Pre-authorization for therapeutic drugs is one step on the path to payers requiring similar pre-authorization for expensive clinical laboratory tests
It’s a step on the road to pre-authorization for both certain therapeutic drugs and expensive genetic tests. Blue Cross Blue Shield of Massachusetts (BCBSMA) recently announced that it would work to curb drug abuse through a new pre-authorization program for certain prescription drugs.
Clinical laboratory managers and pathologists should take this as a sign that managed care plans are increasingly willing to tackle issues associated with unnecessary utilization by implementing pre-authorization requirements, among other strategies.
At the top of the pre-authorization list for BCBMSA will be such drugs as Oxcycontin, Percocet, and Vicodin. In recent years, the medical laboratory industry has watched the increase of pain management testing by physicians who treat patients taking these types of addictive drugs.
The Boston Globe reported how insurance industry leaders recognize that the use of pre-authorization to stem the growing addiction rate in Massachusetts is a first for the Bay State. This is understandable for two reasons:
- Both state and national figures show that the number of prescriptions for painkillers has more than doubled in the past decade.
- Data from the federal Substance Abuse and Mental Health Services Administration indicate that Massachusetts residents are using the drugs for nonmedical purposes at a higher rate than the national average.
The BCBSMA program will seek to inhibit “doctor-shopping” by patients inappropriately seeking the drugs. One way it will do this is by screening out short-term prescriptions. For example, for drugs such as Percocet and Vicodin, patients will be allowed one 15-day prescription and one additional 15-day supply.
Additional refills over and above these quantities will trigger a review by the insurer. Further refills will require that certain conditions be met. The prescriber will have to give the insurer assurances that:
- the patient has been counseled regarding addiction risk;
- there is an agreement that any subsequent prescriptions will be written by the same physician; and,
- these prescriptions will be filled by the same pharmacy or pharmacy chain.
Long-lasting opioids, such as OxyContin, will require prior authorization under the new plan. The restrictions will not apply to cancer patients or terminally-ill patients.
Massachusetts Created Online Prescription Database
The Globe reported that many specialists believe longer prescriptions of potentially-addictive painkillers increase the risk of drug misuse and dependency, as well as illicit street use. In its internal review, Blue Cross found that, during 2010, slightly less than 2% of its 2.8 million members received prescriptions lasting longer than 30 days for short-acting opioid painkillers.
In 2010, Massachusetts created an online prescription database to prevent “doctor shopping.” Providers can use the database to see whether a patient has received other narcotic prescriptions within the past year. The Globe reported that, of the tens of thousands of Massachusetts providers authorized to prescribe the potentially-addictive medicines, only about 2,000 have enrolled to use the online prescription database.
State lawmakers are considering legislation that would require physician enrollment in the pre-authorization program. Madeleine Biondolillo, M.D., Director of the Bureau of Health Care Safety and Quality, Massachusetts Department of Public Health, suggested to the Boston Globe that one goal would be to target and engage in pre-authorization the 30% of providers who are responsible for writing around 90% of the prescriptions.
For their part, physicians are concerned that the new pre-authorization program will create administrative burdens for doctors. They are also point out that the program may prevent patients who truly in need these medications from getting the prescriptions that would help their conditions.
According to Blue Cross Chief Physician Executive John Fallon, M.D., M.B.A., BCBSMA spent 18 months developing a pre-authorization program that balances the needs of patients against the need to stem the problem of drug abuse.
This was affirmed by Jan Cook, M.D., Medical Director at Blue Cross, who said the pre-authorization program may eventually produce substantial cost-savings. Initial savings from fewer prescriptions are projected to be modest, perhaps $200,000, he suggested. The big savings would come in the form of a reduction in future substance abuse treatment.
Preauthorization as a Threat to Clinical Laboratories
The question of pre-authorization as a way to manage utilization and reimbursement is an important one for pathologists and clinical laboratory managers. This is particularly true with regard to the increasing clinical use of expensive molecular diagnostics and genetic testing. (See free, downloadable Dark Daily white paper, “Getting Paid for Molecular Tests: How Clinical Laboratories and Pathology Groups Should Respond to Pre-Authorization Requirements by Payers”.)
The new BCBSMA plan is a marker that reminds clinical laboratory managers and pathologists that payers are continuing to move forward with plans to require more pre-authorization for the types of therapeutic drugs and genetic tests that are expensive and may be utilized inappropriately.
—Pamela Scherer McLeod