How payers are responding to the opioid crisis

As the opioid epidemic continues, healthcare spending on opioid abuse and dependence has risen dramatically. Healthcare spending on opioid abuse and dependence totaled more than $28 billion in 2013 and payers footed the bill for $26 billion of that tab, according to one estimate reported by ScienceDaily in September.

FAIR Health, a nonprofit dedicated to improving transparency in healthcare pricing, provides a more conservative estimate. It still shows an exorbitant price tag. Based on an analysis of more than 21 billion private health insurance claims, FAIR Health estimated private payers spent more than $445 million on opioid abuse and dependence disorders in 2015, more than 13 times what they paid in 2011.

Increases in costs of services over time help to explain some of the increase in spending. However, growth in the number of individuals diagnosed with opioid dependence and abuse appears to be the main driver. On average, patients with opioid abuse and dependence diagnoses cost private payers nearly $16,000 more, or five times as much, as other patients. In addition to emergency care, therapy, physician office visits and drug screening were some of the most significant contributors to cost.

“For payers, our data probably confirm on a wider scale what they probably are all seeing in their own operations – that the substance abuse problem, particularly but not exclusively related to opioids, is serious and growing,” Robin Gelburd, president of FAIR Health, told Healthcare Dive in an email.

Payers taking a multi-pronged approach to opioid epidemic

Some payers are taking action to address the opioid epidemic. Cigna, for example, is working on multiple fronts to reduce opioid prescribing and to improve coverage for patients at risk for or diagnosed with an opioid abuse or dependence disorder, Dr. Doug Nemecek, CMO for behavioral health at Cigna, told Healthcare Dive in an interview.

Last month, Cigna announced an initiative aimed at reducing opioid prescribing by 25% in three years among its provider networks. This initiative, which shares the same goals as the U.S. Surgeon General’s “Turn the Tide” pledge, calls on provider organizations in the Cigna Collaborative Care program to take steps to address the opioid epidemic. These steps include learning about alternative chronic pain treatments and interventions, screening patients for opioid abuse and dependence, and improving coordination of care for patients.

So far, provider organizations seem enthusiastic about the initiative, according to Nemecek. Nearly a quarter of the 160 Cigna Collaborative Care provider organizations have made the commitment and more are signing up everyday. The initiative might seem like an empty promise to some cynics, but Cigna is working closely with providers to encourage quality improvement action related to treatment of chronic pain conditions and opioid abuse and dependence.

Analytics allow Cigna to identify providers who are not following best practices for opioid prescribing. The payer shares reports with providers in its networks to show how their prescribing patterns compare to new CDC guidelines and other providers. As providers report back, Cigna will collect information on effective strategies and eventually include them in an anti-opioid prescribing “playbook” to aid future quality improvement efforts.

Cigna is also using analytics to identify patients at risk for opioid misuse or dependence. If a patient is flagged, Cigna will reach out to them directly to educate them about the risks associated with prescription opioids and about alternative treatments and interventions for chronic pain conditions. Cigna has also stopped requiring prior authorization for medication-assisted treatment so that patients can more readily receive opioid misuse or dependence treatment.

Collaboration will be key to solving the opioid epidemic

Outside of efforts aimed at the providers and patients directly involved with Cigna, the payer is also involved in policy-making at a national level with nonprofit groups and industry association​s dedicated to fighting the opioid epidemic. For instance, Cigna provides claims data to the American Society of Addiction Medicine to aid the development of evidence-based quality improvement measures specific to opioid abuse and dependence treatment.

“We know there is no silver bullet,” Nemecek said. “It is going to take lot of partners and people working together. We know we still have a long way to go to truly address the opioid epidemic.”

Fortunately, Cigna isn’t the only payer taking steps to address the opioid epidemic. Aetna and Blue Cross Blue Shield (BCBS) Massachusetts are two other payers who have taken action, as CNN reported earlier this year. Aetna uses analytics like Cigna to identify patients at risk for opioid abuse or dependence. BCBS Massachusetts has made opioid prescribing more difficult. Both payers have seen opioid prescribing gone down.

The opioid epidemic is taking a tremendous toll. While payers have financial motivation to reduce opioid prescriptions, there is of course a human element. “We know there are lots of our customers out there who have opioid use disorders and chronic pain conditions who are not getting the appropriate care,” Dr. Nemecek said. “This is about making sure they get the best treatment possible.”  

Filed Under: Payer
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