By Sam Sutton
09/26/2018 05:00 AM EDT
Medicaid recipients in New Jersey looking for medicine to treat their opioid addictions continue to face a major hurdle that no longer exists for patients covered by commercial health insurance plans.
New Jersey, which is on pace to lose more than 3,000 of its residents to drug overdoses this year, requires patients covered by state Medicaid plans to receive prior authorization from their carrier before they can be prescribed buprenorphine — commonly referred to by its brand name Suboxone — to suppress cravings and manage opioid withdrawal symptoms.
That’s not the case for New Jerseyans covered by commercial insurance. Last year, then-Gov. Chris Christie signed legislation barring commercial insurers from requiring prior authorization for Suboxone. The New Jersey Substance Use Disorder Law entitles patients covered by commercial plans to any medication-assisted treatment, often referred to with the shorthand MAT, deemed medically necessary by a physician, psychiatrist or psychologist.
The prior authorization process can take longer than a week, forcing patients to wait before they can start their recoveries. For many addicts, that delay is untenable — and sometimes fatal.
“Prior authorization erodes trust between patients and providers,” said Natasha Dravid of the Camden Coalition of Healthcare Providers, which recently started a pilot program to address the treatment delay. “They’re being told they can’t get what they need.”
It’s unclear why the 2017 legislation Christie signed left prior authorization intact for Medicaid recipients. Prior authorization is a common tool used by insurers to control utilization and cost, said Matthew D’Oria of the New Jersey Health Care Quality Institute. Both would likely be considerable in New Jersey, given the frequency of opioid use disorder among those covered by the state’s Medicaid plans.
According to data from Horizon Blue Cross Blue Shield of New Jersey, the state’s largest health insurer, patients covered by its Medicaid plans were more than five times as likely to be diagnosed with opioid use disorder in 2017 than those covered by commericial plans. More than 37 members per 1,000 covered by a Horizon Medicaid plan were diagnosed with the disorder last year, compared to just 7.4 per 1,000 among those covered through its commercial plans.
Gov. Phil Murphy’s administration has started to explore steps to eliminate prior authorization barrier as part of a broader effort to increase the utilization of medication-assisted treatment, according to officials from the state’s health department and Department of Human Services.
“Although the prior legislation related to prior authorization only applied to the commercial market, the Department is reviewing this issue as it relates to the Medicaid program. The Department is continuing to look for opportunities to expand access to medication assisted treatment and this issue is part of that review,” a spokesman from the Department of Human Services, which oversees the state’s Medicaid coverage said in a statement.
The Murphy administration recently announced it had received more than $30 million in federal grants to help address the state’s addiction epidemic, which is currently claiming about eight lives per day. The largest single grant, $21.6 million from the Substance Abuse and Mental Health Services Administration, will fund a series of initiatives, such as access to medication assisted treatment, Narcan — an opiate antidote — and other alternative pain medications.
With the opioid overdoses estimated to have claimed an astonishing 72,000 lives nationwide last year, the pressure for insurers and providers to remove barriers to addiction treatment has intensified in recent years, even with new sources of funding for MAT. Some commercial insurers, including Cigna and Aetna, have already dropped prior authorization requirements for buprenorphine. Pennsylvania Gov. Tom Wolf, a Democrat, waived prior authorization for his state’s Medicaid recipients earlier this year.
“There’s no reason you should distinguish between people based on whether they’re poor or not,” said Linda Schwimmer, president and CEO of the New Jersey Health Care Quality Institute. “They should be eligible to get the most effective treatment as quickly as possible.”
One program that’s already started to address the prior authorization gap is the Suboxone Gold Card, spearheaded by the Camden Coalition of Healthcare Providers along with the Addiction Medicine Program at Cooper University Hospital in Camden and Project H.O.P.E., a federally qualified health clinic. Health insurance carrier UnitedHealthcare has granted those providers a “gold card” that allows them to skip the prior authorization process for Suboxone prescriptions for medicaid recipients.
The program allows South Jersey Medicaid recipients to start their buprenorphine treatments sooner, eliminating any delays that might force them to find another means to satisfy their addiction.
As of mid-August, about 130 patients had been treated through the program, said Dravid, who leads clinical redesign initiatives for the Camden Coalition. While it’s difficult to measure the program’s impact — that would require measuring overdoses that haven’t occurred — Dravid said early data suggests patients who are able to receive medication in a timely manner are less likely to require an emergency room visit or inpatient treatment.
“The data is starting to come in, in dribs and drabs, and it does look like individuals we’ve started on Suboxone through UnitedHealthcare have decreased their [emergency department] use, their inpatient use,” said Lynda Bascelli, Project H.O.P.E’s chief medical officer. “The trend is definitely toward improved outcomes.”
The program has also freed up resources for physicians whose office staff had to submit paperwork to carriers to receive authorization for Suboxone prescriptions, Bascelli and Dravid said.
Those early successes, along with the Murphy administration signaling its willingness to examine policies that extend access to medication-assisted treatment, will likely result in a push to convince policymakers to waive prior authorization at the state level, Camden Coalition CEO Kathleen Noonan said.
“All signs for us are that, assuming that this project continues to pan out, we’ll head to Trenton and advocate for an expansion,” she said.
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