Advocacy Update

Feb. 7, 2019: State Advocacy Update


The Kentucky Medical Association (KMA), the American Society of Addiction Medicine (ASAM) and AMA are supporting a bill that would prohibit prior authorization for medication-assisted treatment (MAT) for opioid use disorder. As introduced House Bill 121 would prohibit the practice by insurers doing business in the state as well as Medicaid and Medicaid managed care organizations. The bill would apply to any prescription drug that is used in the treatment of opioid use disorder, including methadone, buprenorphine and naltrexone.

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"We have enacted many laws in Kentucky to help reverse the epidemic," said Kentucky Representative Kim Moser, the bill's chief sponsor. "Now it's time to take meaningful steps to remove barriers to evidence-based treatment for opioid-use disorder."

"Without question, this bill will save lives in Kentucky," said AMA Executive Vice President and CEO James L. Madara, MD, in a letter.

As part of the effort to help pass HB 121, the AMA and KMA developed a brief advocacy document on the issue for legislators and other stakeholders.

For more information about HB 121, please contact KMA's Cory Meadows.

The AMA encourages all states to consider introducing legislation to prohibit prior authorization of MAT as one of several policies to help end the nation's opioid epidemic. Contact Daniel Blaney-Koen to learn more about AMA model legislation on this issue.

On Jan. 18 Arizona received federal approval to require certain Medicaid patients to meet "community engagement" requirements, such as work, education, job training or community service, as a condition of receiving Medicaid benefits. Beginning in 2020, Medicaid patients in Arizona will have report at least 80 hours per month of such activities. Patients who fail to report compliance will be locked out of the program for two months. The approved waiver does provide an exemption to members of federally recognized tribes and is the first approved waiver to include such an exemption. The state estimates that 120,000 Medicaid patients will be affected by the new rules. Arizona is the eighth state to receive permission to impose work requirements on Medicaid patients and it is estimated that 120,000 patients will be affected.

Arizona will also eliminate a three-month retroactive eligibility period for most Medicaid beneficiaries. The retroactive eligibility period provided reimbursement of medical bills incurred up to three months prior to a beneficiary's application date, a safeguard against medical debt and uncompensated care costs.

The AMA opposes Medicaid work requirements and lock-out periods, and supports retroactive eligibility. The AMA Litigation Center recently submitted an amicus brief challenging similar work requirements in Kentucky.

A patient on long-term opioid therapy for the treatment of back pain was successfully tapered off all opioids after Illinois anesthesiologist David Walega, MD, implanted a temporary spinal cord stimulator (SCS) during a 10-day trial period. Objectively she was able to increase her quality time with her young children and husband, she was able to sleep restfully and uninterrupted by pain for the first time in five years, and told Dr. Walega that she was so happy "to finally get her life back." Prior to the SCS trial, she had lost her job due to the severity of pain and side effects from opioids, was mostly bed-ridden and deeply depressed.

Upon completion of the SCS trial, Dr. Walega submitted the required forms and letters of medical necessity to obtain prior authorization and approval to implant a permanent SCS system. The health insurer's specialty benefit management company, however, denied the SCS on the basis that the device and treatment was not "medically efficacious."

After months of appeals to the specialty benefit management company, which was located in California, and the physician reviewer, who was located in Florida, Dr. Walega was finally able to obtain approval to implant a permanent SCS for this patient. Yet, the appeals process—including the initial denial, follow-up denial and then peer-to-peer review by the health insurance company physician—took hours that Dr. Walega said cut into the time he was able to spend with patients.

"She went through eight months of additional pain, depression and anxiety when we had a proven treatment that was clearly helping her," said Dr. Walega. "But since the permanent implant, she's back to being a mom, goes on walks with her husband, and is working toward getting back in the job market. She is not using any opioids at all."

For Dr. Walega's other patients who would benefit from SCS, he reports that denials are increasingly common, and it is rare that the physician reviewer for the health plan is an anesthesiologist or pain specialist. In fact, a recent peer-to-peer review for a patient with neuropathic arm pain from myelomalacia was performed by a pediatrician.

"I have the deepest respect for my physician colleagues, but these health plans are using physicians to deny care when that physician has never practiced pain medicine, never trained as an anesthesiologist nor used SCS or other interventional therapies," Dr. Walega explained. "It's ludicrous and maddening."

Share your story on the AMA's End the Opioid Epidemic website.

AMA President-elect Patrice Harris, MD, made a recent visit to Louisiana to address physicians and medical students at the Louisiana State Medical Society (LSMS) Annual Meeting. She focused on six main areas in her speech: patients' access to care, the high cost of care, regulatory burdens on physicians, chronic disease, opioids and gun violence. She also highlighted the AMA's work to protect access to coverage.