Bloomfield insurer Cigna hopes its latest assault on the opioid epidemic — encouraging doctors to sign a pledge to reduce opioid prescribing — proves an effective arrow in its quiver of strategies to reduce customers' opioid use by 25 percent over the next three years.
Elements of the pledge, aimed initially at large medical groups in its Cigna Collaborative Care arrangements that represent more than 82,000 doctors, include learning alternative pain treatments that are safe and effective; screening for opioid-use disorders; connecting patients to evidence-based treatment; talking about treating substance-use disorder as a chronic illness, not a moral failing; taking steps to improve the quality and coordination of care for patients being treated with opioids; and prescribing alternative therapies when they're available.
Dr. Doug Nemecek, a psychiatrist and Cigna's chief medical officer for behavioral health, said doctors overall have supported the pledge, which the company announced in November. Groups representing about 12,000 of the doctors have already signed on and Cigna expects many more to participate, he said, as the company sets its sights on the 25 percent opioid-use reduction, one of the most aggressive goals publicly shared by insurers.
"We're confident that we're going to be able to hit that goal," said Nemecek, who admits some have called it unambitious while others have said the goal is too aggressive. "We chose the 25 percent goal because we need to have a target and we need to shoot for something."
Cigna is one of many insurers and doctor groups taking steps to combat prescription drug abuse, which has become a crisis in Connecticut and nationwide.
A main driver fueling the opioid crisis is too many unnecessary opioids being prescribed, Nemecek said. Accidental deaths involving drugs, alcohol and opioids have increased steadily in Connecticut since 2012 from 355 deaths that year to 723 in 2015. To counter that trend, doctors must decrease the supply of unnecessary opioids, while insurers must work with physicians and other partners to make sure that people are getting the most appropriate evidence-based, high-quality care for their chronic pain conditions and/or for their substance-use disorders, Nemecek said.
Cigna said its pledge is consistent with the U.S. Surgeon General's "Turn the Tide" pledge and the Centers for Disease Control (CDC) and Prevention's opioid prescribing guidelines.
"I expect every insurer is concerned about these issues and doing something to try to address them," Nemecek said. "At Cigna, we really made this a top priority … to address this and make sure that this epidemic gets taken care of."
Anthem Blue Cross and Blue Shield, among its efforts to prevent and reduce opioid addiction and overdose, changed its pharmacy policy to limit coverage of opioids for its commercial and Medicaid members to a seven-day supply per prescription fill for members starting a short-acting opioid. In addition, it has prior authorization criteria for members starting long-acting opioids, said Sarah Yeager, a spokeswoman for Anthem in Wallingford.
Members who are new to starting opioids and are not currently using a long-acting opioid will require prior authorization. Members currently using a long-acting opioid will not require prior authorization.
Members who are newly prescribed a long-acting opioid and are actively treating for cancer or those who are terminal and undergoing palliative care will be approved, Yeager said, noting the policy is consistent with CDC guidelines.
"The policy represents Anthem's commitment to the ongoing evaluation of the safety and efficacy of drug therapies and to continuing to evolve our coverage policies based on new clinical evidence and real-life experience," she said.
In April, Anthem's commercial health plans launched the Pharmacy Home Program to reduce inappropriate use of prescription drugs by establishing one home pharmacy to more effectively coordinate care for at-risk members. The program aims to reduce the number of pharmacies a member uses and improve quality of care by helping to better coordinate care, Yeager said.
Members identified for this program are asked to create a pharmacy home — one in-network pharmacy where they get all prescriptions filled. Claims are reimbursed when filled at their designated home pharmacy, with a few exceptions, she said.
"This program is just one part of our overall strategy to help redirect members to appropriate care, prevent addiction, and hopefully, prevent deaths and major medical problems from overdose and drug interactions," Yeager wrote.
Doctors, in addition to insurers, have also been active in addressing safe prescription and addiction issues, said Matthew Katz, executive vice president and CEO of the Connecticut State Medical Society (CSMS).
CSMS supported the establishment of the state's Alcohol and Drug Dependency Council in the 1990s, with CSMS physician leaders among its founding members, Katz said. In the early 2000s, CSMS worked with the state attorney general's office and Department of Consumer Protection to establish the state's Prescription Monitoring Program (PMP) and CSMS has worked with state legislators and regulators to expand PMP, including a requirement that all healthcare professionals who prescribe narcotics register to use the program.
More recently, with opioid abuse and heroin use rising in recent years, CSMS backed legislation that allows first responders to carry and administer naloxone to reverse overdose effects and allows others the same civil immunity protections when assisting addicts during an overdose, among other measures.
"With tighter controls over the prescribing of opioids, our opportunities to identify people with substance-abuse problems increase," Katz said. "Yet our work will not be complete unless there are adequate mechanisms and resources in place to treat those we have identified. CSMS has been clear and consistent that resources for the treatment of all addiction must be increased."
Cigna, in addition to working with physicians and encouraging them to sign the pledge, also is creating profiles for physicians of what their prescribing patterns look like compared to CDC guidelines and other physicians in their community, Nemecek said.
"We know that physicians all agree that appropriate prescribing is good and physicians are very responsive to feedback on how they compare to standards and to their peers," he said. "So we know that kind of feedback helps them see their practice and make any changes that might be appropriate."
Cigna also will share profiles with collaboratives' leaders to show how their physician groups are prescribing compared to guidelines and Cigna's other collaboratives, he said. Cigna also is asking the groups what they're doing individually to improve the opioid situation, for example, whether they're providing more education for physicians, or creating new guidelines for physicians, clinics and hospitals with which they work.
Cigna wants to ensure people who have chronic pain or substance-use disorders are getting appropriate quality care, he said.
"So in addition to our overall goal of reducing unnecessary prescriptions, we still need to treat all of these people who still have pain problems and we need to treat those people who have addiction issues," he said.
From an addiction-treatment perspective, Cigna is also expanding and creating what it calls designated substance-use disorder facilities, which are in-network facilities that provide care that is more cost efficient both for Cigna and customers, Nemecek said.