Landmark deal on medication-assisted treatment a model for nation

Barbara L. McAneny, MD , Former President

Every day in America, about 130 people die of opioid-related drug overdoses, the majority of which are due to heroin and illicit fentanyl. That data from the Centers for Disease Control and Prevention (CDC) should spark our nation to move with all deliberate speed to eliminate every barrier to medically proven, lifesaving treatment for opioid-use disorder (OUD) and other substance-use disorders.

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The Commonwealth of Pennsylvania last fall removed one of the most senseless and short-sighted forms of prior authorization that exists—one that delays access to medication-assisted treatment (MAT) for opioid-use disorder. Nearly 5,000 Pennsylvanians died of drug overdoses between March 2017 and March 2018, the CDC says.

When it comes to treating patients with OUD, we know what works. MAT for opioid-use disorder saves lives. MAT helps people maintain recovery, saves money, reduces crime, and helps people regain their health and their lives.

These are just some of the reasons why the U.S. surgeon general’s Spotlight on Opioids report calls MAT the “gold standard” for treatment.

But time is of the essence, and payers across the nation commonly impose prior-authorization requirements that patients and physicians must meet before medications are available for treatment. When patients seek help, it is unconscionable to make them wait days or weeks for the right treatment.

There is no valid reason to delay or deny medically proven care that can help end the nation’s opioid epidemic and improve patients’ health and lives.

That is why the Pennsylvania’s action—which in 2016 had a drug-related death rate nearly double the national rate—marked a breakthrough.

The commonwealth and seven major health insurance companies agreed to remove prior-authorization requirements for MAT. Insurers have also committed to including a comprehensive range of medications to treat substance-use disorders on the lowest cost-sharing tier of a health plan’s pharmacy benefit. The agreement also ensures that insurers will cover at least one form of the opioid-overdose antidote naloxone—without quantity limits.

The AMA has worked closely with the Pennsylvania Medical Society (PAMED)—and medical societies in other states—for many months to implement this action. Our efforts have included direct advocacy with key policymakers within the state, national-level advocacy with payers and national policymaking groups, and federal advocacy in support of removing barriers to high-quality, evidence-based care. Read more of our spotlight analysis, conducted with PAMED and Manatt Health, that details the considerable progress being made in Pennsylvania and what more can and should be done.

My colleague, AMA President-elect and AMA Opioid Task Force Chair Patrice A. Harris, MD, put it well in commending Pennsylvania: “The leadership shown by the governor and his administration to reach this agreement should act as a call for all states to demonstrate that they support patients’ access to care over needless administrative burdens.”

I couldn’t agree more, and I urge all physicians to join the AMA to call on payers in every state to remove prior authorization for MAT. Ask your state and specialty medical societies to partner with the AMA in this public effort. If the payers won’t do it on their own, then we urge state medical societies to partner with us to help introduce our model legislation—“Ensuring Access to Medication Assisted Treatment”—and work to get it enacted. 

Among other things, the model bill prohibits utilization-management barriers such as step therapy and prior authorization for MAT. The model bill also requires all payers to provide coverage and access to all forms of MAT. Contact the AMA Advocacy Resource Center for more information.

This vital advocacy is informed by your stories.

Tell us about the administrative barriers, such as prior authorization or step therapy, that you have experienced in your practice when trying to provide multidisciplinary or multimodal pain care, or comprehensive treatment for a substance-use disorder.

We all certainly have more work to do, but unless and until all payers agree to remove all barriers to such care, opportunities to save lives will be missed. Which state will be next to take such bold and necessary action?

Find out more about the AMA’s work to end the opioid epidemic, as well as the efforts undertaken by the Pennsylvania Medical Society.

Together, we can change policy and save lives.