“There was no reason for the delay,” said John Gallagher, MD. “She simply wanted to get into a methadone clinic as quickly as possible for herself and her baby.”
Once he and his staff finally got through to someone who could approve a prior-authorization request, it took only a few minutes, and Dr. Gallagher could then immediately arrange for the specialized care. “I’m pleased to report that mom did well in treatment, and she delivered a healthy baby,” he said.
Dr. Gallagher’s situation is all too familiar for physicians in Pennsylvania and across the nation. They spend countless hours on senseless prior-authorization requests that are almost always approved. Not only do prior-authorization requirements cause unnecessary delays that negatively impact patient care, they also force medical staff and physicians to sink time into making phone calls to insurance companies during business hours, taking time away from patients.
But that is changing in Pennsylvania. Gov. Tom Wolf secured an agreement last year with the seven largest health insurance companies in the commonwealth that removes prior authorization for methadone, naltrexone and at least one form of buprenorphine. In addition, the agreement requires the medications to be on a health plan’s lowest cost-sharing tier.
“As we fight the opioid crisis, our focus should be on removing barriers to treatment wherever they may exist and helping people battling addiction get the treatment they need,” said Pennsylvania Human Services Department Secretary Teresa Miller. “When someone decides they are ready for treatment, time is critical. Time spent waiting for a service authorization makes it more difficult for the individual who initiates treatment to remain engaged in treatment.”
The agreement, the first in the nation, was helped by sustained advocacy by the AMA and Pennsylvania Medical Society (PAMED). Dr. Gallagher chairs PAMED’s opioid task force.
The process to remove prior authorization for medication-assisted treatment (MAT) began over a year ago when Gov. Wolf called a meeting in the state capitol that included physicians, health insurance companies and other stakeholders.
Dr. Gallagher advocated for the need to streamline the approval process so that patients could begin treatment faster, calling on the insurance company representatives to explain why prior authorization for MAT was necessary. The AMA Opioid Task Force has worked with PAMED and many other medical societies to call for a removal of prior authorization for MAT.
“The insurance companies wouldn’t answer my questions, they kept dodging,” Dr. Gallagher said. “So, Attorney General (Josh) Shapiro said, ‘Let’s get back to Dr. Gallagher’s question. You’re not giving him an answer. Why are we doing this?’ And we got no good answers, so we kept up the pressure and discussions with the governor and his administration to follow up and eventually we won.”
The AMA and PAMED continue to engage with Pennsylvania policymakers to monitor implementation of the agreement. Contact the AMA Advocacy Resource Center ([email protected]) to learn how to take action.
“We have long advocated for the removal of prior authorization and other barriers to increase access to MAT for substance-use disorders,” said AMA President-elect Patrice A. Harris, MD, MA. “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.”