The Opioid Epidemic and PerformRx s Approach to Address It: A Collaborative Model with PBM, Payor and Behavioral Health Andrea Gelzer, M.D., M.S., FACP Senior Vice President and Corporate Chief Medical Officer
The Prescription Opioid Problem The amount of prescription opioids sold quadrupled from 1999 to 2010, yet there had not been an overall change in the amount of pain that Americans reported. Providers wrote nearly a quarter of a billion opioid prescriptions in 2013. This is enough for every American adult to have their own bottle of pills. One in four patients receiving long-term opioid therapy struggles with opioid addiction. AmeriHealth Caritas 2
Risk Factors for Prescription Opioid Pain Reliever Abuse and Overdose Obtaining overlapping prescriptions from multiple providers and pharmacies. Taking high daily dosages of prescription opioid pain relievers. Having mental illness or a history of alcohol or other substance abuse. Living in rural areas and having low income. AmeriHealth Caritas 3
Medicaid Covers the Neediest Populations Infants and children Pregnant women, parents, and other nonelderly adults Individuals of all ages with disabilities Low-income seniors Other vulnerable populations AmeriHealth Caritas 4
A Multifactorial Issue Requires a Multifaceted Approach Pain management Integrated care management and support Specialized programs AmeriHealth Caritas 5
Integrated Care Management and Support AmeriHealth Caritas 6
Neonatal Abstinence Syndrome on the Rise 70 Deliveries per 1,000 2014 2015 2016 60 58.40 50 46.32 40 38.87 40.60 36.97 43.00 34.05 30 29.95 28.13 28.66 25.59 27.13 20 19.69 17.37 14.57 14.62 18.97 17.91 14.80 22.56 16.58 10 10.25 8.01 7.84 10.60 0 PA 1 PA 2 PA 3 DC MI SC LA FL ENTERPRISE AmeriHealth Caritas 7
Specialized Programs - Maternity Making prenatal care a priority. Tailoring drug treatment to meet pregnant women s unique needs. No judgement. Working hand-in hand with providers. Showing up to help at-risk babies and moms. AmeriHealth Caritas 8
Challenges Availability of treatment options. 42 CFR Part 2 regulations. Behavior change. Prescription Drug Monitoring Programs. AmeriHealth Caritas 9
MEDMGMT_1732068
Drew Maiorini Vice President, Clinical Programs Pharmacy Strategy
Pharmacy - Point Of Sale Edits at the pharmacy provide checks on high risk prescriptions * Over 90 Morphine Milligram Equivalents Daily Greater than 5 days supply Limits prescription approval to short-term dosing without therapy management/review Provides ability to identify providers and members for outreach *Based on CDC guidelines
Sample Initiative Schedule Stage Date the change starts Dosing Limit Day Supply Limit 1 August 9, 2017 (members new to therapy only) No more than 90 MME combined* 2 October 1, 2017 No more than 170 MME combined* 3 November 1, 2017 No more than 150 MME combined* 4 January 1, 2018 No more than 120 MME combined* 5 February 1, 2018 No more than 90 MME combined* *The MME calculation will accumulate across products if members are receiving more than one opioid concurrently. No more than a 5 day supply No more than a 14 day supply No more than a 10 day supply No more than a 7 day supply No more than a 5 day supply
Identification Stratify members and prescribers based on risk level Members Multiple pharmacies Multiple providers Harmful drug combinations High dose and duration Prescribers Total volume of prescriptions Harmful combinations High dose and duration 14
DTM Interaction Send provider-targeted member-detailed letters to prescribers Outreach to prescribers to coach on titration schedules Identify eligible candidates for supportive and/or alternative therapies Link with Case Management Identify members for medication assisted treatment Connect with COEs for addiction treatment Physical therapy Behavioral Health support
Behavioral Health Strategies Michael Golinkoff, Ph.D., MBA President, PerformCare SVP, AmeriHealth Caritas
PerformCare Initiatives Working Collaboratively with State and Local Entities PA s Department of Human Services Centers of Excellence Program PA Attorney General s Opioid Task Force Lancaster County s Partnership for Public Health initiative focusing on Opioids PerformCare Specific Initiatives Aggressive provider and family education Expanded use of Recovery (Peer) Specialists Development of a Substance Use Disorder application of our Enhanced Care Management Program Promote the use of Medication Assisted Treatment AmeriHealth Caritas 17
