Payers respond to the opioid epidemic
by Chet Seward, Senior Director, CMS Division of Health Care Policy
As this special issue of Colorado Medicine demonstrates, a collaborative effort is needed to address the opioid epidemic. One front is health insurers, who are deploying their own strategies with network physicians and beneficiaries. CMS encourages physician members to explore resources, programs and potential partners in the payer realm.
CMS reached out to the medical directors of major health insurance plans in Colorado. Below are their responses.
Elizabeth Kraft, MD, CMO, Anthem
Anthem has adopted a multi-pronged approach to combat the devastating national opioid abuse epidemic which centers on 1) addressing opioid prescribing practices with educational seminars and pharmaceutical management; and 2) early identification and treatment support.
Anthem has already reduced opioid use in Colorado by 15 percent and covered up to a 150 percent increase in admissions in residential treatment, inpatient and partial hospital programs for opiate use disorders. Locally, Anthem has robust prevention and treatment programs in place, including:
• Increased access to and support from behavioral health services as part of medication assisted therapy for opioid addiction;
• Robust education efforts within Anthem’s Enhanced Primary Health Care (EPHC), including streaming videos on treatment for pain and opioid overuse;
• Aligning with the March 2016 CDC guidelines for opioids for chronic pain, which includes removing any prior authorization for MAT drugs and limiting prescriptions for short-acting opioids to seven days; and
• Creating the Pharmacy Home program that assigns members with concerning patterns of number of prescribers and scripts for opioid to one pharmacy and/or provider, which has reduced hospital and ER admissions.
Mark Laitos, MD, CMO, Cigna
Cigna has made significant progress toward reaching its goal to reduce opioid use among its customers, with the help of health care providers. Within the last 12 months, Cigna customers’ use of prescribed opioids has declined nearly 12 percent – about halfway to achieving the company’s goal of 25 percent reduction by 2019 – which would return to 2006 levels, before the drug crisis.
While Cigna has adopted a multi-pronged response to the epidemic that includes multiple stakeholder groups, the key to this initial progress has been Cigna's work with doctors, especially those that participate in its Cigna Collaborative Care arrangements.
Cigna assists doctors in preventing, recognizing and treating opioid misuse by:
• Analyzing integrated claims data across pharmacy and medical benefits to detect opioid use patterns that suggest possible misuse by individuals, and then notifying their health care providers. This helps identify individuals with substance use disorders more quickly so they can get the help they need.
• Alerting doctors when their opioid prescribing patterns are not consistent with the Centers for Disease Control and Prevention’s (CDC) guidelines that include opioid selection, dosage and duration.
• Establishing a database of opioid quality improvement initiatives for doctors that can help them determine next steps for improving patient care, including referrals into chronic pain management or substance use disorder treatment programs.
Cigna is also implementing additional customer safety measures in support of the CDC guidelines. Effective July 1, most new prescriptions for a long-acting opioid that are not being used as part of treatment for cancer or sickle cell disease, or for hospice care, will be subject to prior authorization, and most new prescriptions for a short-acting opioid will be subject to quantity limits.
Finding a long-term solution means modernizing the approach to prevention, treatment and communication regarding substance use disorders. Cigna is committed to working together to identify the right solutions.
Kevin R. Fitzgerald, MD, CMO, Rocky Mountain Health Plans
Health plans and physicians need to collaborate to tackle this important issue together, so that we have access to data and some leverage with our members to change behavior. Rocky Mountain Health Plans has been working with community physicians, other prescribers, pharmacies, and patients for a number of years. We share policy and procedures that practices that prescribe opioids should consider putting in place for offices, along with other resources like opioid contracts.
We also have a Drug Safety Program specifically designed around schedule 2 medications that has been in place for a number of years. That program will identify patients (health plan members) with aberrant opioid prescription patterns (i.e., multiple narcotic prescriptions in a month, filling those prescriptions at a number of different pharmacies, etc.) and linking the patient to one prescriber (who agrees to be their sole source for prescriptions of opioids) and one pharmacy (for filling those prescriptions) or they are not paid for by our health plan. We also look for patterns of ER usage that might identify doctor shopping and through our care management department link those patients with one primary care physician. We will also address with the patient their behaviors and refer them to addiction counseling and other services as necessary.
RMHP partnered with the community and our local health information exchange (QHN) to develop the system where providers can place the opioid contract they have with a patient for other providers to see (like the ER and referral specialist).
Judy Zerzan, MD, MPH, CMO/Client and Clinical Care Office Director, Colorado Department of Health Care Policy and Financing
Our pain management resources and opioid use webpage can be accessed at: colorado.gov/hcpf/pain-management-resources-and-opioid-use. It contains a collection of provider resources, including links to the department’s prescription opioid policies, what is covered by Health First Colorado (Colorado Medicaid) to treat pain or other behavioral health conditions (pharmaceutical and non-pharmaceutical), information about the state of Colorado’s Prescription Drug Monitoring Program, and professional publications and peer-reviewed literature about opioid use and its associated risks.
In a continued effort to address the growing opioid epidemic in Colorado, the Department of Health Care Policy and Financing continues to tighten its policy on prescribing and dispensing opioid pain medications to Health First Colorado (Colorado’s Medicaid program) members.
The goal of this new treatment-naïve opioid policy is twofold. First, to reduce the number of Medicaid members who might develop an addiction to opioids when it could be prevented. Second, to reduce the amount of excess opioid pills in the community.
The department wants to ensure members have appropriate medication to treat their pain, without excessive doses that are not needed. All the steps that we can take within reasonable parameters are important and should be taken.
Progress to date has been encouraging.
Posted in: Colorado Medicine | Initiatives | Prescription Drug Abuse