Removing Medicaid Prior Authorizations for Buprenorphine May Not Increase Prescribing

Removing prior authorizations (PAs) for buprenorphine as treatment of opioid use disorder (OUD) alone may not increase prescribing among those who have Medicaid, according to results of a study from JAMA Health Forum. The study authors said multi-pronged efforts are needed to increase buprenorphine access to address the ongoing burden of opioid overdoses.¹

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According to the Substance Abuse and Mental Health Services Administration, buprenorphine is approved to treat OUD and should be prescribed as a treatment plan that includes counseling and other services for patients. It is an opioid partial agonist that is safe and effective when prescribed that helps to minimize the effects of withdrawal and cravings.²

Investigators of the study intended to determine whether the removal of Medicaid PAs would be associated with changes in buprenorphine prescriptions. The study authors collected quarterly data at the state level starting from January through March 2015 (first quarter) through January through March 2019 (the last quarter). States were included if the PAs at the start of 2015 required fee-for-service or managed care organization plans with similar PA policies that had at least 2 quarters of data before and after the PA was removed; however, they removed Vermont and Illinois due to higher prescribing rates and repealing PAs, respectively. Twenty-three states were included in the analysis.¹

Between 2015 and 2019, the 23 states removed Medicaid PAs for at least 1 formulation of buprenorphine and 6 states had at least 2 quarters or pre- and post-policy change data. Investigators found that states that maintained the PAs differed at baseline, including a lower number of buprenorphine prescriptions per 1000 enrollees, lower likelihood of handing expanded Medicaid, and fewer individuals receiving methadone through a treatment program per 100,000 individuals.¹

The study authors reported that the removal of PAs was not associated with consistent changes in the buprenorphine prescriptions per 1000 individuals with Medicaid and the removing the PAs was not associated with prescribing. Furthermore, there was not an increase in prescriptions after PA removal that was not observed in states above the median, according to the results.¹

Additionally, in states with Medicaid expansion, non-expansion states had an increase in prescriptions after PA removal at 27.3% and expansion states demonstrated a 22% decrease in prescriptions, according to the study authors.¹

The study authors said the results “indicate that efforts to remove Medicaid buprenorphine PAs alone may not result in meaningful increases in prescriptions.” They added that for patients with OUD, experiences with stigma, preferences for autonomy, and more patient-centered experience could affect the interest in buprenorphine treatment, which could affect the uptake of the drug.¹

The study included several limitations, according to the authors. There was not data on the number of Medicaid enrollees who had OUD, so the investigators were not able to determine if the number of those on buprenorphine is a result of care availability or its implications for those with Medicaid who have OUD. Furthermore, PA policies were treated as the main influence, however the burden on prescribers could differ depending on the policy and the practice’s resources to process PAs.¹

Reference

1. Christine PJ, Larochelle MR, Lin L, McBride J, Tipirneni R. Removal of Medicaid Prior Authorization Requirements and Buprenorphine Treatment for Opioid Use Disorder. JAMA Health Forum. 2023;4(10):e233549. doi:10.1001/jamahealthforum.2023.3549
2. Substance Abuse and Mental Health Services Administration. Buprenorphine. September 18, 2023. Accessed November 20, 2023. https://www.samhsa.gov/medications-substance-use-disorders/medications-counseling-related-conditions/buprenorphine