Medication-Assisted Treatment (MAT) for Opioid Use Disorder

Improving Access in Iowa

Between 2010 and 2015, admissions to substance abuse treatment programs for individuals with opioid use disorder increased by 80% in Iowa.

Medication-assisted treatment is the gold standard for treating opioid use disorder. Research has found that treatment using FDA-approved medications including buprenorphine or methadone can reduce the risk of death by 50% or more among patients.

Studies have also found that savings on health care spending alone outweigh the costs of providing MAT to Medicaid recipients.

It is difficult to access MAT in Iowa. As of 2016, only 46 out of 163 substance use disorder treatment agencies in the state provided any kind of MAT.

“It’s been a lifesaver for me…I was unemployable, I was constantly in and out of jail, and I couldn’t pass a drug test to get off probation. I have a job now, I have relationships, and I just got into university.”

A current MAT patient in Cedar Rapids

The Problem

When it comes to treatment for opioid use disorder, waiting periods can carry dangerous risks. Providing services in a timely manner helps to retain patients and reduces the risk of fatal overdose.

Under current policy, Iowa Medicaid is making waiting periods longer for patients. Prior authorization requirements delay the initiation of care and place an additional burden on providers.

“I went to a thirty day inpatient and I tried hard. Then they introduced me to a suboxone doctor…As soon as I took it, that voice in my head that I’ve had my whole life that screams ‘escape,’ it’s like it was gone.”

A MAT patient in Des Moines

The Solution

Lawmakers can take action to remove unnecessary red tape standing between patients and lifesaving treatment.

Iowa can join a growing number of states in requiring that insurance providers cover medications to treat opioid use disorder without prior authorization.

This reform would reduce waiting periods, encourage more providers to prescribe MAT, and show that Iowa is serious about extending a hand to those struggling with opioid addiction.

Without readily available evidence-based treatment, efforts to restrict access to prescription opioids use can result in increases in use of illicit opioids.

“Hoops to Jump Through”

Medicaid recipients seeking treatment with buprenorphine will typically encounter two different waiting periods. First, they will wait to get an appointment with one of a limited number of providers who are waivered to prescribe the medication. If they are able to get an appointment and their provider determines that they are a good candidate for buprenorphine treatment, they still face an additional waiting period because Medicaid requires prior authorization before the prescription can be filled.

There is no medical justification for this additional waiting period, and providers recognize that it places their patients at risk.

“I have worked in family medicine and I have worked in psychiatry, and those are two of the biggest players who prescribe MAT. The insurance is more of a headache than anything I’ve ever dealt with, and I think that is just such a deterrent.”

A MAT provider in Iowa City

“I would honestly say insurance is my number one barrier to starting new patients in treatment…I have one patient who I spent over 5 hours on the phone getting the medication approved. That is just time that I do not have carved out as a provider”

A MAT provider in Cedar Rapids

“You want to strike while the iron is hot. I don’t want to encourage treatment and then pause. Because what are they going to do the next day or in the meantime? Go keep using heroin until two days before you come back?”

A MAT provider in Iowa City

“People will know enough to know that they’re supposed to come in when they are in withdrawal, and then I have to tell them that unless you have $30 in your pocket to buy two days of medication, we probably can’t do it today. People get upset in that situation.”

A MAT provider in Cedar Rapids

Frequently Asked Questions on MAT

What are Iowa Medicaid’s current prior authorization requirements for Medication-Assisted Treatment including Buprenorphine?

Combination buprenorphine/naloxone medications (henceforth referred to as buprenorphine) are one of the most effective treatments for opioid use disorder. Unlike methadone, buprenorphine can also be prescribed by providers who are not in specialized clinics as long as they have completed a necessary eight-hour training to obtain a buprenorphine waiver. This allows providers in primary care, emergency medicine, and other fields to expand access for patients in need of treatment.

Currently, Iowa Medicaid requires providers to submit a prior authorization request before initiating buprenorphine treatment. This authorization form verifies information related to the patient’s diagnosis and treatment plan, but also creates a delay between the time that the provider submits the request and when it is authorized. In a 2017 nationwide physician survey, 64% of providers said that prior authorization requirements created a delay of at least one business day. 1 30% reported waiting at least 3 business days for prescriptions to be authorized.

Why does Medicaid require prior authorization for Buprenorphine?

Proponents of prior authorization requirements for MAT claim that these measures are intended to control costs and promote the use of behavioral therapy for patients receiving medications. Although well intentioned, it has become clear that these requirements create more problems than they solve by delaying access to effective treatment.

