Report to Congress finds wide variation in utilization management policies to control costs and prevent diversion of addiction-treatment drugs
The Medicaid and CHIP Payment and Access Commission (MACPAC) today released a report to Congress on Medicaid utilization management policies for medication-assisted treatment (MAT), finding that utilization management policies vary widely across the country and the extent to which these policies pose barriers to addiction treatment is unclear.
Report to Congress: Utilization Management of Medication-Assisted Treatment in Medicaid was mandated by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act, P.L. 115-271). State Medicaid programs are increasingly turning to MAT to treat opioid and alcohol use disorders, and depending on utilization management to ensure appropriate care, control costs, and prevent drug diversion. The SUPPORT Act directed MACPAC to examine national trends in MAT and assess whether utilization management of these medications creates barriers to care.
The report focuses on a range of utilization management policies, including preferred status, prior authorization, step therapy, prescription limits, quantity or dose limits, and lifetime limits in eight states: Arkansas, Illinois, Maine, Missouri, Tennessee, Utah, Washington, and West Virginia.
“Our review found a trend among states to eliminate prior authorization. This is encouraging, since it removes one potential barrier to MAT access,” said MACPAC Chair Melanie Bella. According to the MACPAC study, the number of states requiring prior authorization for MAT medications declined, from 48 in 2011—2013 to 30 in 2018. State Medicaid agencies also were eliminating lifetime limits and removing requirements that patients undergo psychosocial counseling when prescribed certain drugs.
But other approaches, such as when a state removes a drug from its preferred drug list, could make it more difficult for beneficiaries to obtain MAT when they are ready to seek treatment, Bella said. The report found that 50 states and the District of Columbia assigned preferred status to oral naltrexone from 2011 to 2013 but just 44 states did so in 2018.
Also according to the report, prescriptions for buprenorphine nearly tripled from 2013 to 2017, from approximately 1.8 million to 5.2 million, and naltrexone prescriptions more than quadrupled, from 99,000 to 444,000. Both medications are used to treat opioid use disorder (OUD). “These data suggest that more people are getting needed treatment,” said Bella. However, she said, at the same time a large treatment gap remains: In 2017, only 44 percent of Medicaid beneficiaries under age 65 with OUD received any substance use disorder treatment.
Other findings of the report include:
- States and managed care organizations apply more utilization management policies to medications than to counseling (which is considered a component of MAT) and fewer utilization management policies to medications used to treat alcohol use disorder than those used to treat OUD.
- States are adding quantity or dosing limits to MAT drugs, and eight states implemented policies in 2016 that require providers to check prescription drug monitoring programs before prescribing any controlled substance, including MAT drugs.
Download the October 2019 Report to Congress: Utilization Management of Medication-Assisted Treatment in Medicaid at macpac.gov.
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ABOUT MACPAC
The Medicaid and CHIP Payment and Access Commission is a non-partisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, the Secretary of the U.S. Department of Health and Human Services, and the states on a wide array of issues affecting Medicaid and the State Children’s Health Insurance Program (CHIP). For more information, please visit: www.macpac.gov.
