MIAMI VALLEY — Healthcare organizations and providers are playing a role to be more accountable in the ongoing opioid epidemic, with some providers taking steps to lower how many prescribed opioids their patients and members are using.
CareSource, a nonprofit managed care organization headquartered in Dayton, has made lowering opioid usage a priority. They have seen results from a program implemented in 2016, cutting the number of opioids that their members are prescribed by 40 percent in the last 18 months. CareSource also expects the number of prescribed opioids to drop by the end of the year.
“We believe that managed care plans can play a key role in fighting the opioid epidemic,” said Jonas Thom, vice president of behavioral health at CareSource. “We know that helping members get on a path to recovery and self-sufficiency leads to better outcomes.”
With 1.8 million Medicaid members in Ohio, Kentucky, Indiana, West Virginia, and Georgia, CareSource saw themselves in a position to respond to the opioid epidemic by providing oversight of prescriptions.
“CareSource is an insurance plan, so reducing substance use among our members is a part of our mission to help people have productive and fulfilling lives,” Thom said. “Because we cover the cost of prescriptions, we have a responsibility to ensure opioids are prescribed and covered appropriately. We also know we have to attend to substance abuse and mental health not as side issues, but as a main focus of supporting our members and our community.”
In 2016, CareSource began a prescriber outreach program to notify providers who are prescribing high numbers of opioids. By utilizing claims data, CareSource has been able to identify members at risk for substance use disorder, diversion, overdose or other adverse events, and alert providers, according to a press release.
CareSource goes on to explain in their press release that they also analyze the volume of opioids that providers are prescribing to their members as measured by Morphine Milligram-Equivalent Doses (MED or MME), which tracks the number of pills, dosing schedules, and strength. CareSource then sends letters to providers prescribing opioids, showing how their overall MED prescribing compares to their peers and suggesting strategies to reduce opioids in their practices. CareSource continues to pursue this program and plans to expand it.
“CareSource produces the High MED letters on an ongoing basis, typically monthly but more frequently as needed,” Thom said. “CareSource will not only continue this program into the foreseeable future, but also evolve it into a digital tool.”
The overall initiative, titled “MED Letters,” also won a Pinnacle Award from the Ohio Association of Health Plans and is one aspect of CareSource’s entire Behavioral Health strategy.
“CareSource has seen significant, positive results not only in getting members with substance use disorders into recovery, but also in preventing substance use disorders in the first place,” Thom said. “We have seen a 25 percent increase year over year in the number of members engaged in Medication Assisted Treatment, an evidence-based method in which other medications are used to taper off the opioids.” He added that CareSource has increased the number of providers who provide Medication Assisted Treatment.
Thom discussed other measures that CareSource has taken to address the risks with opioids.
“We have also reduced the number of one-time, 30-day prescriptions by 30 percent through pharmacy edits, in which we approve prescriptions for a fewer number of days or approve an alternative pain management treatment,” Thom said.
They have also promoted a “pharmacy lock-in” policy, which Thom said “requires patients to fill all prescriptions at one pharmacy or see one physician” and “eliminates doctor and pharmacy shopping because the patient’s care is coordinated.”
From tracking opioid prescriptions to monitoring their patients more frequently, there are a number of avenues that healthcare providers take to avoid over-prescribing opioids.
Mary Godwin, a psychiatric nurse with the Miami County Recovery Council (MCRC) explained that, “in order to assist healthcare providers to ensure they are not over-prescribing, it is required to obtain an OARRS report, (the Ohio Automated Rx Reporting System) before prescribing.” Godwin added that prescribing smaller dosages, scheduling frequent appointments before refilling prescription opioids, and obtaining urine drug screens at each appointment before prescribing can also assist in preventing over prescribing opioids.
Premier Health has also implemented a program to encourage alternative treatments for patients with chronic pain, helping patients get in touch with different resources and, in some instances, working to get to the root cause of their pain.
“Premier Health is nearly midway through a two-year pilot program in collaboration with Health Services Advisory Group (HSAG), the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Ohio,” Scott Kanagy, DO, chief medical officer at Upper Valley Medical Center, said. “Through this partnership, nearly 80 Premier Health primary care providers in Montgomery and Miami counties are providing alternatives to medication in managing chronic pain.”
Kanagy explained that this program not only works on adjusting prescribing practices but also connects patients with “community resources through which they can receive specialty care and, in some cases, address root causes that traditionally might have led to an opioid prescription.”
Other alternative treatments for chronic pain include physical therapy, surgery, acupuncture, and nerve blocks, according to Kanagy. “This is an important initiative, as 80 percent of heroin users first misused prescribed opioids,” he said. ”This program does not ban opioid prescribing, but rather encourages responsible opioid stewardship.”
Kanagy said that those early results have been encouraging, showing patients participating in this program with Premier Health providers are using fewer prescription opioids.
“Early results suggest that opioid prescribing in this pilot group of Premier Health providers is decreasing, as are emergency room visits for patients who are prescribed opioids,” Kanagy said.
“We recognize that 80 percent of heroin users first misused prescribed opioids, so we want to do our part to address the overdose epidemic that has gripped our region for several years.”
In addition to this program, Premier Health’s campaign to address dependency on opioids also includes public-service announcements and the installation of unused medication receptacles at each of its hospitals, including Upper Valley Medical Center, Kanagy said.
“About 100 pounds of unused medications have been disposed of just in UVMC’s unused medication receptacle,” Kanagy said.
Healthcare providers can also watch for warning signs that their patients might be abusing their prescriptions. “Some of the warning signs that a patient may be abusing opioids would be a change in their behavior, missing their scheduled appointments, declining urine screens, and requesting refills before they are needed,” Godwin said.
“We might notice rapid increases in the amount of medication needed, or frequent and unscheduled refill requests,” Kanagy added. “We also keep an eye out for suspicious behaviors such as ‘doctor shopping.’ This is when patients go from provider to provider in an effort to obtain multiple prescriptions in a short period of time.”
Kanagy went on to say that healthcare providers usually address these types of concerns on a case-by-case basis.
“For example, if one of our providers suspects a patient is using drugs inappropriately due to dependency, he or she would have a conversation with a patient and explore the circumstances surrounding their opioid use,” he said. “Was there a valid reason, like a vacation, for why they had an opioid prescription filled at a pharmacy that is not their established pharmacy? If the patient is open to assistance, the physician also would work to connect them with appropriate resources in the community.”
MCRC is able to work with healthcare providers who have concerns about their patients abusing prescription opioids.
“Healthcare providers have worked with MCRC in the past if they suspect their patients are abusing opioids and all of the staff here at MCRC work together to assist those in need of reducing harm to themselves and offering them the assistance they need to remain sober,” Godwin said.
Reach Sam Wildow at firstname.lastname@example.org