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New UCF study examines insurance barriers to access opioid addiction medication
While insurance coverage of some forms of buprenorphine has improved over the years, researchers say coverage of new, more effective forms of the medication is lacking
Peer-Reviewed PublicationIMAGE: BARBARA “BASIA” ANDRAKA-CHRISTOU IS AN EXPERT IN HEALTH SERVICES, HEALTH POLICY AND SUBSTANCE-USE DISORDER TREATMENT. PHOTO CREDIT: BLAKE OSTING view more
CREDIT: PHOTO CREDIT: BLAKE OSTING, UNIVERSITY OF CENTRAL FLORIDA
By Danielle Hendrix ’15
ORLANDO, July 13, 2023 – In 2021, more people died from opioid overdoses in the U.S. than any other year in history, according to data from the U.S. Centers for Disease Control and Prevention.
However, a new University of Central Florida study recently published in Health Affairs shows that one of the most effective medications for treating opioid addiction is one of the least covered by insurance plans often used by patients with substance use disorder.
Researchers found that although most plans covered the immediate-release sublingual form of buprenorphine, extended-release buprenorphine injections were covered by less than half of commercial plans and less than a fifth of Medicare Advantage Plans. Furthermore, while most Medicaid plans did cover it, more than a third presented a barrier by requiring prior authorization before prescription.
The study’s lead author, Barbara “Basia” Andraka-Christou, says her key passion in research is trying to understand how to expand access to these life-saving treatments.
"Approximately 20% of people actually use buprenorphine or another similar medication called methadone for treatment of opioid-use disorder,” she says. “Most people don't get any treatment, or if they do get treatment, they're getting something that's less effective. Unfortunately, there have been a lot of barriers to accessing it, and some of those have been either lack of insurance coverage or various prior-authorization requirements.”
Buprenorphine can be prescribed by any clinician licensed by the Drug Enforcement Administration and comes in two overall forms: an oral immediate release version that is taken daily or a monthly extended-release intramuscular injection. Since some of the oral versions of the medication are available in generic form, they tend to be the cheaper option. The injection is newer and still under patent, making it the more expensive option.
How the Research Was Performed
Andraka-Christou, an associate professor in the School of Global Health Management and Informatics at UCF, teamed up with Thuy Nguyen from the University of Michigan, W. David Bradford from the University of Georgia and Kosali Simon from Indiana University to examine Medicaid, Medicare Advantage and commercial insurance formulary files to compare insurance-imposed restrictions for buprenorphine from 2017-21.
They studied factors like insurance coverage, prior-authorization requirements, and other potential access barriers like step therapy and quantitative limits across commercial providers, Medicaid, and Medicare.
“Medicaid covers about a third of people in the U.S. with opioid-use disorder and Medicare covers both the elderly and disabled populations,” she says. “That’s important because among older Americans, the rates of opioid overdoses have also been increasing. Because people flow in and out of different types of insurance, it’s very important to look at all insurance sectors.”
What Andraka-Christou and her team found were stark differences in coverage and prior authorization barriers depending on the form of buprenorphine requested. Nearly all plans covered at least one form of immediate-release buprenorphine in 2021, and prior-authorization requirements and quantity limits gradually decreased for immediate-release buprenorphine.
The intramuscular, extended-release injection was subject to the most variance by insurer type. Their research determined that Medicare and commercial insurance were less likely to cover the cost of the buprenorphine injection — with only 46% of commercial plans and 19% of Medicare Advantage plans covering it — as compared to Medicaid. On the other hand, most Medicaid plans covered the extended-release version in 2021, although 37% still required prior authorization.
Despite the oral version now being largely covered by insurers, Andraka-Christou says there is a downside in that it’s easier for opioid-use disorder patients to relapse if they skip doses. With the monthly intramuscular injection, that is less likely to happen.
“The reason prior-authorization requirements are a problem is that someone with an addiction may have a short window of time during which they're willing to go and get treatment,” Andraka-Christou says. “From a public health standpoint, it’s very important to not have prior-authorization requirements for these types of medicines. The injection is also very expensive because it's still on patent, so those requirements probably exist to cut costs. However, if someone had to wait days for the injection and has an overdose in that timeframe, then it might be less costly to not require prior authorization.”
The barriers related to the oral version of buprenorphine have been a topic of conversation in U.S. healthcare for a while, but Andraka-Christou’s team found that prior-authorization requirements for oral versions are minimal today compared to 10 years ago. With this new finding, she urges researchers, advocates and policymakers to shift their attention to the intramuscular injection version and work on addressing those barriers.
