Aetna's prior authorization program under scrutiny
Last week, CNN published a story, shining light on Aetna's problematic utilization management programs. The story highlights courtroom testimony from a former Aetna medical director in California in which he states that he never reviewed medical records when deciding whether to authorize or deny care. California Insurance Commissioner David Jones, as well as the California Department of Managed Health Care, launched an immediate investigation into Aetna's practices and has been followed by Insurance Commissioners in Colorado, Connecticut and Washington.
Insurers' prior authorization and other utilization management programs continue to be the major barriers to care for patients and major administrative burdens to physicians. Reported negative clinical impacts, patient care delays, and interference with clinical expertise reflect the daily experiences of both patients and physicians navigating health insurers' prior authorization systems.
As illustrated by the CNN reporting, companies are increasingly determining the course of treatment, even though physicians have the clinical expertise, years of training, and first-hand knowledge of the patient necessary to recommend the most appropriate care in each individual case. The AMA has a number of resources available to medical societies interested in addressing prior authorization and other utilization management programs, including principles, model legislation, survey data, and videos on electronic prior authorization.
Additionally, a recently released consensus statement (PDF) developed by the AMA, AHA, AHIP, APhA, BCBSA, and MGMA on improving the prior authorization process is available to you to help in your prior authorization efforts.
MAT helps reduce post-incarceration fatal opioid-related overdoses
A statewide substance use disorder treatment program in Rhode Island focused on people released from prison was a driving factor in reducing opioid-related mortality across the state, according to a new study in JAMA Psychiatry.
The program emphasized screening individuals for opioid use disorder and initiating them on or maintaining their medication assisted treatment (MAT—including methadone, buprenorphine or naltrexone) regimen throughout incarceration. Upon release, the Rhode Island Department of Corrections worked to connect patients to the established community-located Centers of Excellence in MAT to help ensure continuity of care.
The results of the study found a decrease in overdose deaths from 26 of 179 individuals released from Jan. 1 to June 30, 2016, to 9 of 157 individuals from Jan. 1 to June 30, 2017—a 60 percent reduction in mortality.
"We have known for a long time that MAT works and that people leaving the incarcerated setting are at extremely high risk for fatal overdose," said Josiah "Jody" Rich, MD, MPH, Professor of Medicine and Epidemiology at Brown University and one of the authors of the study. "We now know that, even in the face of a devastating fentanyl-laced epidemic, that prompt implementation of MAT can lead to a dramatic drop in overdose deaths. Communities concerned about fatal overdose in their population now have an effective strategy to pursue- implement comprehensive screening, initiation of MAT with linkage to effective community treatment programs for people passing through correctional facilities."
"Focusing on incarceration and the overdose risk post-incarceration reduces the harm of the life-altering social consequences of incarceration while treating a health condition that is clearly responsive to effective treatment," said Traci C. Green, PhD, MSc, Department of Emergency Medicine, Brown University, and the study's lead author. "This approach is an investment that works, saves lives, and reduces overdose in the community."
The Rhode Island Medical Society noted that the program is one of several innovative approaches in the state that has been developed with Governor Gina Raimondo's Overdose Prevention and Intervention Task Force that includes RIMS and many other stakeholders.
The AMA strongly supports increased access to post-incarceration MAT and advocates for "correctional facilities to increase access to evidence-based treatment of opioid use disorder, including initiation and continuation of [MAT] in conjunction with counseling, in correctional facilities within the United States and that this apply to all incarcerated individuals including pregnant women." Visit the AMA's End the Opioid Epidemic microsite to learn more.