First, the cost of buprenorphine is lower than a number of other drugs that are available without prior authorization to treat chronic long-term conditions such as diabetes. While buprenorphine may carry some initial costs to payers, studies have shown that providing MAT is cost-effective due to lower expenditures on outpatient emergency services and inpatient hospital admissions for patients taking medication.2

Secondly, while many patients find behavioral therapy to be a useful component in their treatment, evidence of the impact of behavioral therapy remains mixed compared to the robust evidence for the effectiveness of the medication itself.3 The vast majority of providers will choose to require behavioral therapy as a part of treatment, but denying coverage for medication based on current enrollment in counseling runs the risk of denying care to those who are most vulnerable.

How have other states modified prior authorization requirements?

In response to the rise in opioid-related deaths across the country, a number of states have worked to address the administrative barriers associated with connecting patients to treatment. Prior authorization requirements are one of these administrative barriers, and the American Medical Association has noted “there is no medical, policy or other reason for payers to use prior authorization for MAT.”4 There are a number of different ways that states have modified their laws to reflect this growing medical consensus, but several examples are:

New York– In 2016 New York passed Senate Bill 8137,5 which included comprehensive legislation that prohibited managed care providers from imposing any prior authorization requirements for preferred forms of buprenorphine or injectable naltrexone. This law allows Medicaid recipients to receive these select medications the same day that their providers prescribe them, and reduces the risk of care discontinuation or adverse outcomes that occur during treatment delays.

Maryland- In 2017, Maryland followed with an even more inclusive reform when it passed House Bill 887.6 This law prohibits specified insurers, nonprofit health service plans, and health maintenance organizations from applying a prior authorization requirement for a prescription drug to be used for treatment of opioid use disorder if it contains buprenorphine, methadone, or naltrexone. This allows providers to choose from a wider selection of medications based on what best fits their patient’s needs, without consideration for different prior authorization requirements.

Illinois– Illinois worked to address the role of prior authorization requirements in 2015 as part of the state’s Heroin Crisis Act.7 The relevant provision within the larger statute required that managed care and fee for service payers cover medications to treat opioid use disorder, and that this coverage is not be subject to a prior authorization mandate or lifetime restriction limits.

Pennsylvania– With over 2000 opioid-related overdosefatalities in Pennsylvania in 2016, Governor Wolff recently took the measure of ending prior authorization requirements for medications used to treat opioid use disorder. This measure was one component of the state’s public health emergency declaration, which
allows the governor to suspend certain administrative regulations related to treatment.

Vermont– The State of Vermont has made suboxone© film (buprenorphine-naloxone) a preferred medication that does not require prior authorization if the dosage is limited to 16 mg/day. Vermont instituted this policy earlier than other states, and has been notable for having the lowest rate of overdose fatalities inthe New England region.8

How do these changes benefit patients and providers?

  • In rural areas with limited access to addiction specialists and methadone clinics, this measure would help to expand access to substance abuse treatment through primary care.
  • This measure reduces the burden that time-consuming prior authorization requirements place on medical providers. This is especially relevant for mental health and addiction providers who are already overburdened throughout the state.
  • This measure allows patients to receive same-day medication, which reduces the risk of relapse or fatal overdose that can occur during temporary treatment barriers and delays.

Citations

1 American Medical Association. (2018). 2017 Prior Authorization Physician Survey.
URL: https://www.ama-assn.org/sites/default/files/media-browser/public/arc/prior-
auth-2017.pdf
2 Mohlman, M. K., Tanzman, B., Finison, K., Pinette, M., & Jones, C. (2016). Impact of medication-assisted treatment for opioid addiction on Medicaid expenditures and health services utilization rates in Vermont. Journal of substance abuse treatment, 67, 9-14.
3 Fiellin, D. A., Barry, D. T., Sullivan, L. E., Cutter, C. J., Moore, B. A., O’Connor, P. G., & Schottenfeld, R. S. (2013). A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine. The American journal of medicine, 126(1), 74-e11.
4 Madara JL. Letter from the CEO of the American Medical Association t to the National Association of Attorneys General. February 3, 2017. URL: https://searchlf.amaassn.org/letter/documentDownload?uri=%2Funstructured%2Fbinary%2Fletter%2FLETTERS%2
5 N.Y. Legis. (2016). Senate Bill S8137. URL:
https://www.nysenate.gov/legislation/bills/2015/S8137
6 M.D. Legis. (2017. House Bill 887. URL: https://legiscan.com/MD/text/HB887/2017
7 Illinois General Assembly. (2015). Public Act 099-0480. URL: http://www.ilga.gov/legislation/publicacts/99/099-0480.htm
8 Center for Disease Control and Prevention. (2017). Drug Overdose Deaths in the United States 1999-2016. National Center for Health Statistics. URL: https://www.cdc.gov/nchs/data/databriefs/db294.pdf