Medical management tools are a critical piece of ensuring patients receive safe, effective, and affordable care based on scientific evidence. These types of tools include:

• Medical appropriateness reviews
• Formulary and provider tiered network designs
• Prior and concurrent authorization
• Quantity/dosing limits and step therapy approaches

As the industry works to tackle the opioid epidemic, these tools have become increasingly important when addressing pain management, reducing unnecessary opioid prescribing, and treating opioid use disorder (OUD).

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Treatment of Pain and Opioid Prescribing

When administering pain medication, plans, physicians, and pharmacists work closely together to educate and inform patients and prevent future opioid abuse. Some examples of how medical management might be applied to the treatment of pain and opioid prescribing include:

• Recommending that non-opioid and non-medication alternatives to treatment, such as physical therapy or acupuncture, be tried for a period of time before prescribing opioids. In the area of low back pain, for example, early opioid prescriptions in acute disabling low back pain are associated with longer disability, increased surgical rates, and a greater risk of later opioid use.1
•  Requiring that prior authorization be obtained before prescribing opioids to make sure that the prescription conforms to safe, evidence-based best practices. For example, patients who are prescribed opioids are often on other prescription drugs, some of which may have potentially dangerous interactions when co-prescribed, such as benzodiazepines. Additionally, there is evidence of wide variation and over-prescription of opioids after elective surgery.2
• Requiring quantity limits for initial opioid prescriptions, maximum daily dosages, limits to short-acting opioids, and maximum refills to promote access to appropriate pain care and reduce the risk of addiction and diversion of opioids. There is evidence, for example, that hospitalized elderly patients are prescribed opioids in doses higher than recommended, leading to falls.3
• Conducting claim reviews to identify patients who may be misusing pain medications based on evidence of multiple prescriptions for opioids from multiple doctors and pharmacies. A 2017 report from the HHS Inspector General, for instance, found that 90,000 Medicare beneficiaries are at serious risk of opioid misuse and overdose, with some 22,000 beneficiaries obtaining prescriptions from multiple doctors.4

Treatment of Opioid Use Disorder (OUD)

Health insurance providers also want to ensure comprehensive treatment programs are available and accessible for those suffering from addiction. For example, one widely recognized and recommended therapy is medication assisted treatment (MAT), which helps patients overcome their substance use disorder through medications like methadone, buprenorphine, and naltrexone, along with services such as cognitive behavioral counseling, peer support services, and community-based support groups. Medical management plays an important role here to ensure effectiveness, adherence, and holistic treatment of the patient. For example:

• Promoting appropriate use of methadone and naltrexone because they could interfere with other types of medications and potentially worsen existing conditions.
• Working with clinicians to ensure tailored, patient-focused treatment programs are established to improve outcomes, promote adherence, and are adjusted if necessary to support the patient’s recovery.
• Encouraging use of “centers of excellence” for OUD that coordinate with specialized staff and peer recovery specialists.
• Regularly monitoring members newly prescribed MAT medication to support treatment adherence.

CDC Guideline Reinforces Need for Medical Management

In 2016, the Centers for Disease Control and Prevention (CDC) issued a Guideline for Prescribing Opioids for Chronic Pain for primary care physicians that includes medical management recommendations such as using non-opioid and non-medication pain care as a first line of therapy, prescribing the lowest dose and fewest opioids that would be effective for each patient, regularly reviewing the risks associated with opioids with patients, and closely monitoring patients to promote safer use and better outcomes.

Conclusion: Medical Management Works

Medical management works. It works to ensure everyday clinical practice is consistent with safe, evidence-based care. And it works to stave off the ever-growing opioid crisis. In fact, a recent study found that enrollees within Medicaid plans that use prior authorization have lower rates of abuse and overdose following initiation of opioid medication treatment.5 Preserving and protecting medical management will be an essential part of ongoing efforts to address the opioid crisis and the persistent challenges to safety, quality, and affordability.

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¹ http://www.choosingwisely.org/clinician-lists/aapmr-opiates-for-low-back-pain/
² Wide Variation and Over Prescription of Opioids After Elective Surgery. Thiels CA, et al. Annals of Surgery. October 2017.
³ High-Risk Medications in Hospitalized Elderly Adults: Are We Making It Easy to Do the Wrong Thing? Blackman N, et al. Journal of the American Geriatrics Society. November 28, 2016.
⁴ Opioids in Medicare Part D: Concerns about Extreme Use and Questionable Prescribing. HHS OIG Data Brief OEI-02-17-00250. U.S. Department of Health & Human Services. Office of the Inspector General. July 2017.
⁵ Medicaid Prior Authorization and Opioid Medication Abuse and Overdose. Cochran G., et al. The American Journal of Managed Care. May 2017.