“I think providing access to life-saving treatment needs to be a priority for policymakers and community advocates, and that’s where my passion comes from,” Andraka-Christou says. “The fact is that we have this ongoing, horrific crisis, but we also have tools like buprenorphine and methadone that could cut the risk of overdose deaths in half if they weren’t so underused. State lawmakers could help lead this effort by requiring insurers to cover extended-release buprenorphine without prior authorization.”
Researcher Credentials
Andraka-Christou received both her juris doctorate and doctorate in law and social science from Indiana University Bloomington. She joined UCF’s School of Global Health Management and Informatics, part of UCF’s College of Community Innovation and Education, in 2017. Her areas of expertise include health services, health policy and substance-use disorder treatment. Much of her research on the evolving opioid epidemic is summarized in her book The Opioid Fix: America’s Addiction Crisis and the Solution They Don’t Want You to Have (Johns Hopkins University Press, 2020).
JOURNAL
Health Affairs
METHOD OF RESEARCH
Data/statistical analysis
SUBJECT OF RESEARCH
Not applicable
ARTICLE TITLE
Buprenorphine Treatment For Opioid Use Disorder: Comparison Of Insurance Restrictions, 2017–21
Doctors warn of looming threat to America’s surgical research
IMAGE: UVA HEALTH'S BRUCE SCHIRMER, MD (LEFT), AND ADISHESH K. NARAHARI, MD, WARN THAT A "BROKEN PIPELINE" OF FUNDING FOR SURGEON-SCIENTISTS COULD HARM PATIENT-CARE INNOVATION. view more
CREDIT: COURTESY ADISHESH K. NARAHARI, MD
Surgeons who also conduct important biomedical research are struggling to obtain research funding, and that “broken pipeline” could spell extinction for surgeon-scientists and slow innovations for patients if something isn’t done, a team of UVA Health experts warns.
Researchers led by Bruce Schirmer, MD, of UVA's Department of Surgery, found that surgeon-scientists often succeed in obtaining research support early in their careers but then are much less likely than peers in internal medicine to translate that into ongoing research funding.
The reasons for this are complex, Schirmer and colleagues say in a new scientific paper, but include the heavy clinical demands surgeons face and the ongoing need to maintain and refine their skills. This often leaves them with little time to compete for research funding and to conduct research that would ultimately benefit patients.
That, Schirmer and colleagues warn, could have dire implications for the future.
“Surgeons have been responsible for many of the significant advancements in treatments of diseases, especially those of the cardiovascular, digestive, neurologic, endocrine, pulmonary and urologic systems, as well as most types of cancer. Lack of ongoing funding for surgical research could limit such contributions in the future,” Schirmer said. “These data should be a wake-up call to the surgical community to reconsider when research is optimally performed during surgical training and how resources to subsequently support it can be best secured.”
Surgical Research Funding
Schirmer and his team looked at research grants obtained by trainees in both surgery and internal medicine. They found that trainees obtained F32 grants from the National Institutes of Health to support dedicated research at similar rates, but the internal medicine trainees were almost six times more likely to parlay that later into R01 grants, the NIH’s oldest and most competitive funding mechanism. The internal medicine researchers were also five times more likely to obtain a career development K-award from the NIH.
The researchers label the discrepancy a “shocking drop-off” and say it represents a “major problem” for the surgical specialty.
“Surgeons are struggling to find funding, and many of them are not able to obtain funding despite trying for 10 years. Surgeon-scientists have made many advances in biomedical research in fields such as transplantation, oncology and diabetes,” said UVA Health surgery intern Adishesh K. Narahari, MD, PhD, the first author of the new scientific paper. “In short, surgeons need to apply for funding early and become proficient at navigating the biomedical research world. Otherwise, we may see a decrease in innovation and lack of new solutions to not only surgical problems but many areas of biomedical research.”
Narahari, Schirmer and their collaborators say swift action is needed and have formulated recommendations to address the problem. These suggestions include:
- Develop alternate grant-funding mechanisms to support surgeon-scientists;
- Establish programs at individual institutions to support surgical residents who wish to do research;
- Encourage surgeons to do research by evaluating surgeon-scientists using different job-performance metrics than surgeons who do not do research.
If steps aren’t taken, the UVA researchers warn, surgical research will suffer.
“We hope this paper sparks a movement to encourage the development of surgeon-scientists through curricular, programmatic and supportive mechanisms that foster those highly interested in such career paths to be most productive and successful,” Schirmer said. “We hope those who oversee surgical education and training will strongly consider these findings.”
Findings Published
The researchers have published their findings in the scientific journal Annals of Surgery. The team consisted of Narahari, Anirudha S. Chandrabhatla, Emily Fronk, Simon White, Shreya Mandava, Hannah Jacobs-El, J. Hunter Mehaffey, Curtis G. Tribble, Mark Roeser, John Kern, Irving L. Kron and Schirmer.
Narahari was supported by NIH grant F30CA236370.
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