posted by Chris Regal, AHIP Senior Health Research Associate
on April 26, 2018
A staggering 43.6 million Medicare beneficiaries were prescribed opioid painkillers under the program in 2016. While the Centers for Medicare and Medicaid Services works to reform prescribing practices, health plans have already taken steps to address the epidemic among seniors.
SCAN Health Plan, which serves over 194,000 Medicare beneficiaries in California, decreased the number of members taking opioids by 26 percent over the last three years and decreased the total number of opioid prescriptions by 11 percent over the same period. We recently spoke with Sharon Jhawar, Chief Pharmacy Officer at SCAN, about the company’s approach to tackling the opioid crisis and how it achieved such successful outcomes.
Sharon Jhawar: Over the past several years, we have developed a five-prong strategy to address opioid-related issues with our members.
The first element of our initiative is provider education. Since the CDC Guideline for Prescribing Opioids for Chronic Pain was updated in 2016, we have been focusing a lot of energy to recalibrate how providers prescribe and treat acute and chronic pain. Primarily that means retraining the provider community on appropriate first-line treatment options over opioids for chronic pain and emphasizing that a three-day supply of opioids is often sufficient for post-op or acute pain.
Beyond that, there are providers who are not well-equipped to have conversations with patients who have opioid use disorders (OUD). We partnered with the American Society of Addiction Medicine (ASAM) and hosted a course to help providers gain the tools they need to have these conversations and to better understand how to assess and monitor those that need treatment for OUD.
This spring, we will roll out prescribing pattern information to our medical groups so that they can see how providers stack up against peers. The medical groups can review reports and identify which providers could benefit from additional education. Our goal is to change behavior.
The second prong of our opioid strategy is to reduce the supply of opioids with point-of-sale edits and quantity limits. These edits serve as an additional check by a pharmacist of prescribed amounts. We want pharmacists to ask if the prescribed amount is appropriate for that patient.
Third, we need to provide access to treatment and access to an antidote. Naltrexone, buprenorphine, and methadone are all available to our members as OUD treatments. And with naloxone available over the counter without a prescription, we want people close to those who have overdosed in the past to carry the drug—much the way a parent of a child with an allergy may carry an EpiPen.
The fourth prong of the strategy is member support and education. We need to destigmatize OUD and let those suffering know that it is common and that they are not alone. At SCAN, we have case management to ensure that people have access to cognitive behavioral counseling and peer support systems, and that their families have support systems—addiction impacts everyone. We also connect patients and their families to community resources as needed.
Finally, we need to raise awareness and work together. We are part of several coalitions with other organizations with similar goals. As a health plan, we are but one entity in the system. It takes all of us together—hospitals, physicians, pharmacy benefit managers, pharmaceutical companies, and health plans—to fight this epidemic.
Jhawar: Over the past three years, we saw a 26 percent decrease in members utilizing opioids. We also decreased the total opioid prescriptions by 11 percent over this time.
Jhawar: We must take a combination approach—first, consider a non-steroidal, and also discuss alternative treatments that may beneficial. Acupuncture and chiropractic services are both available benefits; SCAN enhanced these benefits this year to increase access. Physical therapy and occupational therapy are normal benefits, as well.
Jhawar: This is largely about the point-of-sale edits. An alert is raised when a prescription is being filled where there is concurrent use. We have seen a 33 percent decrease of concurrent use over the last several years, and our concurrent use now is relatively low—last year we were at 2 percent. The biggest differences have been with the point-of-sale edit and education initiatives.
Jhawar: In the Medicare population, we might be dealing with more folks who have co-morbidities that contribute to pain—diabetic neuropathy, fractures, circulation issues—and, as a result, many of our members have been on opioids for many years. However, we think there are more similarities than differences regardless of the population served. The approach must be holistic and address the crisis from every angle.
Jhawar: One of the big opportunities is to increase access to medication-assisted treatment—under Medicare Advantage, seniors have access—but we have to make sure that the prescribers are there. Only one-third of people with OUD are receiving treatment. Last year we partnered with ASAM to train providers to deliver medication-assisted treatment (MAT), with CME for participants.
We are moving in the right direction, but it is not easy! We need to be persistent and focus on helping those in need. It is important that our care management and coordination be stronger than it has ever been before. Though coordinating care across numerous specialists can be difficult, we need to get better at that to make a difference.