In the wake of the recent massive out-of-court settlement by a maker and three distributors of opioids, experts weigh in on the role managed care stakeholders should play at this critical juncture.
In October 2019, three major drug distributors and an opioid maker settled out of court with two Ohio counties to the tune of $260 million. The agreement, which calls for cash payments to victims and donated addiction treatments, could become the model for settlement of other pending cases. First Report Managed Care consulted a group of managed care experts to assess the issue at this critical juncture. Our experts highlight individual and systemic failures, examine a national initiative that is attempting to effect meaningful progress, suggest strategies of their own, and advise how to allocate out-of-court settlement dollars.
Edmund J Pezalla, MD, MPH, founder and CEO at Enlightenment Bioconsult in Hartford, CT, pointed to two underlying causes of the opioid crisis. “First, there are few other options for treating both acute and chronic pain. Additionally, there are not enough clinicians who can identify and treat patients with substance abuse problems.”
Most of our panelists concurred that the government and health care stakeholders have generally failed patients. “The system is not integrated or even equipped to provide the necessary spectrum of care,” said Larry Hsu, MD, medical director for the Hawaii Medical Service Association in Honolulu, HI.
Charles Karnack, PharmD, BCNSP, assistant professor of clinical pharmacy at Duquesne University in Pittsburgh, PA, blames state boards of pharmacy for improper oversight, as well as ethical lapses by wholesalers, chain pharmacies, and individual pharmacists. “How can state boards of pharmacy not know about so-called pill mills when they are supposed to be fulfilling their mission to protect public health. It is unconscionable to think that a small-town pharmacy that can order, receive, store, and dispense such a vast number of opiate doses to residents of rural America.”
Arthur Shinn, PharmD, president of Managed Pharmacy Consultants in Lake Worth, FL, noted that prescribers are responsible for their fair share of the blame as well. “I have an office in Florida and for a time was making the drive down there from North Carolina. I would see billboard after billboard for pain clinics. You knew that many of them were pill mills.”
A Gateway to Heroin Addiction
We reached out to a medical director for a health insurer who agreed to speak with us anonymously. He explained that ignoring the issue has resulted in a large volume of prescription painkillers on the market and leftover supplies in homes. “This [oversupply] serves as a gateway to heroin, since most heroin abusers have a history of misuse of opioids,” he said. “They turn to heroin when their prescriptions become too expensive or run out. Inadequate access to medication-assisted treatment (MAT), as well as a shortage of trained professionals in many areas of the country have contributed to the problem.”
Despite inroads, there remains a general inability to provide adequate mental health care. Dr Karnack noted that the current Administration’s efforts to undercut the ACA are not helping.
“We should be offering comprehensive insurance coverage via improved Obamacare, not junk health care plans that exclude coverages. These comprehensive plans should avoid delayed payments, eliminate waiting periods, and be available in every county in every state.” He added that behavioral health coverage should mimic coverage for medical and surgical comorbidities.
While Dr Shinn said he believes increased regulation of opioids has helped, F Randy Vogenberg, PhD, RPh, principal at the Institute for Integrated Healthcare in Greenville, SC, warns against overregulation. “We need to focus on execution. We are stuck in cycles of more regulation and legislation that have pretty much failed.”
Keys to Effective Execution
What does effective execution look like? According to Dr Pezalla, clinics should receive expanded funding. Dr Karnack agrees. “All states should have treatment facilities in rural as well as urban areas. Federal and state funding for these behavioral health programs need to cover the long term, vs annual grants subject to the whims of Congress and state legislatures. Additionally, ongoing federal and state funds are desperately needed for additional treatment facilities for short-term stays. Finally, states should not use behavioral health as an exclusion for Medicaid.”
At the provider level, Dr Pezalla said that clinicians need to be compensated for time to adequately treat patients with mental health conditions. He also thinks increased funding for training mental health professionals will help improve outcomes over the long-term. Finally, Dr Pezalla called for “reducing restrictions on the use of buprenorphine and other substance abuse treatment medications.”
