Opioid crisis brings paradigm shift

The increasing rate of opioid addiction might be grabbing the headlines lately, but it is not news to addiction treatment professionals. Clearly, the significantly increased attention is bound to bring changes, challenges and opportunities as various stakeholders look for ways to address the crisis.

Given the societal and financial stakes involved, it is not surprising that insurance companies are starting to take action to stem the tide. Consider the fact that in 2015, private health insurance plans’ average costs for a patient diagnosed with opioid abuse or dependence were more than 550% higher—almost $16,000 more per patient—than for the average patient, according to the not-for-profit data company FAIR Health. What is surprising, however, is the relative lateness of the payer industry’s efforts.

Cigna is one of the first insurers to set specific goals for what it hopes to do to address growing opioid use and levels of addiction to these medications. Over the next three years, Cigna has a goal of reducing opioid prescriptions by 25%. A key part of this effort involves tracking physicians and other providers to give them “feedback about how their opioid prescribing patterns compare to the Centers for Disease Control and Prevention (CDC) guidelines as well as how they compare to their peers in the community,” says Doug Nemecek, MD, MBA, chief medical officer with Cigna’s behavioral health business in Eden Prairie, Minn.

Additionally, the organization has crafted a pledge for prescribers to sign and is encouraging them to check state Prescription Drug Management Program databases when prescribing more than a 21-day supply of a pain drug.

Cigna has also created programs to prevent and identify opioid addiction in about 40 of its more than 165 accountable care organizations (ACOs). These ACOs are “developing and sharing best practices in identifying and screening patients with opioid use problems and referring them to necessary care,” says Nemecek. “We are also educating patients on how they can talk to their physicians and get access to appropriate evidence-based care for both chronic pain and for substance use disorders.”

Focus on evidence-based care

New approaches to reimbursement for opioid addiction treatment might also be on the table for payers. Nemecek emphasizes the need for clinicians to deliver evidence-based care. This is a development that addiction treatment centers would do well to heed given its growing implications for reimbursement and network status.

Indeed, Cigna is already thinking along these lines. Last year, the insurer started a data project with the American Society of Addiction Medicine to distill practices that led to superior outcomes based on claims data. It’s a variable that the treatment industry struggles to isolate on its own.

And the payer is willing to consider enhanced reimbursement for better outcomes—a tenet of today’s accountable care models.

Rather than simply paying a daily rate based on different levels of care, such as residential care versus outpatient, “we could design reimbursement contracts that focus on the outcome and the ultimate holistic health of the individual,” says Nemecek.

To support such an approach, the industry would have to develop nationally accepted outcome standards first. For now, Cigna is focusing on medication-assisted treatment (MAT) as an evidence-based approach to opioid addiction and has eliminated prior authorization requirements to improve access.

Insurance giant Anthem recently announced it too would eliminate prior authorization for MAT and has increased efforts to connect MAT and counseling services after discovering that less than 20% of its MAT patients were receiving counseling in conjunction with the medication.

Longer treatment times

Treatment centers may be looking at the reimbursement issue from a different perspective.

“Opioid addiction is unique in that it frequently requires a longer continuum of care than that offered in a traditional 30-day treatment program,” says Marvin Ventrell, executive director of the National Association of Addiction Treatment Providers in Denver. “We have learned that we have to stay much more aggressively involved for longer periods of time when treating opioid addiction, especially among young people.”

At the same time, Ventrell also recognizes that outcome measures are going to be key to the future of addiction treatment.

“Much of this is going to come down to whether we can show good outcomes from treatment,” he says, noting that treatment centers are well-positioned to implement evidence-based practices.

To that end, he urges treatment center clinicians and directors of operations to focus on the best research to identify and adopt the most useful evidence-based practices and then conduct their own internal outcome studies. “We need to show that people who go to treatment do well after treatment for a significant period of time,” he says.

A new era?

If there is one relatively positive point to be reaped from the opioid epidemic, it is the fact that the discussion surrounding it emphasizes the brain science behind addiction and the fact that addiction is a chronic illness, much like diabetes or high blood pressure By disengaging morality-based judgments and personal failure narratives that often dog discussions about addiction, today’s current atmosphere could erode some of the stigma associated with opioid addiction and behavioral health disorders overall.

“The public and policymakers may have been less willing to see addiction as a chronic brain disease” in the past, says Ventrell. In that sense, the opioid epidemic “definitely provides an opportunity to destigmatize addiction considerably.”

As insurers and treatment centers look for new ways to manage patient care and measure outcomes, treatments centers could be stepping into a new role within the broader healthcare system.

“We hope to see the medical science and the payer model come together so that the payers clearly recognizes the value of adequately treating a serious disease up front,” says Ventrell.

He notes that the insurance industry as a whole has not yet recognized the need to offer inpatient treatment as a first option. “The idea that we are going to let someone fail in outpatient care before we can get them in inpatient care not only jeopardizes the patient’s life but increases the cost to the individual and to society,” he says.

According to CDC, 91 Americans die every day from opioid overdoses, and in 2015, the United States witnessed 33,091 overdoses from prescription opioids—a 16% increase over 2014.

Joanne Sammer is a freelance writer based in New Jersey.