Prior authorization is one of the major tools in the insurer toolkit for managing cost and utilization. Most providers hate it, none like it.
But prior approval for medical treatment for those addicted to opioids, including heroin, and other drugs is in a different category, says Corey Waller, MD, a senior medical director at the Camden Coalition for Healthcare Providers in New Jersey.
“Any delay equals an increased risk of death, and we’ve removed that risk from almost every other disease entity where we have a known life-saving intervention,” says Waller, an addiction and emergency medicine physician and expert in caring for patients with high-cost conditions.
Patients with addictions are unlikely to wait the hours or days it takes health insurers to approve the medications they need, says Waller.
Insurers are changing their practices, but not without some outside pressure. After Eric Schneiderman, New York State attorney general, investigated the prior authorization practices of Anthem and Cigna, the companies dropped the process for what are called medication-assisted therapies, which include buprenorphine and naloxone. Although Schneiderman’s reach does not extend beyond New York, both insurers implemented the changes nationwide. Buprenorphine is prescribed to help people quit or reduce their use of opioids. Naloxone is used in emergencies to treat opioid overdoses.
Although some insurers have changed their prior authorization practices, too many haven’t, says Corey Waller, MD.
Attorneys general throughout the country can reach similar agreements with all health insurers, the AMA said in a February letter to the National Association of Attorneys General. For patients with opioid use disorder, utilization management rules can have a negative effect on their care and health, wrote AMA CEO James L. Madara, MD. “With respect to opioid use disorders, that could mean relapse or death from overdose,” the letter said.
Shortly after the AMA letter, Aetna announced it was removing prior authorization rules on all buprenorphine products effective March 1 for all commercial formularies. Aetna did not explain what prompted the change, except to say it was committed to reducing the rate of opioid-related overdoses, emergency department visits, and deaths.
Even if some important insurers have changed their prior authorization requirements, many haven’t. Waller asks whether such restrictions are legal when none exist for other life-threatening conditions. “For many conditions, there is no wall between the patient and the lifesaving intervention,” he explains. “But for addiction, where there is stigma and actually discrimination against these patients, putting a barrier between the patient and a definitive treatment is almost the standard of care.”
Consider, for example, the no-questions-asked approach in how hospitals treat heart attack patients. Like opioid addicts, they come to the emergency department. And while a heroin addict might wait hours or days, a patient with chest pains sees a specialist right away. Cardiologists do diagnostic tests and maybe a procedure that costs tens of thousands of dollars, Waller says. The insurer pays the bill.
“There’s no prior authorization for a $50,000 intervention that decreases mortality at the same or lesser rate than a prescription for buprenorphine or naloxone would,” Waller comments. “No one would stand for that. Yet, there’s a prior authorization process for something that costs pennies on the dollar compared to that big intervention.”
The 2008 law that established parity for mental health and addiction treatment was supposed to prevent such disparities. Yet, insurers routinely ignore the law, Waller argues.
The counterargument, insurers say, is that prior authorization allows for exceptions and, if applied correctly, helps get patients the most appropriate drugs and perhaps counseling, says Susan A. Cantrell, CEO of the Academy of Managed Care Pharmacy.
“Certainly, there are drawbacks to prior authorization, but there’s also a reason for it in terms of taking care of the patient,” she says. “And that is to ensure that you’re not just focusing on the medication, and that the wraparound treatment—the support system that the patient needs—is taken into consideration and that all the resources are brought to bear to help treat that patient.”