Health Plan Takes On Opioid Overutilization for Medicare Patients

A nonprofit health plan provides beneficiaries low-cost access to medication-assisted treatment. The insurer also implements prescription restrictions and physician education.

With six of every 1,000 Medicare beneficiaries and almost nine of every Medicaid beneficiaries abusing prescription opioids, health plans have a strong incentive to help their members address this problem. Getting people off opioids yields tremendous benefits for the individual but also for the health plan that can be stuck paying for all the health effects of addiction.

That improvement may require an upfront investment by the health plan, and a California insurer is finding that its nonpfit status gives it more leeway to address the issue proactively.

Opioid treatment spending increased 1,000% over the five years from 2011 to 2015, according to a study from FAIR Health, an independent nonprofit that manages the database of privately billed health insurance claims. That was one impetus for SCAN Health Plan to address the opioid crisis with a multipronged approach that is showing good results.

SCAN is a nonprofit organization that operates a Medicare Advantage plan with 185,000 members in California. The devastating effect of opioid addiction prompted SCAN to develop holistic, proactive measures to reduce opioid overutilization and increase awareness among members and physicians in its network, says CEO Chris Wing.

'Good numbers'

The percentage of SCAN beneficiaries using opioids dropped 16% from the first quarter of 2014 to the second quarter of 2017, going from 18.6% of all plan beneficiaries to 15.7%. SCAN also got its opioid prescribing rate to 5%, below the national average of 5.74% and the California average of 5.46%.

The effort also reduced the percentage of members utilizing concurrent opioids and benzodiazepines from 1.9% to 1.37%—a 27% reduction.

“It’s not going to be a quick fix but we’re posting some good numbers by making sure we’re very strict on our formulary so that anything that might be addictive is monitored closely, and by providing easy access to the drugs necessary for treatment of addiction,” Wing says. “We spend a lot of time educating providers, because though we think providers should already be educated because of all the noise about opioids, they have to be educated on so many important topics these days. We want to make sure we’re actually helping them rather than just bombarding them with more instructions or criticism.” 

Multipronged approach

SCAN addresses opioid overutilization in several ways, starting with providing beneficiaries access to medication-assisted treatment. Most SCAN health plans offer the drug opioid addiction medication buprenorphine for a $5 copay and open formulary access to Naloxone, which can rapidly reverse opioid overdoses. Naloxone can be furnished without a prescription by pharmacists.

The health plan also has a prescriber education program, offering CME credits. It emphasizes that opioids are not first-line therapy for chronic pain and a three-day course should be sufficient for acute pain. The education program encourages the lowest-effective dose to start, along with other prescribing guidelines.

SCAN also makes an effort to reduce the inappropriate supply of opioids with requirements for prior authorization and quantity limits.

Beneficiaries using opioids also are provided education with the aim of destigmatizing addiction and explaining that the recovery process typically includes relapses.

“We want a two-way conversation. We want highly educated members having conversations with highly educated physicians and finding the right way to use opioids,” Wing says.

Wing notes that being a nonprofit helps SCAN take an aggressive approach to reducing opioid overutilization.

“We’re not the only plan that cares, but being a not-for-profit gives me a certain latitude. Our mission is what drives us, rather than worrying about what I’ll report to shareholders,” Wing says. “We have a budget and want to meet it, but if we come up with an initiative that is potentially a budget killer and it might help with seniors’ health and independence, I’m going to get dispensation from the board. So we have a little more flexibility to do things like having 45,000 members in to educate them, offering CME for doctors, the things that might cost a little bit but can be successful in addressing this problem.”