other studies identify the use of PA as a barrier to timely receipt of MOUD and continuity of care. [12][13][14][15][16][17][18][19][20][21] Removal of PA in Medicare Part D plans, following an FDA labeling change for buprenorphine products and related Centers for Medicare & Medicaid Services (CMS) guidance, 22 was associated with an increase in prescribing of buprenorphine and naloxone and a decrease in substance use disorder-related inpatient admissions and emergency department visits. 16 Relatedly, removal of PA for MOUD was associated with a decrease in the likelihood of relapse among patients with OUD enrolled in a Medicare Advantage plan.…”

The Role of the Pharmacist in Combating the Opioid Crisis: An Update

“…5 As many as 8-12% of patients will develop an opioid use disorder once started on opioid therapy. 6 Since 1999, there have been 760,000 deaths due to opioid use disorder and that number is still growing despite effective Prevention While prescription of opioids has fallen in US private and public healthcare sectors, pharmacists must remain vigilant as they play a pivotal role in preventing opioid overdoses being responsible for controlling opioid distribution to patients. 23 This results in great responsibility as pharmacists must assess if opioid therapy is suitable for their patients;not properly doing so can carry dire consequences.…”

“…5 As many as 8–12% of patients will develop an opioid use disorder once started on opioid therapy. 6 Since 1999, there have been 760,000 deaths due to opioid use disorder and that number is still growing despite effective treatments for OUD and improved awareness. 3 , 7 The consequences of the opioid epidemic costs the United States $56 billion dollars each year.…”

“…40 Ferries et al conducted a retrospective, cross-sectional study evaluating the impact of removal of prior authorization for MOUD (buprenorphine, buprenorphine-naloxone, and naltrexone) in a Medicare Advantage population. 6 Following removal of the prior authorization, there was a decrease in opioid utilization, an increase in MOUD initiation, and a 4% reduction in return to prescribed opioid use (relapse) rates. Members initiating MOUD after removal of the prior authorization and those with an OUD diagnosis had a 19% decrease in return to prescribed opioid use and 47% decrease in the likelihood of relapse, respectively.…”

“…Members initiating MOUD after removal of the prior authorization and those with an OUD diagnosis had a 19% decrease in return to prescribed opioid use and 47% decrease in the likelihood of relapse, respectively. 6 Tennessee passed legislation in 2017 to establish nonresidential treatment guidelines for the use of buprenorphine to establish an "adequate care" standard. 13 An interprofessional group in Tennessee developed nonresidential buprenorphine treatment guidelines, which are updated annually.…”