Insurers, doctors work to curb opioid prescriptions

HBJ Photo | Steve Laschever ProHealth Physicians Chief Medical Officer Dr. Richard Guerriere said his doctor group has taken a pledge to reduce the number of opioids it prescribes patients.

Harold L. Paz, Chief Medical Officer, Aetna

Doug Nemecek, Psychiatrist and Chief Medical Officer for behavioral health, Cigna

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By John Stearns

Health insurers are wielding their significant influence and claims data to address the nation's opioid crisis and are making headway in a key battlefront: encouraging doctors to prescribe fewer opioids that can turn addictive and deadly.

Opioid prescriptions rose from about 76 million in 1991 to 259 million in 2012, giving the U.S. the “dubious distinction” of being the planet's largest opioid consumer, Dr. Harold L. Paz, chief medical officer at Aetna, wrote in a report outlining the company's strategy for combating the epidemic.

A deluge of opioid prescriptions years in the making will take time to reverse, but insurers are urging doctors to reduce prescriptions and are seeing results.

Anthem Blue Cross and Blue Shield in August said opioid prescriptions dropped 17 percent in Connecticut in the past year and that its parent company met a national goal to reduce opioids filled at pharmacies by 30 percent since 2012;

Cigna in April said it reduced prescriptions 12 percent among its customers in the prior 12 months toward a targeted 25 percent cut by 2019;

Aetna estimated prescriptions among its members could decrease 11.9 percent this year from 2016 and wants to reduce inappropriate opioid prescribing among members by 50 percent by 2022;

UnitedHealthcare said its commercial health plan members in 2015 showed a 41 percent decrease in the number of opioid prescriptions written.

Steps insurers are taking to curb prescriptions and overdoses include alerting heavy prescribers and providing peer comparisons; limiting coverage to seven-day supplies for new prescriptions; promoting alternative pain management; supporting medication-assisted treatment for opioid addiction; and increasing access to overdose-reversing naloxone.

“I do think that the medical community, particularly in Connecticut, has been galvanized around this problem; the statistics are sobering in terms of how the usage has accelerated,” said Dr. Richard Guerriere, chief medical officer for ProHealth Physicians, which has about 200 physicians and 150 advanced practice clinicians in the state.

ProHealth is among roughly 175 U.S. physician groups that signed Cigna's pledge to reduce opioid prescribing by 25 percent by 2019 and to treat opioid use disorder as a chronic condition.

By April 2017, Cigna had decreased opioid prescribing across its commercial book of business by 12 percent, putting it about halfway toward its initial goal, said Dr. Doug Nemecek, a psychiatrist and Cigna's chief medical officer for behavioral health.

“If we can continue this progress and get to 25 percent before 2019, we're not going to stop, we're going to keep going and go as far as we can in reducing opioids and impacting patients who can get care without the opioids,” Nemecek said.

Cigna, like other insurers, is asking physicians to consider alternative pain treatment.

Those alternatives include chiropractic, acupuncture, cognitive behavioral therapy, physical therapy, yoga and other exercises to manage and reduce the pain, Nemecek said.

“This is really about making sure that every individual is getting the best care they can, is getting healthy,” he said. “We're doing what we can for patients who have pain, we're preventing addiction and treating people who have addiction in better ways to truly allow people to be as healthy as they can be.”

Doctor's perspective

Cigna has collected best practices from physician groups on opioid prescribing and shares those with medical groups across its network so physicians can learn from each other on decreasing inappropriate opioid prescribing, Nemecek said.

ProHealth's Guerriere said his group is combining education and clinical programs to help primary care doctors with their pain-management decisions. A pain management specialist gave doctors a presentation in June on opioid prescribing, including how to properly evaluate pain and use alternative pain regiments.

ProHealth also ensures its practitioners check the Connecticut Prescription Monitoring Program (PMP), a state database that tracks a patient's controlled substance use, including prescriptions by other providers.

“If somebody is on a chronic opioid, they have to document in our electronic health record that the PMP was checked,” Guerriere said.

ProHealth also has an opioid-use agreement with chronic pain patients, requiring patients to commit to random drug tests, promise not to receive opioids or other controlled substances from other providers and agree that medicines will be cut off if the contract is broken, he said.

ProHealth also is pursuing a relationship with Hartford Hospital's Pain Treatment Center in West Hartford, a group that specializes in pain management.

Additionally, ProHealth is upgrading its electronic health record system to allow emailing controlled substance prescriptions to pharmacies to enhance prescription security and control.

“Gradually we're trying to take steps to close all the loopholes,” Guerriere said.

While insurers like Cigna seek to reduce opioid prescriptions, there are exceptions.

“We certainly don't want to take away opioids from people who truly need them,” Nemecek said. “We've said from the beginning, if you have cancer, you're in hospice care, other conditions like that, we are not going to get in the way of appropriate opioid prescribing.”

Cigna also is working to address opioid abuse among veterans, who suffer from chronic pain at a higher rate than the general public and are more likely to die of opioid overdoses, by funding programs to help them. Cigna also will soon roll out a hotline available 24/7 for veterans, their family members or caregivers, whether Cigna customers or not, for counseling and assistance.

Prevention, intervention and support

In his strategy report, Aetna's Paz said the insurer is working to prevent opioid misuse and abuse, intervene when it identifies at-risk behavior and support those who are addicted through evidence-based treatments.

He sent letters to roughly 1,000 “super prescribers,” based on their narcotic refill-to-fill ratio, to assess their prescribing versus peers.

Aetna also created a controlled substance use program to identify patients who might misuse or abuse opioids, then alerts prescribers and offers help to patients, in part by increasing access to naloxone, he wrote.

It's also supporting medication-assisted treatment used in combination with behavioral therapy, Paz said.

“We're exploring nontraditional options as well,” he wrote. “A new pilot features phone and text outreach to members between sessions to help keep them on track” and initial results are promising.

By 2022, Aetna wants to increase the percentage of members with chronic pain treated by an evidence-based multimodal approach by 50 percent and also increase the percentage of members with opioid use disorder treated with medication-assisted therapy and other evidence-based treatments by 50 percent.

Like other insurers, UnitedHealthcare does not require prior authorization for preferred medications that are used to treat opioid dependence.

Using its analytics, UnitedHealthcare said it can help identify individuals who may be at risk for dependence and intervene sooner.

It also utilizes a Pharmacy Lock-In program to view prescribing patterns. Once enrolled, members must obtain their prescriptions from a single pharmacy, reducing the likelihood of overprescribing or conflicting prescriptions, UnitedHealthcare said.

Anthem has a similar program it calls Pharmacy Home Program.

UnitedHealthcare, through its drug utilization review process, also can identify members who have started opioid-dependence therapy to reduce their reliance on opioids, but continue to receive an opioid medication, allowing it to notify physicians about a possible relapse and encourage intervention.

Anthem is working with primary care providers to get more of them certified to provide medication-assisted treatment, particularly for opioid use disorders.

Anthem said it's committed to helping affiliated health plans double the number of members who receive behavioral health services as part of medication-assisted, drug and talk therapy for opioid use disorder by 2019.

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