To address provider shortages, Dr Hsu urged increased use of physician assistants (PAs) and nurse practitioners (NPs), along with adequate training for these individuals to help with early screening, diagnosis, and management. David Marcus, director of employee benefits at the National Railway Labor Conference in Washington, DC, suggested that payers could make remote clinician access more readily available to those who need treatment. Dr Karnack said that programs that offer tuition reimbursement in exchange for practicing in underserved areas can help, but the process needs to be modified to simplify the application process and eliminate rejection of reimbursement based on technicalities in an effort to save money.
The medical director who requested anonymity outlined his vision of a comprehensive multi-step process focused on addiction prevention. Managed care organizations must:
- Ensure that prescriptions adhere to Centers for Disease Control and Prevention prescribing guidelines: dosage, length of prescription, appropriate use;
- Decrease use of long-acting opioids;
- Set up systems that increase the odds that prescriptions are used safely: claims processing screening for high-risk drug combinations with opioids, quantity limits, and other pharmacy management tools;
- Educate dentists and oral surgeons given their high rate of opioid prescribing;
- Promote alternatives to opioids, including rehabilitation interventions;
- Prevent and detect fraudulent use: identify physicians with high rates of opioid prescribing and patients who use multiple prescribers or pharmacies;
- Promote and expand MAT: plans should not require prior authorization on preferred medications used for opioid dependence; and
- Provide programs that offer long-term-support: promote support groups and better coordinate community services.
Dr Pezalla said that payers can try other novel solutions, but many are unproven. “Payers have exhausted the control aspects by limiting quantities or opioids. As they move onto alternatives, it’s harder because there is less data. For example, will expanded access to chiropractic resources, physical therapy, and other interventions really help?”
The Shatterproof Initiative
With so many moving parts, it is easy to see how cumbersome processes, red tape, unproven solutions, and more leads to inaction. Plus, with so many stakeholders involved it’s easy to shirk responsibility. Organizations such as Shatterproof, a national nonprofit organization run by the father of a young man who ended his life due to addiction, are trying to clear the underbrush and create a path toward meaningful change.
The organization’s National Principles of Care call for routine screenings, a treatment plan for every patient, fast access to treatment, long-term disease management, improved care coordination, and behavioral care from trained providers.
It’s a difficult list to tackle, but the potential benefits are obvious. “These are also the best ways to treat chronic pain,” Dr Pezalla pointed out. “But it is challenging to get providers to adhere to best practices for pain, [let alone] get them to use these [principles] to manage substance abuse.” He noted that payers can help by arranging for rapid access to screening and referral through “a combination of paying specifically for these activities and providing telemedicine programs.”
Dr Vogenberg is skeptical. “They’re great ideals, but we are stuck in a system that rewards mediocrity. Plan sponsors need to embrace these principles with adequate funding. Payers aren’t pushing for change and providers are waiting for payers to offer more funding or resource support.”
Mr Marcus was more optimistic. “All of [the Shatterproof] principles can be implemented by payers relatively quickly.” He noted, however, that “providers may be resistant to force alternative treatments, particularly for patients who present with significant pain.”
However, Dr Vogenberg’s replied, “None of these can be accomplished unless all key stakeholders are participating.”
So, where to start? The medical director who requested anonymity said he would begin with the principles that he thinks are the least challenging to implement: improved access to treatment, long-term management, and an enhanced network of behavioral health specialists. Dr Karnack said he believes that care coordination is doable, but it must “include timely payments and avoid prior authorizations.”
Increased Screening, but Then What?
Some of our experts said screenings appear to be the least challenging to implement. “This can become as routine as measuring blood pressure (BP),” offered Dr Shinn. Dr Pezalla added, “Screening can be done via digital or other means to reduce the need for providers to ask about it.” But he noted that the initiative does not end there, as screening “increases the need for counseling and
referrals. Increasing compensation for nonphysician providers to provide this service would help.”
Dr Vogenberg pointed out that screening is already being performed, “but there is no one to go to for follow-up.” Dr. Karnack said that while screening is on the rise, rural areas are not benefitting. NPs and PAs can help address this need by collaborating with pharmacists as part of an interdisciplinary team.
