While some insurers may have dug their heels in and fought against payment for addressing addiction, others are pushing in a different direction.
The high costs of covering the after-effects of opioid abuse are especially acute for nonprofit, safety-net insurers, such as those represented by the Association for Community-Affiliated Plans. ACAP estimates that, between 1993 and 2012, inpatient hospital stays tied to opioid use increased by about 150 percent across the nation. And one 2011 study estimated a cost of about $25 billion to the health care system in 2007 stemming from opioid abuse.
As such, ACAP — which represents about 60 safety-net health plans in 24 states — gathered a handful of its members to come up with ways that payers can help the delivery system trim those costs and cut down on unneeded ED visits. CEO Margaret Murray says it’s critical that hospitals work closely with their payers to help get a full picture of patients’ treatment.
“Hospitals have just one slice of the view of the beneficiary, but they don’t know what drugs the person is getting from other providers,” Murray says. “They might know that they’re in their emergency room because of overdoses or because of drug-seeking behavior, but they won’t know what’s happening down the street when the person is going to the other hospital or other providers, and that’s where the plan comes in because they’re able to see across the spectrum.”
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"How Hospitals Are Fighting on the Frontlines of the Opioid Crisis"
Solutions identified by the ACAP members were gathered in an April 2015 report, and included everything from locking patients into one pharmacy provider to keep them from bouncing between locations looking for drugs, to having plan-employed health navigators reach out to primary care doctors when their patients visits an unaffiliated ED.
One ACAP member, Children’s Community Health Plan, in Wisconsin, has had ongoing issues with mothers getting hooked on opioids while pregnant, and then giving birth to babies with neonatal abstinence syndrome, in which the baby is also addicted. Kenneth Schellhase, M.D., medical director of the health plan, estimates that his staff sees about 10 to 15 such cases a month — out of about 4,000 births covered. The issue is a sensitive one, with mothers hesitant to admit their addiction for fear they might lose custody of their babies.
Children’s Community Health Plan, which has 135,000 members and is owned by Children’s Hospital of Wisconsin, has sifted through the data for pregnant women looking for any addiction red flags. Then, if the timing is right in a pregnancy, it has discreetly reached out to the pregnant women and their providers to make sure the doctor is aware of the addiction, and that the baby will need to be weaned off opiates when born.
“It can be surprisingly easy for the other doctors not to be aware of what’s going on in somebody’s medical world,” Schellhase says. “It’s really just to sort of to let providers know that this is happening and kind of leave it in their hands, but give them some tools to help deal with it.”
Texas Children’s Health Plan — a 390,000-member insurer also owned by a kids’ hospital — was seeing problems with adolescents showing up in the ED for opioid poisoning. Digging into claims data, they found that many were obtaining drugs through dentists or orthopedists, rather than primary care, and often without using their benefits. So, the plan has worked to train family physicians on how to screen, spot and refer teens who are abusing drugs to behavioral health services. The approach has shown promise, and independent doctors have proven eager to learn more, says Rose Calhoun, director of quality and outcomes management for the health plan.
“If you think about a physician who’s out in practice in a small town or rural area, it’s challenging to get away from their office to learn,” she says. “But when the hospital has someone who can go out and work with doctors in the community, they’re very receptive and they appreciate it.”