posted by AHIP
on July 23, 2018
The opioid epidemic has become the public health crisis of this generation. For Gateway Health, a Pittsburgh-based managed care organization, the epidemic has hit their communities and members particularly hard—Gateway Health serves consumers in four of the five states with the highest opioid overdose death rates (Pennsylvania, Ohio, West Virginia, and Kentucky). Pittsburgh is at the epicenter of the crisis, with a dramatic rise in opioid-related deaths over the last several years.
Gateway Health is implementing innovative ways to more effectively manage pain and treat substance use disorders through whole-person care that integrates physical and behavioral health services.
To learn how Gateway Health is tackling issues related to opioid addiction and treatment, AHIP spoke with Dr. Steven Szebenyi, Vice President and Chief Medical Officer, and Will Wenger, Director of Product Strategy & Innovation, Behavioral Health.
Dr. Steven Szebenyi: From a pharmacy perspective, we have focused on improving safety and care coordination for our high dose-chronic duration patients. In Pennsylvania, Medicaid plans are required to limit the amount and duration of opioids a person receives. And for those already receiving high doses of opioids, plans must help patients taper to safer amounts. When we work with these patients for tapering, we make every effort to avoid unintended consequences that may drive patients to look elsewhere for pain relief—including illegal sources. Street drugs are driving the increased death rate from opioids.
Dr. Szebenyi: We are forging relationships with provider groups to support whole-person care of our patients for addiction management, behavioral health, and pain management. Through such partnerships, our patients are able to access services not traditionally covered under Medicaid, including massage therapy and acupuncture for pain, along with robust, comprehensive, coordinated care for patients while tapering. We are actively expanding complementary care to support our patients who are experiencing pain, covering non-pharmacologic options such as massage therapy and physical therapy services.
We have developed processes to support identification of patients with addiction, including SBIRT (Screening, Brief Intervention, and Referral to Treatment) assessments administered by the primary care physician (PCP), with processes to support referral to treatment. Our website is constantly updated to ensure accurate and timely information for our providers, supporting their efforts to address addiction in their patients. While monitoring continues, preliminary analysis is favorable, with more patients being screened by the PCP for addiction, with many referred for addiction treatment.
We have also worked hard to educate both patients and providers about opioids and other approaches to managing pain through our website, newsletters, and other targeted engagement efforts.
Will Wenger: We have developed an integrated care delivery model for supporting patients with pain management, incorporating the patient’s primary care physician and behaviorist. Through a pilot in central Pennsylvania and one in Delaware, we will implement a care pathway with behavioral health clinicians using cognitive behavioral therapy (CBT) to help patients expand their coping skills related to the pain, while also teaching them non-medication methods to reduce pain.
Dr. Szebenyi: Tapering patients from high doses has been a challenge for some patients—since we initiated the program, about 60 percent of chronic, high-dose opioid patients have been tapered down successfully. There are a variety of factors that prevented the other 40 percent of patients from successful tapering, including unwillingness on the part of the physician or the patient. In these cases, we redouble our efforts and introduce pain and addiction specialists to the program.
Another challenge has been to build the necessary infrastructure and capacity to meet the high need for care including addiction doctors, recovery centers, and pain management specialists.
Wenger: One challenge we have faced in the effort to provide patients with quality care for their addiction is with “cash clinics” that charge upwards of $300 per office visit, just for a prescription of medication assisted treatment (MAT). When insurance is not used either at the office or by the patient at the pharmacy, another challenge is created as we are not able to track the patient’s care, stymieing our ability to provide the member whole-person care support. We need to move toward putting in place quality measures for physician visits, laboratory services, pharmacy, and behavioral health—and if any one of these areas is missing or falling short, the entire process should be flagged. This would reduce providers that are out of our current reach and therefore improve patient safety and coordination of needed care.
Wenger: Physical health and behavioral health historically do not talk much—physical health, addiction, and behavioral health are considered separate domains. We must recognize that we are all working towards the same goals with cross-specialty treatment plans, collaboration and care coordination, and careful and consistent protocols to address the patient’s whole-person care while also protecting patient privacy.
Dr. Szebenyi: We need to think about the consequences of what we do; whether it is providing opioids in the first place or tapering a patient’s opioid use, we need to be aware of unintended consequences. Addressing just one part of the problem isn’t effective and will just push on other weak spots on our approach. Think about it as “squeezing a balloon”—the air just shifts from one area to another. We need to build care management programs and provide adequate access to pain management and addiction services. We need to build the necessary delivery capacity and infrastructure to ensure people have access to the care they need.