One of the keys to making screening and referral more seamless is, according to Mr Marcus, “Take the burden of finding a site of care away from the PCP [primary care provider]. Make it easy to refer through a behavioral health company or division of the health plan.”
Mr Marcus added that long-term disease management will be an extremely challenging Shatterproof principle to implement. He understands the need to treat addiction as an illness to be managed over the long-term, but he said he worries when that concept is intermingled with the more immediate need of treating pain. “Acute pain necessitates drug treatment and opiates are commonly prescribed in this instance. Limited fills, followed with nonopiate drug therapy, followed by alternative pain management treatment should be implemented in most cases. Only for the most severe cases of long-term pain should long fills of opiates be provided.”
Mr Marcus also addressed the elephant in the room: the stigma associated with drug addiction. He suggested that the stigma is tied to substance abuse itself—not the patient who is suffering from the disease—which can actually be helpful. “There is no doubt that addiction is a disease, but the circumstances leading to the addiction should not be overlooked. Societal acceptance of addiction as a disease would be helpful as it might make more resources available, but this alone would not be enough to resolve the crisis. The moral stigma associated with substance abuse could also be leveraged to discourage people from using opiates and encourage alternative pain management options.”
Practical or Pollyannaish?
Dr Vogenberg remains skeptical about whether any of these principles will be implemented meaningfully anytime soon. “All are doomed due to inadequate processes and ineffective use of scarce resources. Even when success occurs, it is rarely sustainable. Efforts to reinforce success typically fail.” In an era of shorter appointment times, lower reimbursements, and many unknowns regarding the future of the US health care system, how realistic is any of this?
Mr Marcus acknowledged the challenges, but said he sees solutions within reach. “We have migrated into a digital era that continues to evolve essentially by the minute. Where there is a problem that needs to be solved, there exists numerous opportunities to find a solution.” He said that while it might be difficult to see the forest for the trees, one solution begets others, and eventually there can be an impressive array of options. “Creativity and innovation seem to thrive in the midst of a crisis.”
In the absence of systematic change, what can stakeholders with boots on the ground do now? Dr Karnack thinks that more pharmacies should be providing counseling on the proper use of medications such as naloxone. By his reasoning, pharmacies have become places patients come to for immunizations. Some even provide wellness visits. They can also be the place where counseling services are offered.
Despite the challenges of implementing screening, Dr Shinn said it would be his top recommendation to providers. “The BP screen is so routine we hardly think about the process—it just happens. What if screening for addiction was the same?” He thinks many clues go unnoticed. “Patients indicate their alcohol consumption habits on the form in the waiting room, but providers rarely address it. Patients might also be quick to demand antibiotics or sleep aids, which are prescribed with hardly a second thought.” Dr. Shinn said screening questions and detailed notes can later help the provider make the right decision should a patient need pain treatment.
Dr Marcus agreed. “PCPs and pharmacists are the best suited to immediately recognize addiction and propose alternative treatment. If addiction appears present at the point of care, physicians should consider prescribing non-opiates in lieu of opiate treatment.”
Avoiding a Big Tobacco Repeat
As for the recent out-of-court settlement—and those still to come—what needs to be done to make sure this new windfall does not proceed similarly to the Big Tobacco settlement from the 1990s. Significant portions of that settlement money did not end up benefiting victims.
It is important to be vigilant in guaranteeing that funds go “only in organizations that can spend
them on substance abuse treatment and research,”
said Dr Pezalla. Dr Hsu added, “Make sure these organizations are directly involved in preventing, screening, diagnosing, treating, or providing support for addiction.” Mr Marcus agreed, adding: “Programs that fund public education on the risks associated with opiate use and alternative pain management options should be marketed.”
Dr Karnack said he would like to see monies allocated quickly but with oversight. “Immediate funding can help to establish additional outpatient treatment facilities and support additional beds in inpatient treatment facilities. Oversight by state or county auditors or oversight boards will help assure the public that these funds are being used appropriately.”
Can past mistakes be avoided? “Time will tell,” said Dr Vogenberg, before adding this caution: “What we’ve learned from the tobacco settlement is that it lacked clarity and merely put a bandage on a systemic problem. It didn’t fix it."