Association of Formulary Prior Authorization Policies With Buprenorphine-Naloxone Prescriptions and Hospital and Emergency Department Use Among Medicare Beneficiaries

Abstract

IMPORTANCE Prior authorization requirements may be a barrier to accessing medications for opioid use disorder treatment and may, therefore, be associated with poor health care outcomes. OBJECTIVE To determine the association of prior authorization with use of buprenorphinenaloxone and health care outcomes. DESIGN, SETTING, AND PARTICIPANTS This comparative interrupted time series analysis examined enrollment and insurance claims data from Medicare beneficiaries with an opioid use disorder diagnosis or who filled a prescription for an opioid use disorder medication between 2012 and 2017. Over this period, 775 874 members were in 1479 Part D plans that always required prior authorization, 113 286 members were in 206 plans that removed prior authorization, 189 461 members were in 489 plans that never required prior authorization, and 619 919 members were in 485 plans that added prior authorization. Data analysis was performed from April 2019 to February 2020. EXPOSURES Removal or addition of prior authorization and new prescriptions filled for buprenorphine-naloxone. MAIN OUTCOMES AND MEASURES Buprenorphine-naloxone use, inpatient admissions, emergency department visits, and prescription drug and medical expenditures. RESULTS The study population in 2012 included 949 206 Medicare beneficiaries (mean [SD] age, 57 [15] years; 550 445 women [58%]). Removal of prior authorization was associated with an increase of 17.9 prescriptions (95% CI, 1.1 to 34.7 prescriptions) filled for buprenorphine-naloxone per plan per year, which is a doubling of the number of prescriptions, on average. Each prescription filled was associated with statistically significant decreases in adverse health care outcomes: substance use disorder-related inpatient admissions decreased by 0.1 admission per plan per year (95% CI, −0.2 to −0.1 admission per plan per year), and substance use disorder-related emergency department visits decreased by 0.1 visit per plan per year (95% CI, −0.13 to −0.03 visit per plan per year) (all P < .001). Combining these results, removal of prior authorization was associated with a reduction in substance use disorder-related inpatient admissions by 2.0 admissions per plan per year (95% CI, −4.3 to −0.1 admissions per plan per year) and substance use disorder-related emergency department visits by 1.4 visits per plan per year (95% CI, −3.2 to −0.1 visits per plan per year). CONCLUSIONS AND RELEVANCE Removing prior authorization for buprenorphine-naloxone was associated with an increase in the medication use and decreases in health care utilization and expenditures.

Barriers and Facilitators to the Use of Medications for Opioid Use Disorder: a Rapid Review

“…Knowledge (1) 36 Lack of provider awareness/understanding of buprenorphine (1) Provider knowledge of buprenorphine (1) Logistics (10) 16,20,25,33,35,36,40,42,44,48 Requirement of prior authorization ( 3 barriers identified by patients, while practical and logistical issues related to time, regulatory factors including DEA oversight were the most common barriers identified by providers. Administrator-identified or system-level barriers echoed the logistical barriers identified by both patients and providers.…”

“…One of the most frequently cited of these barriers was the need for prior authorization before OUD medications can be prescribed. 16,25,33,42 Tellingly, one national survey of commercial health plans found that as the percent of plans who cover OUD medications has increased (65 to 97%), so has the percent of plans that required prior authorization (8 to 39%). 42 Other barriers have persisted in limiting patients' access to OUD medications even when insured.…”

Trends in healthcare expenditures and resource utilization among a nationally representative population with opioids in the United States: a serial cross-sectional study, 2008 to 2017

“…Given the high costs associated with opioid use, healthcare payers are financially incentivized to reduce opioid prescribing, mitigate opioid overdoses, and provide care to those with opioid addiction and misuse. For example, removal of formulary restrictions for buprenorphine-naloxone, which is used for treatment of opioid use disorder, was associated with an increase of 17.9 prescriptions per plan per year among Medicare beneficiaries [ 34 ]. Moreover, removal of formulary restriction resulted in a reduction in substance use-related inpatient admissions (2.0 admissions per plan per year) and emergency department visits (1.4 visits per plan per year) [ 34 ].…”

“…For example, removal of formulary restrictions for buprenorphine-naloxone, which is used for treatment of opioid use disorder, was associated with an increase of 17.9 prescriptions per plan per year among Medicare beneficiaries [ 34 ]. Moreover, removal of formulary restriction resulted in a reduction in substance use-related inpatient admissions (2.0 admissions per plan per year) and emergency department visits (1.4 visits per plan per year) [ 34 ]. The U.S. Department of Veterans Affairs, the largest integrated healthcare system in the United States implemented the Opioid Safety Initiative in 2013 to reduce opioid prescribing and reported a 56% reduction in opioid prescribing, an 83% reduction in opioid and benzodiazepine co-prescribing, and a 77% reduction in high-dose opioid prescribing from 2012 to 2019 [ 35 ].…”

The association of Medicare Part D prior authorization for buprenorphine–naloxone with adherence to opioid use disorder treatment guidelines in the United States

“…Research shows that PA is associated with less medication use [2]. A recent study found that patients with an opioid use disorder (OUD) diagnosis enrolled in Medicare plans that required PA for buprenorphine-naloxone-a medication used to treat OUD-had lower use of buprenorphine-naloxone and higher rates of OUD-related hospitalization and emergency department visits [3]. Although health plans assert that PA results in better-quality treatment, this assertion has not been empirically tested.…”