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Health insurance companies say they are ratcheting up scrutiny of physician prescribing and health plan enrollee use of opioids and other medicines that can lead to addiction.
Several insurers are launching new programs that encourage an evidence-based approach to substance abuse treatment or installing better monitors of populations of patients at risk for potential abuse amid the nation’s opioid crisis. Among the companies developing new lines of attack or enhancing existing programs in the battle against opioid abuse include
“Reducing prescriptions alone isn’t enough,” said Doug Nemecek, chief medical officer of Cigna Behavioral Health. “We need to change the way we treat people who are suffering from chronic pain, and we also need to recognize substance use disorder as the chronic disease that it is.”
Cigna has collaborated with the American Society for Addiction Medicine to create performance-based measures to eventually develop guidelines that could be used by insurers to establish protocols that would be used by doctors.
A New York Times report last week indicated that there has been some progress in the battle against opioid addiction. Citing data from health information firm IMS Health, the Times report said there’s been a “12% decline in opioid prescriptions nationally since 2012.”
The insurers and drug benefit management companies say they hope to put an even bigger dent in the number of annual prescriptions for opioids.
“While the annual number of prescriptions for opioids has been falling for the past few years, there still are enough written to provide opioids for every adult in the U.S.,” Cigna’s Nemecek said. “That number needs to continue to decrease–significantly and rapidly–because there are too many people suffering from substance use disorder and dying from opioid overdose.”
At Anthem, which operates Blue Cross and Blue Shield plans in 14 states, the insurer announced last month an effort called “Pharmacy Home” that works to reduce addiction to opioids by enrolling high-risk health plan members in the program.
An at-risk member could be someone who has filled five or more controlled-substance prescriptions, according to the criteria. There are other criteria that include a health plan member visiting three or more medical care providers for controlled substance prescriptions. If Anthem reviews claim activity within 60 days of sending the member a health plan member letter and behavior doesn’t change, a single pharmacy location will be identified for the person to fill all their prescriptions.
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It’s not uncommon for a person suffering from addiction to attempt to get prescriptions from multiple doctors and pharmacies in an effort to get opioids and other drugs fraudulently. The pharmacy benefit management company Express Scripts said its “RationalMed” program integrates pharmacy, medical and lab data to find gaps or duplications of medical care. Express Scripts said doctors are alerted so they can take action after RationalMed issues alerts “on multiple therapies and therapy classes, including opioids,” the company said in a statement.
OptumRx also analyzes pharmacy claims data to identify “people who have overlapping use of at least two different long-acting opioid medications, multiple providers prescribing the same or similar narcotics or multiple pharmacies dispensing the same or similar narcotics,” spokesman Matthew Stearns said.
Abusers are often caught. Express Scripts, for example, said the company’s fraud and abuse program referred more than 2,300 cases of potential fraud to clients and law enforcement agencies in 2015 alone.
