Group Recommends Employers Discuss Opioids with Health Plans, PBMs

Marcotte

The country’s opioid crisis is estimated to have exceeded $1 trillion from 2001 to 2017, and it is predicted to cost an additional $500 billion by 2020, according to an analysis from Altarum, a nonprofit health research and consulting institute.

The impact is being felt by employers. According to the Altarum report, the costs of the opioid crisis are borne by individuals in the form of lost wages and lost productivity.

The National Business Group on Health, a nonprofit association of more than 420 large U.S. employers, is recommending employers work with their health plans and pharmacy benefits managers (PBMs) to ensure they are implementing national guidelines for prescribing opioids.

The group recommends that employers ask if their efforts and their work with clinicians includes the following:

• Strategies to mitigate risk of addiction before starting and periodically when continuing opioid therapy;
• Limits on opioid prescriptions for acute pain to short durations. Three days or less will often be sufficient;
• Use of immediate-release opioids when starting therapy for chronic pain instead of extended release/long-acting opioids;
• Use of the lowest effective dose when prescribing opioids; and,
• Avoidance of concurrent prescribing of opioids and benzodiazepines whenever possible.

“While health plans and PBMs have initiated various opioid management programs, opportunities remain to implement the guidelines,” says Brian Marcotte, president and CEO, of the National Business Group on Health. “The Business Group recommends employers work with their vendor partners to review the guidelines and take action to fill any gaps. In addition to the devastation it causes employees and their families, research shows opioid misuse costs employers billions of dollars from absenteeism and presenteeism alone, affects hiring and retention, and negatively impacts worker productivity, workers compensation claims, and overall medical costs. Because of the magnitude of the impact, the Business Group has prioritized educating employer members on the guidelines to urge their implementation.” 

Ultimately, healthcare executives, including hospital and physician leaders, play a major role in educating clinicians, reexamining and changing prescribing guidelines and pain management protocols, and in implementing changes in clinical practice, according to Marcotte. “Healthcare executive leadership is essential to stemming this crisis and preventing further devastation,” he says.

Marcotte offers five ways for healthcare executives to help employers curb opioid abuse:

• Formulate strategies to mitigate risk of addiction before starting and periodically when continuing opioid therapy. Healthcare executives can provide clinician and patient education about non-opioid and non-pharmacological approaches to chronic pain management, as well as non-opioid alternatives to acute pain management. “Advise physicians to initiate and continue opioid therapy only where the benefits outweigh the risks,” Marcotte says.
•  Limit opioid prescriptions for acute pain to short durations. Three days or less will often be sufficient. “Ensure that clinicians prescribe the lowest dosage and duration necessary for acute pain episodes,” he says. 
•  Encourage use of immediate-release opioids when starting therapy for chronic pain instead of extended release/long-acting opioids. “Assure that physicians prescribe immediate-release opioids for chronic pain, unless it is not appropriate,” Marcotte says.
• Encourage use of the lowest effective dose when prescribing opioids. “Assure that physicians prescribe the lowest effective dose before higher doses are considered,” Marcotte says.
• Avoid concurrent prescribing of opioids and benzodiazepines whenever possible. “Educate physicians about the risks of prescribing opioids and benzodiazepines concurrently to patients and advise them against it,” he says. 

Health organizations and PBM roles

Health plans and PBMs can assist employers in assuring plan designs that are compliant with the CDC guidelines including limiting coverage for initial prescriptions to small quantities, and robust coverage of alternatives for pain management, both pharmaceutical and non-pharmaceutical, according to Marcotte.

“They can also educate members about alternatives and the risks of opioids,” he says. “When working with health plans, employers can ask them what efforts are being taken around responsible opioid prescribing, and whether the CDC guidelines are being used by physicians, hospitals, and pharmacies in their networks. Health plans should ensure that provider networks favor conservative care approach to opioid initiation and practice evidence-based treatment of opioid addiction.”

Health plans should also offer provider education on CDC guidelines and non-pharmacological alternatives for chronic pain management, and member education on the risks of opioid addiction and the availability of alternatives, he says.

“When working with PBMs, employers can ask what measures they are taking to monitor and identify overprescribing, pharmacy shopping, and other signs of inappropriate prescribing or dispensing. They can also monitor for concurrent prescribing of opioids and benzodiazepines,” he says.

According to the Business Group's Large Employers’ 2018 Health Care Strategy And Plan Design Survey, employers are working directly with their health plans and PBMs to address the issue using the following strategies:

• Approving a limited supply of opioids;
•  Limiting coverage of opioids to a network of pharmacies and/or providers;
• Ensuring coverage of alternatives for pain management such as physical therapy;
• Providing training in the workplace to increase awareness and recognition of symptoms;
• Encouraging physicians to communicate about the dangers of opioids; and
• Encouraging physicians who are prescribing more frequently than expected to change prescribing patterns consider alternatives for pain management.