It was a Friday afternoon, and a young man — the doctor called him “J” — needed help. J was addicted to heroin. The doctor, Mike Kalfas, had treated him several times before with buprenorphine, a drug that blocks opioid cravings and is part of a class of drugs most successful in keeping patients in recovery.
J had recently gotten out of jail on a drug-related charge, Kalfas said. There, he’d had to stop using buprenorphine because it wasn’t available.
“I wrote him the prescription, and it’s 5:30 p.m. on a Friday when he left my office,” Kalfas told Kentucky lawmakers earlier this month. “About 6:30 p.m. the paper comes over the fax machine, denying his medication.”
J’s insurance company had denied the prescription. Kalfas needed to complete what’s called “prior authorization” paperwork, a tool insurance companies use to both make sure a patient needs that medication and contain costs.
But Kalfas and his staff had gone home for the weekend. On Monday morning, his assistant saw the denial and immediately called J’s insurance company to submit medical records to get the prescription approved. By 10:30 a.m., the nurse had obtained approval for J to fill the buprenorphine prescription. But it was too late.
“Unfortunately J overdosed and died about 9:30 a.m. Monday morning,” Kalfas said, who owns a primary care and addiction practice in Ft. Thomas. “That happens more often than I like to admit.”
Kalfas spoke at a legislative committee hearing on a bill that he said could have saved J’s life. Shortly after his testimony HB 121 passed through committee and then the full House.
The bill would prevent Medicaid insurance companies from denying prescriptions for drugs like buprenorphine by requiring prior authorization. Both the federal government and the medical community say these types of drugs, called medication-assisted treatment or MAT, have the highest success rates in treating people with opioid use disorder and preventing relapse.
Kentucky is among 39 other state Medicaid programs that require buprenorphine go through a prior authorization process before being filled in a pharmacy, according to a 2018report by the federal Substance Abuse and Mental Health Services Administration.
Two states — Maryland and Pennsylvania — have laws that ban prior authorization of MAT drugs for Medicaid enrollees. Andrey Ostrovsky, the former chief medical officer at the federal Center for Medicaid and CHIP Services, said if Kentucky lawmakers pass this law the state would be ahead of the game nationally in making sure people can get access to opioid treatment.
“If this goes through, Kentucky will go from being a villain in terms of a public health perspective to potentially being the hero,” Ostrovsky said, who is currently the behavioral health chief medical officer at health care company Solera Health. “Eliminating prior authorization for evidence-based medication-assisted treatment is one of the most sound policy decisions the state could make in this day and age.”
Some critics of the bill say removing prior authorization would increase the illegal diversion of MAT drugs into the streets. Others say there’s already existing law on the books that negates the need for HB 121.
That law allows Medicaid enrollees to access buprenorphine without prior authorization for 14 days. But this only applies to new patients. For people who aren’t getting treatment for the first time, the 14-day waiver doesn’t help them.
So far, the main critic of the measure is the Kentucky Association of Health Plans, a trade association that represents the five companies that Kentucky pays to run Medicaid.
Executive Director Stephanie Stumbo said the group is against the bill because prior authorization can deter Medicaid enrollees from abusing the drug and doctors from overprescribing it.
“These are serious medications, some that are themselves prone to abuse,” Stumbo wrote in an email.
She also said prior authorization can be used to deter doctor shopping, where a patient goes to multiple doctors for prescriptions and then might sell medication illegally, called diversion.
But University of Kentucky researcher Michelle Lofwall said research disproves that. She said that studies have shown the reason people get buprenorphine illegally is because they can’t get treatment from a doctor.
“Trying and failing to enter into legitimate buprenorphine treatment was a significant risk factor for using buprenorphine off the street,” Lowfall said.
She also said Kentucky has a system that works well to tell authorities if a person is doctor shopping — the Kentucky All Schedule Prescription Electronic Reporting (KASPER) system. Every time a patient gets a prescription for a controlled substance — including MAT — that prescription is put into the system.
Representative Kim Moser, a Republican from Taylor Mill, said the Kentucky Association of Health Plans is concerned that lifting this barrier could mean more Medicaid enrollees get buprenorphine treatment, which would increase costs. But Moser said the change will only allow people seeking help to get that help quicker.
“Really, this is not a change in coverage,” Moser said. “It’s a change in the timing. We know that individuals seeking treatment — it usually takes them a long time for them to get to the point to ask for help. We don’t want to put up yet another barrier.”
Lowfall said it is definitely a possibility that getting rid of prior authorization could lead to more Medicaid enrollees getting drug treatment. The change could also lead more addiction specialty doctors to accept Medicaid insurance. Often fulfilling a prior authorization means submitting hundreds of pages of medical records, and the staff to complete that task.
“There’s a lack of providers that take patients who have Medicaid because the reimbursement is poor and because the prior authorization process is incredibly burdensome,” Lofwall said.
The Cabinet for Health and Family Services, which sets the policies the Medicaid insurance companies have to follow, also has concerns about new drugs that could cost a lot. For instance, if a new MAT drug comes on the market, it could cost much more than current treatments. The bill as written would mandate Medicaid pay for those treatments, no matter the cost to the state.
“The primary concern is the unknown exposure of new derivatives or methods of delivery entering the market that could have significantly higher costs,” Cabinet spokesman Doug Hogan wrote in an email. “If this concern is addressed, the legislation is likely to improve access and outcomes, potentially reducing costs in the long term.”
Dr. Mike Kalfas is hopeful the bill passes and is signed by Gov. Matt Bevin. Prior authorization of MAT, he said in the House committee hearing, is an attempt to get his patients to give up.
“It’s trying to get them to give up, and they do. They up dead, they end up in jail,” Kalfas said. “It’s [HB 121] going to allow me to do my job, to save people when they need it.”
The Senate Banking and Insurance Committee is scheduled to meet Tuesday. HB 121 isn’t on the agenda, but the committee will hear a Senate bill that would remove some of the same prior authorization barriers.
State officials in Kentucky have delayed the start of some new eligibility rules for a portion of its Medicaid population.
Kentucky is one of 36 states to expand its Medicaid program under former President Barack Obama's health care law to cover more people. President Donald Trump's administration gave Kentucky permission to require those people to do things like get a job, go to school or do community service work to maintain their coverage. The Bevin administration calls these rules the "community engagement" requirements.