By Glenn Howatt
Despite Minnesota’s professed commitment to battling opioid abuse, the state’s own health insurance program for the poor is among the biggest barriers in getting anti-addiction drugs to patients, according to doctors at several clinics across the state.
Physicians use the drug Suboxone and its generic equivalents to help people recover from opioid addiction, but government red tape can delay getting the drugs into the hands of Medical Assistance enrollees — delays that can be deadly.
“We have all seen patients relapse or die in that intervening time,” said Dr. Emily Brunner, an addiction medicine specialist at St. Joseph’s Hospital in St. Paul. “It is a lifesaving medication. There is just no reason for the delay.”
Although the state has launched a multiagency effort to address the rising number of opioid-related deaths, cut down on opioid prescribing and broadened access to treatment, it has not followed the lead of some other insurers that have made it easier for doctors to give their patients anti-addiction medications.
Every outpatient Suboxone prescription written for a Medical Assistance enrollee must first get approval from the state bureaucracy, a process known as prior authorization, that can result in delays of one to several days.
“The state is the one that is putting all this money into Suboxone, and they are the ones with the biggest barrier,” said Dr. Kari Rabie, medical director at the Native American Community Clinic in Minneapolis. “Opioid withdrawal is extremely uncomfortable,” Rabie said. “If you can’t get patients started right away, we know they are going to use” again.
The Minnesota Department of Human Services, which administers the health insurance program for the poor that is also known as Medicaid, said it knows about the concerns.
“This has been a topic of some robust discussion within the agency,” said Deputy Commissioner Chuck Johnson. “We are very supportive of medication-assisted treatment and want to see it expanded.”
“Where prior authorization fits within that is something we have been having concerns about,” he said.
‘I wanted to be sober’
Heather Sonnee stopped using heroin more than five years ago with the help of Suboxone, and she knows what can happen when an insurance company authorization doesn’t come through — it has happened to her twice in just over a year.
She credits the drug for reducing her cravings and clearing the way for recovery.
Suboxone “gave me the power of choice back. I knew I wanted to be sober, I wanted a different life so bad, and that medication made it possible,” she said.
Around April of this year Sonnee needed to refill her prescription but was told her pharmacy couldn’t do it because the prior authorization needed for a renewal had not gone through. It took nearly two weeks to get it straightened out, she said.
“Going into withdrawal unplanned is a very dangerous place for somebody in my situation,” said Sonnee. “If I didn’t have my feet both planted firmly in a recovery community, I don’t know what would have happened.”
One ingredient of suboxone is buprenorphine — itself an opioid, but one whose formulation limits the euphoric effect and tamps down cravings for other opioids. Stopping Suboxone without tapering down the dosage can create unpleasant side effects.
“That withdrawal is so incredibly awful, to be able to through that on your own without any medication is very scary,” Sonnee said. “A situation like that literally could kill somebody. I know it sounds extreme but it is not.”
The side effects can be so bad that some will go back to pills or heroin, putting them at risk for an overdose.
“It is totally unconscionable what insurance providers are doing by setting up these prior authorization barriers,” said Dr. Gavin Bart, director of addiction medicine at Hennepin Healthcare in Minneapolis. “I have had people put into temporary tailspins because of the issue.”
‘It’s hard to find a doctor’
Treatment advocates say prior authorization is just one of the many problems that stand in the way of access to anti-addiction medications.
Unlike pain pills, Suboxone requires doctors to have special training and a waiver from the U.S. Drug Enforcement Administration (DEA) before they can prescribe it.
“I did not need any medical training to prescribe opiates, but I did need training to prescribe a medication that gets people back to normal,” said Dr. Ryan Kelly, an internal medicine and pediatrics physician at the University of Minnesota who also practices at the Community-University Health Care Center in Minneapolis.
The DEA also limits a doctor’s Suboxone caseload to 30 patients in the first year, eventually allowing them to ratchet up to 275 patients after a few years.
“It is hard to find a doctor,” said Tanner Curley, who is recovering from heroin addiction. “There are a lot of doctors who didn’t have the license to prescribe. Those that did were flooded with patients.”
It can also be hard to fill a Suboxone prescription because some pharmacies do not keep a complete inventory of all its variations, including generics. The drugs come in either tablet or film form; even insurance companies that don’t require prior authorization do have restrictions on which type they will pay for.
“It is not uncommon for our patients to go the pharmacy and they don’t have Suboxone in stock,” said Shana Hall, a chemical dependency nurse at Community-University Health Care Center.
“They don’t have an understanding about what a delay means to our patients,” Hall said of state regulators.
Johnson said the state requires prior authorizations because the drug is costly and to ensure it’s not being prescribed inappropriately or diverted to the black market.
But addiction doctors say those concerns are unwarranted given the medical and social costs associated with opioid addiction. Some studies have shown that street sales of diverted Suboxone are more prevalent where people find it difficult to get treatment.
“The safety concern is really not … borne out in the literature and in clinical experience,” said Dr. Yngvild Olsen, a Maryland physician and board member of the American Society of Addiction Medicine.
Maryland’s Medicaid program dropped prior authorization two years ago and the state’s legislature banned the practice. It has created a change that “has really been like night and day,” Olsen said.
Despite Minnesota Medicaid’s concerns, most of the managed-care companies that serve Medicaid enrollees (about 900,000 of the 1 million total enrollees) have dropped the prior authorization requirement. That includes UCare, Blue Cross and Blue Shield of Minnesota and HealthPartners. They have also dropped the requirements for all their non-Medicaid members.
“We are doing all we can to help members have easy access to medications that alleviate symptoms of dependence and withdrawal,” said Dr. Scott Kammer, UCare’s associate medical director.
We live in a capitalist society. We proclaim belief in a free market economy. Yet we lament that we cannot get care to a population in need of it. I think a look from the economic perspective is the best way to deal with this; “if you pay them, they will treat!” Set up a demonstration project and you’ll probably see that it is cost-effective in the long run.