PA DHS Centers of Excellence Commonwealth has set up COEs for Opioid Treatment When a patient presents for treatment a professional from the COE evaluates the patient with their family The COE clinical team includes: behavioral & physical health care providers community-based care navigators community-based resources (food, housing, jobs, etc.) COE team provides coordinated, comprehensive care PerformCare works collaboratively with the COEs Make sure that eligible members that show up at the COEs are enrolled in Medicaid Augment the COEs efforts by enrolling participants in our ECM program Sit on the Executive Steering Committee of the COE AmeriHealth Caritas 18
Lancaster County Partnership for Public Health The Partnership is a collaboration among the Lancaster County Drug and Alcohol Commission, the University of PA Health System, SouthEast Health Services and PerformCare Try to address the Opioid Crisis through: Public awareness and education for all residents Coordinate among agencies to optimize utilization of resources Research and advocacy to impact practice and policy PerformCare is performing a community system analysis to assess quality of services and identify gaps in services AmeriHealth Caritas 19
Mission Statement Reduce recidivism and readmission to Inpatient care. Connect high needs, high risk Members to needed, appropriate and correct services Provide high-touch care management for inpatient discharge planning Help to bridge Care Gaps Promote Recovery Help high needs, high risk Members with community stabilization by educating and supporting the members in getting well, staying well and being healthy 20
The Team Enhanced Care Management Department: Acute Enhanced Care Management (Acute ECM) Team Long Term Enhanced Care Management (LT ECM) Team The ECM team is comprised of: Pennsylvania Licensed Clinical Care Managers. Certified Addictions Counselors Prior experience in behavioral health service delivery Knowledge of PerformCare County-specific resources Knowledge of Health-Choices funded level of care Medical Necessity Criteria 21
ECM Outcomes Quality of Life improvement for Members Decreased Acute and Need scores with increased Significant and Moderate scores on the Adult Needs and Strengths Assessment (ANSA) comparing the start of ECM involvement and discharge from the Program. Decrease in volume of Inpatient Behavioral Health readmissions Increase length of time in the community between inpatient admissions Remain engaged in the SUD continuum of care Increased utilization of recovery focused programs Increase in successful Inpatient Diversions via use of Recovery Management Plans Decrease in the number of members classified as Chronic 22
Medication Assisted Treatment PerformCare promotes the use of Medication Assisted Treatment (MAT) for Opioid Addiction Actively refers members to MAT programs Working to expand the number of providers and facilities that offer MAT Assure that MAT is offered along with Cognitive Behavior Therapy or Motivational Interviewing as an augmentative psychotherapy 23
References 1. Dowell D, Haegerich TM, Chou R. JAMA. 2016 Apr 19;315(15):1624-45. CDC Guideline for Prescribing Opioids for Chronic Pain--United States, 2016. 2. IMS Health, National Prescription Audit (NPATM). Cited in internal document: Preliminary Update on Opioid Pain Reliever (OPR) Prescription Rates Nationally and by State: 2010-2013. 3. Ossiander EM. Using textual cause-of-death data to study drug poisoning deaths. Am J Epidemiol 2014 Apr 1;179(7):884-94. 4. Banta-Green CJ, Merrill JO, Doyle SR, Boudreau DM, Calsyn DA. Opioid use behaviors, mental health and pain development of a typology of chronic pain patients. Drug Alcohol Depend 2009;104:34 42. 5. Boscarino JA, Rukstalis M, Hoffman SN, et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction 2010;105:1776 82. 6. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain 2007;8:573 82. 7. Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2014. 8. Boscarino JA, Rukstalis M, Hoffman SN, et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction 2010;105:1776 82. http://dx.doi. org/10.1111/j.1360-0443.2010.03052.x 9. Substance Abuse and Mental Health Services Administration. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. The DAWN Report. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2013. Available from URL: http://www.samhsa.gov/data/2k13/dawn127/sr127-dawn-highlights.htm