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Report Bolsters Case for Lifting Prior Authorization on MAT in New York

December 10, 2019

Strong backers of expanded access to medication treatment for opioid use disorder (OUD) in New York are eagerly awaiting Gov. Andrew Cuomo's action on adopted legislation to restrict insurers' use of prior authorization for these drugs.

A pair of bills governing these actions at the Medicaid and private insurance levels received legislative approval earlier this year and require the governor's signature to become law. Allegra Schorr, president of the Coalition of Medication-Assisted Treatment Providers and Advocates of New York State, tells Behavioral Healthcare Executive that the only indication from the Cuomo administration in recent weeks has been that the governor's office continues to study the potential impacts of the legislation.

Schorr terms the delay in the administration's action on the legislation “very concerning.”

Worry over increased costs to publicly funded health programs from expanded access to medication-assisted treatment (MAT) often causes state leaders to hesitate to embrace the removal of prior authorization requirements. But advocates in New York are pointing to results of a new study from RTI International that suggests improved access to medications for OUD would substantially reduce health care costs associated with untreated addiction.

The report, Economic and Health Effects of Removing Prior Authorization from Medications to Treat Opioid Use Disorders Under New York State Medicaid, estimates that a state Medicaid formulary without prior authorization would result in a 22% decrease in inpatient admissions and a 104% drop in emergency department visits, contributing to a savings of nearly $52 million in public dollars over a 12-month period.

“Every time someone comes in for treatment, and we know that [MAT] is no question the standard of care, we know that someone may very well go out and use if we can't respond with a medication and serve them immediately,” Schorr says.

The bills that are awaiting the governor's action are S. 5935/A. 7246, applying to Medicaid and all three of the federally approved medications for OUD, and S. 4808/A. 2904, covering initial and renewal prescriptions for buprenorphine and naltrexone under commercial insurance. The Medicaid legislation, sponsored by State Sen. Pete Harckham, would bar prior authorization for the OUD drugs unless the prescription was written for a non-formulary or non-preferred form of the medication.

Study methodology

The RTI International study, issued last month and prepared for the Legal Action Center, applied some hypothetical conditions for New York because data were not available on actual prescription drug costs or the specific criteria that are used to develop preferred drug lists and managed care formularies.

Therefore, in order to seek a reliable estimate of the impact of greater access to medications for OUD, the researchers examined results of a 2016 study that compared hospitalization patterns for Vermont Medicaid beneficiaries with OUD who were and were not receiving medication treatment. “The report is clearly scientific,” Schorr says of the RTI International analysis.

The cost reductions that are suggested in the analysis are based on anticipated results of a 20% increase in buprenorphine use, a 22% drop in inpatient admissions for patients receiving medication, a 104% decrease in emergency department visits in this group, and an 80% decrease in all-cause mortality for patients on medication.

“The human costs are more than clear,” Schorr says. But the report also makes a strong case if the discussion is limited to dollars and cents. “The more you put up barriers [to treatment], the more costs go up.”

The Legal Action Center's summary of the study suggests that prior authorization for MAT in New York “creates a huge barrier to care for people prescribed those medications, including people who are doing well on a medication but then they change plans or their plan changes the medications on its formulary. This also is critical for individuals leaving incarceration on Riker's Island where they are often treated with the brand medication Zubsolv, which is not on the preferred drug list.”

Neighboring New Jersey earlier this year waived prior authorization requirements for MAT under Medicaid, reflecting a trend toward states' reconsideration of measures that have restricted access to potentially life-saving medication treatments.

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