November 20, 2018 04:20 pm Scott Wilson – Pennsylvania is clearing a path for patients ready to ask primary care physicians for help treating opioid use disorder. And those doctors will reclaim potentially life-saving time previously spent on administrative burden.
In a move applauded by the Pennsylvania AFP and other medical organizations, Gov. Tom Wolf last month announced an agreement between his state and seven of the largest health insurers there to end prior authorization requirements for medication-assisted treatment (MAT) of substance use disorder (SUD).
Under the agreement, the insurers -- Aetna, Capital BlueCross, Geisinger, Highmark, Independence Blue Cross, UPMC Health Plan and UnitedHealthcare -- will cover, without pre-approval,
They also will provide MAT coverage "at the lowest patient cost tier on the plan's pharmacy benefit."
The move will align commercial insurers' MAT requirements with those of Pennsylvania's Medicaid fee-for-service and managed care programs.
"It's an encouraging step forward," Brent Ennis, the Pennsylvania AFP's vice president of practice advocacy and government affairs, told AAFP News.
David O'Gurek, M.D., of Philadelphia -- who chaired the AAFP workgroup that oversaw a 2016 update to the "Chronic Pain Management and Opioid Misuse: A Public Health Concern" position paper -- agreed.
"With this requirement lifted for a preferred buprenorphine agent, significantly less administrative time is spent completing forms, attaching chart notes and compiling results to submit to insurance companies, as well as monitoring when prior authorizations need to be renewed," he told AAFP News.
And time saved translates to lives saved.
"For every delay, every lack of completion of review in the timeframe, every fax that apparently got lost and was never received," O'Gurek said, "individuals struggling with opioid-use disorder were at risk for relapse, overdose or death."
Ennis added, "The prior authorization requirement has been a roadblock for patients seeking to begin treatment in an outpatient setting and has complicated efforts to ease the path to treatment after an overdose that lands a drug user in the emergency room."
Pennsylvania's reduction of administrative burden should help, although Ennis noted that obstacles remain.
"Some treatment options preferred by addiction specialists -- certain shots that are good for a month at a time, naltrexone implants -- won't be automatically covered, for instance," Ennis said. "The bills for some of the medications are high enough to lead to bad events for people who seek out cash clinics instead of office-based treatment."
More action is needed, O'Gurek said.
"As we approach prevention, we need to perpetuate a trauma-informed approach. Buprenorphine therapy belongs in the primary care setting, where family physicians can appropriately utilize trauma-informed care principles to address prevention, harm reduction, treatment and reintegration services," he said.
On the national level, the AAFP has told lawmakers that prior authorization for services and medicine related to SUD is burdensome and critically delays access to care. The Academy and five other medical organizations this year provided guidance to Congress in a document titled "Addressing the Opioid Epidemic: Joint Principles."(5 page PDF)
"When patients seek treatment for opioid use disorder, they need to get it now," (then) AAFP President Michael Munger, M.D., of Overland Park, Kan., said in a statement when the document was delivered. "They can't wait until the doctor has obtained prior authorizations for services or for dispensing medications."
O'Gurek praised Wolf's administration, singling out Pennsylvania Secretary of Health Rachel Levine, M.D., whom he called "an ongoing partner in addressing the opioid crisis affecting the Commonwealth."
"There has been acceptance and understanding from the administration on challenges and barriers to treatment and recovery," O'Gurek continued. "Notably, grant funding through the PAC-MAT (Pennsylvania Coordinated MAT) program encourages increasing access to buprenorphine treatment in primary care settings with an opportunity for office-based opioid treatment programs within primary care."
Ennis said the state chapter will continue working with state lawmakers to chip away at issues of cost and administrative burden while monitoring grant programs.
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