Co-Founder; CEO Sick Cells Washington, District of Columbia
Abstract Title: MEDICAID POLICY OVERVIEW OF OPIOID MANAGEMENT FOR SICKLE CELL DISEASE ACROSS STATES
Background: Pain management is integral to the healthcare for individuals with sickle cell disease (SCD). Sickle cell disease is marked by debilitating pain causing vaso-occlusive crises (VOCs) requiring hospitalization. In addition, to these acute events, approximately 50% of individuals with SCD experience chronic pain that must be treated with long-acting and short-acting opioids. With the growing opioid crisis, more restrictions have been put into action to limit prescribing opioids. Consequently, providers have found the opioid epidemic as a justification to minimize prescribing opioids for sickle cell pain. Some states have made efforts to eradicate these limitations for individuals living with SCD that will not disrupt their pain management protocols. Roughly 50-60% of the estimated 100,000 individuals living with SCD in the U.S. are covered by Medicaid.
Purpose/Objectives: This research aims to review the current landscape of opioid policies for SCD under fee-for-service (FFS) Medicaid programs to highlight potential barriers for patients living with SCD across states.
Methods: Sick Cells contracted Artia Solutions to conduct an analysis of coverage policies in the 50 states and the District of Columbia. Sick Cells identified opioid-specific policies and opioid prior authorization criteria for SCD as a treatment of chronic pain to include in the analysis. Using a comprehensive formulary and medical policy data provided by Artia Solutions, augmented by Sick Cells research, we analyzed coverage policies as of February 2023 for state FFS programs for SCD therapies. This issue brief discusses prior authorization (PA) criteria and opioid-specific policies used for SCD across state Medicaid FFS programs. Managed care organization (MCO) plans in states were excluded from this analysis.
Results: This analysis yielded three major key findings. First, state-specific PA criteria for SCD for opioid management are limited. As of 2023, only eight states have opioid PAs specific for SCD (Arizona, Connecticut, Florida, Georgia, Indiana, Kansas, Kentucky, and Maryland). These policies allow a longer duration of PA approval (one year vs. six months) for both long-acting and short-acting opioids for individuals with SCD. In addition, Several states have few exceptions for opioid policies for individuals with SCD. Sick Cells identified 11 states (New York, Florida, Georgia, Texas, California, Louisiana, North Carolina, Illinois, Ohio, South Carolina, and Pennsylvania) with the highest populations of Medicaid and CHIP beneficiaries with SCD using the 2021 Medicaid and CHIP Sickle Cell Disease Report. Within these 11 states, eight have at least one exemption for individuals with SCD. These exemptions include opioid treatment plans and/or urine drug screening, Maximum Morphine Equivalent (MME), total number of prescriptions per month or quantity limits, the requirement of a letter of medical necessity, and confirmation of an SCD diagnosis for long-acting opioids. Lastly, Texas demonstrates the most restrictive access to opioid management for individuals with SCD under Medicaid coverage. Within the PA for Texas, there are restrictive limitations on the quantity, duration, and type of opioids. Beyond an SCD diagnosis, three parameters can restrict gaining access to opioid prescriptions based on timeline and quantity. If the patient does not fall under these parameters, limitations on how much can be prescribed continue. The underlying factor that determines PA for opioids is if the patient does not have three or fewer opiate dispensing pharmacies in the last 60 days. Furthermore, under Texas legislation and guidelines prescribing opioids in the U.S., short-acting opioids should be prioritized over long-acting opioids.
Conclusions/Implications for future research and/or clinical care: Our landscape analysis of opioid management for SCD under state Medicaid programs focuses on three main challenges related to the barriers to opioid policies. These discrepancies provide advocacy opportunities to affect change in legislation, rationalize access, and increase the availability of the processes embedded in our health systems. State Medicaid programs must strive to eliminate gaps in access to opioid management as this can affect one’s quality of life managing chronic pain from SCD. This research creates an avenue for more studies, including legislation against opioid management and how the lack of exemptions and necessary circumstances hinder SCD and many other chronic diseases.
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