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Health plans share best practices to combat opioid abuse


The Association for Community Affiliated Plans recently convened 13 plans to take on together the issue of prescription drug abuse.

Opioid abuse is a scourge that has touched, in one way or another, all of us who work in managed care.  The numbers are daunting: an estimated 14,800 overdose deaths in 2008, and more than 475,000 emergency department visits the following year. And the societal cost of opioid abuse is staggering: an estimated $53 billion to $72 billion per year.

Medicaid managed care plans are in a unique position to intervene with respect to opioid abuse and other substance use disorders. Medicaid plans have a proven track record of coordinating care to address the medical, behav­ioral health, and social service needs of benefi­ciaries. Thanks to the structure of managed care contracts, plans also have the flexibility to take innovative approaches to combat the illicit use of opioids.

But the issue is daunting for health plans to take on alone. That’s why the Association for Community Affiliated Plans convened representatives from 13 like-minded plans to take on the issue of prescription drug abuse in general and opioid abuse in particular. The group recently reported early lessons and identified several successful strategies employed by safety net health plans. They include:

Screening, brief intervention, and referral to treatment (SBIRT).

This is an evidence-based practice used to identify, reduce, and prevent misuse and abuse of alcohol and illicit drugs. Two plans-Texas Children’s Health Plan and Passport Health Plan-focused on educating providers by providing training and other tools in an effort to improve SBIRT services. To incent providers to provide SBIRT services, Passport amended its contracts with primary care providers to pay for SBIRT services on a fee-for-service basis, even when its providers were paid via capitation.

Outreach to beneficiaries.

Identifying members who may benefit from substance use disorder treatment is a formidable challenge. Overcoming it requires creative outreach to gain patients’ trust; a crucial step in engaging patients. Commonwealth Care Alliance made extensive use of outreach professionals, including behavioral health specialists, social workers and mental health counselors. These individuals focused on helping members fulfill critical life needs before addressing substance abuse. Gold Coast Health Plan tapped into a network of community health workers known as promotoras to reach beneficiaries.

Specialized beneficiary support services.

Medicaid beneficiaries with substance use disorders often fail to access medical and behavioral healthcare, or lack access to housing, food, transportation, and more. Managed care organizations are uniquely poised to address the full range of life challenges that may contribute to addiction through specialized support services. CareSource applies a predictive modeling algorithm to identify members at high risk, and then combines a lock-in program with wraparound, high-touch case management services to connect members to community resources to help address needs outside the traditional healthcare system.

Next: Prescriber or pharmacy lock in


Prescriber or pharmacy lock-in.

Medicaid lock-in programs identify beneficiaries with claims that suggest patients are visiting multiple pharmacies and physicians seeking prescriptions-and limit them to a single pharmacy or prescriber for all medications.  Horizon NJ Health identifies candidates for a lock-in through claims data and uses pharmacists as a hub for communication with both patients and the plan. Since pharmacists often interact with patients more than other providers, they play an invaluable role in conveying information about medication adherence and treatment plans.

Medication-assisted Treatment (MAT).

Suboxone (buprenorphine combined with naloxone) is a substitute opioid used to treat addiction. It’s been used effectively in MAT programs for opioid abuse, but in some forms can create euphoria and cause dependence, opening the door for misuse and abuse. To this end, plans are working to promote safe, effective use of Suboxone. AmeriHealth Caritas is formulating quality standards for Suboxone prescription and is developing a network of preferred Suboxone prescribers based on best practices.

Managed care executives face many challenges in the effort to fight substance abuse. Federal regulations that restrict disclosure of participation in federally supported substance abuse programs restrict the information-sharing that is needed to coordinate and improve care for patients with substance abuse issues. Even plans’ internal data structures can become barriers, as many plans experience a two- to three-month lag in claims data, which hampers the timeliness of efforts to identify beneficiaries who could benefit from substance use disorder-related health outreach.

The most recent edition of the JAMA brought a glimmer of good news in the fight against opioid abuse. There has been a slight downtick in rates of opioid use disorders. But opioid abuse continues to exact a steep toll from health systems, social services, public safety, and criminal justice systems. The size of the problem demands collaboration across the entire spectrum of managed care.

Managed Healthcare Executive Editorial Advisory Board Member Margaret Murray is chief executive officer of the Association for Community Affiliated Plans.


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