Removing Prior Authorizations Had Mixed Effect On OUD Care Uptake

Beneficiaries may face barriers to substance abuse care when states impose prior authorizations for substance use disorder treatments, but a broad range of policies can influence Medicaid beneficiaries’ access to care, according to a study published in JAMA Health Forum.

Buprenorphine is a prescribed medication-assisted treatment for opioid use disorder. The researchers used a cross-sectional study in order to assess buprenorphine utilization in two states that lifted prior authorizations on the drug. California removed prior authorizations on buprenorphine in June 2015 and Illinois did the same in July 2015.

The study relied on Medicaid State Drug Utilization Data for California and Illinois from 2013 to 2020. The researchers compared this data to eight control states: Alabama, Florida, Idaho, Kansas, Mississippi, Nevada, South Dakota, and Wyoming.

The researchers found that removing prior authorizations on buprenorphine led to a relative statistically significant decrease in buprenorphine prescriptions in California and a relative statistically significant increase in buprenorphine prescriptions in Illinois. 

Of the two states, only Illinois experienced a relative statistically significant increase in prescriptions when compared to the change in the control states.

The changes to trends in dosage form—film or tablet—were not statistically significant in California, but in Illinois, the prior authorization removal preceded a statistically significant spike in film prescriptions.

There were a few limitations to the analysis, including the time it takes a state’s policies to take effect and the fact that other policies may have influenced these changes. For example, the researchers noted that the results in Illinois may have been influenced by the end of the Medicaid program’s strict tapering dosage for opioid use disorder treatment in Illinois prior to 2015.

The distinct results in California compared with Illinois emphasized the influence that a constellation of policies have on the uptake of medication-assisted treatment for substance use disorders.

California had been experiencing a strong upward trend in buprenorphine prescribing before the prior authorizations were lifted. This trend decreased when the state removed prior authorizations on the drug. The researchers said that this may have lessened the impact of the new policy.

Additionally, the researchers highlighted differences in the prior authorization in California when compared to the process in Illinois. Illinois’s prior authorization process was more complex than California’s.

Buprenorphine is not the only medication-assisted treatment option available in either state. Each state experienced changes in its preferred drug list that might have impacted the results.

Providers and services offered alongside the medications can also influence opioid use disorder treatment uptake.

“The heterogeneity in these findings might indicate that buprenorphine prescribing may not only depend on PA policies, but also other factors such as prepolicy utilization trends,” the researchers concluded.

According to federal law, states have to offer substance use disorder treatment as a maternal health service through Medicaid, specifically buprenorphine and naloxone.

Beyond buprenorphine utilization and coverage, access to substance abuse care can still be hard to achieve in Medicaid. Less than one in five adolescents who have an opioid use disorder receive treatment for their conditions. Less than seven percent of adolescents covered under Medicaid who needed buprenorphine received it through Medicaid.

Prior authorizations continue to be a source of contention in the healthcare industry.