Brian Barnett is an addiction psychiatry fellow at Massachusetts General Hospital/McLean Hospital and Harvard Medical School.
I’m an addiction specialist, and my voice-mail inbox is always nearly full. Some messages are from desperate individuals looking for outpatient treatment or help finding a detoxification program. Others are from patients needing a letter confirming their treatment for a child-custody dispute or care providers informing me that my patients have been hospitalized.
It’s hard to know what to expect, but invariably one type of message awaits: voice mails from pharmacies informing me that a patient’s insurance provider will not approve payment for the medication to treat their opioid addiction unless I obtain prior authorization from the insurer.
Buprenorphine-naloxone, commonly known by the brand name Suboxone, and other medications, such as methadone and naltrexone, are used in combination with therapy and mutual-help groups to offer a new life for patients with opioid addiction. These medications have been shown to at least double a patient’s chances of remaining abstinent from illicit opioids and dramatically reduce overdose deaths. Without them, about 80 percent of patients using heroin relapse within the first month after detoxification.
Medication-assisted treatment for opioid addiction brings innumerable benefits to both patients and society: It allows many addicted individuals to stop committing crimes, rejoin the workforce, reunite with their families and reintegrate into their community. Thanks to medication-assisted treatment, I have personally witnessed dramatic transformations. It’s like watching chemotherapy curing a patient with cancer.
Given these profound benefits, you may think that insurers would make it easy for doctors to prescribe these medications. But that’s not the case.
The prior-authorization process is so cumbersome that many doctors choose not to prescribe medications such as Suboxone at all. As one of the few who does prescribe the medication, I can say that each prior-authorization request I receive is quite burdensome and takes 30 to 60 minutes to complete. And I’m not alone: Other prescribers say prior authorizations are the most significant barrier to getting these medications to their patients.
What does it take to apply for a prior authorization? Pharmacies most often give me a phone number to call to start the process, though occasionally I can do it online or by fax. Sometimes I call the number, and after working my way through several prompts, I discover that it is incorrect or that the insurer has “carved out” its medication benefits to another organization entirely. Sometimes the representatives I encounter cannot even tell me where to call next. Thirty minutes of being put on hold and pressing buttons frequently ends with me searching for the correct number on Google.
Once I’ve finally reached the right place, I am usually placed on hold again before eventually speaking with a representative. This person collects information about my patient that the company already has — his or her address, phone number, diagnoses — and details about my practice. These representatives have no medical training and often ask me to spell the names of the medication and provide them with information about the dosage and frequency, the number of pills I am requesting, and the length of the prescription. After speaking with them, I am usually told that a decision will be rendered in several days.
All the while, my patient is waiting at high risk of relapse due to the horrific effects of opioid withdrawal. In this era of fentanyl-laced heroin, one relapse can mean death.
When approved, prior authorizations usually need renewal every six to 12 months. Another authorization may also be required if I want to increase a patient’s dosage.
Insurers argue that this system exists for safety reasons. What they don’t want to admit is that they are conducting a war of attrition against the addiction treatment community to reduce their short-term costs. In fact, studies show that prior authorizations for medication-assisted treatment are associated with increased rates of relapse and decreased retention in treatment. No similar requirements exist for the highly addictive opioids such as oxycodone that fueled the initial stages of the opioid epidemic. New York Attorney General Eric Schneiderman has recognized this discrimination and successfully sued several insurers to curb this practice there.
America’s addiction treatment community is spread extremely thin amid this overwhelming overdose epidemic. Any time wasted obtaining prior authorizations is time that could have been spent treating patients and working to prevent further overdose deaths.
The time is now for our state attorneys general and legislatures to enforce parity for addiction treatment and bring an end to prior authorizations for medication-assisted treatment. If we can rectify this, we stand a much better chance of having more providers prescribe medications for opioid addiction and getting this epidemic under control. If not, we will look back years from now and realize too late that we missed an easy fix.
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