The opioid epidemic is a moral hazard of existential proportions.
A test of the moral health of the insurance industry in which the question is, Will insurers acknowledge the severity of this threat by subsidizing better ways to treat this threat?
Will insurers accept what patients concede and even cynics confess, that specific treatments for opioid addiction outside the U.S. are more effective than the many but mostly unsuccessful treatment options in the U.S.?
Will insurers admit that it is more expensive to cover what does not work than it is to underwrite what returns people—healthy and strong—to the workforce?
To ask these questions is to know that it is smarter to insure domestic tranquility by experiencing it abroad, that it is easier to promote the general welfare by supporting programs that lessen dependency on welfare, not because these programs are wrong, but because it is wrong to abandon tens of millions of people—including mothers and military veterans—to short, nasty and brutish lives of addiction.
The answers to these questions are available to all.
The answers, thanks to my correspondence with staffers at Clear Sky Recovery, raise the ultimate question of whether we will exist half-slave or half-free, whether we will succumb to the ravages of opioid addiction or avoid this descent altogether, whether we will cause our health to worsen or rally to the cause of health and wellness.
What I ask of insurers is no different than what insurers should ask of themselves: help.
Let us be unafraid to seek help.
Let us also be aware that help is achievable, that help is available, that help is accessible.
Let us free ourselves from the false promises of what is a racket rather than a legitimate means of rehabilitation, what with the bombardment of ads and commercials, what with the inundation of junk mail and junk science—an audiovisual overdose of empty words and meaningless slogans.
Let us wake up to the reality of this situation, that we face a do-or-die decision; a dire choice, indeed.
Either we do what is necessary, either we do what is right, or we plead guilty to the fast death of minds and the slow loss of bodies: a sight too painful to witness but too profound to ignore, a sight too traumatic to forget but sometimes too awful to recall.
Either we unite against opioid addiction, or we allow our divisions to destroy us.
Either we encourage patients to get treatment abroad, or we stop demanding that insurers pay for treatment whose efficacy is questionable and whose rate of failure is so high as to be unquestionable.
We must choose what is just, in lieu of what is popular or convenient.
It’s likely that when people hear about the growing opioid addiction problem in America, the face that comes to mind is the one commonly shown on TV and in the movies, which is a very broad generalization : the young, strung-out heroin addict living on the streets. Or dying of an overdose.
Heroin abuse is definitely a growing problem in America. But it’s not the only opioid-related issue we’re facing. In 2012, an estimated 2.1 million people were suffering from substance abuse disorders from prescription opioid use, and deaths from accidental overdoses of prescription pain relievers quadrupled between 1999 and 2015. Sales of prescription opioids also quadrupled during this period.
While prescription pain killers are often seen as a gateway drug to heroin among the young, the issue is much broader than just one demographic group. The reality is that the face of opioid addiction could be the soccer mom down the block who has been experiencing back pain. It could be the marathon runner who is trying to come back after knee surgery. It could be your grandmother baking cookies as she works on recovering from hip replacement surgery.
In fact, it could be anyone. And that diversity is what has made prescription opioid addiction so difficult to manage.
Drivers of addiction
What is driving this explosive growth of such a potentially dangerous substance? Part of it, quite frankly, has been the incredible improvements in healthcare over the last 20-some years. Hip replacements, knee replacements, spinal surgery and other procedures that were once rare are now fairly common. More surgeries mean more patients who need pain relievers to help them with recovery.
The greater focus on patient satisfaction, especially as the healthcare industry shifts from fee-for-service to value-based care, has also had some unintended consequences. Physicians concerned about patient feedback from Healthcare Effectiveness Data and Information Set (HEDIS) measures or Medicare Star ratings have additional incentive to ensure patients leave the hospital pain-free. Physicians may prescribe opioids, particularly if patients request them, rather than relying on less addictive forms of pain management.
Here’s how that translates to real numbers. An analysis of 800,000 Medicaid patients in a reasonably affluent state showed that 10,000 of them were taking a medication used to wean patients off a dependency on opiates. This particular medication is very expensive and difficult to obtain – physicians need a specific certification to prescribe it. So it is safe to assume that the actual number of patients using prescription opiates is two to three times higher.
Those numbers aren’t always obvious, however, because the prescriptions may be obscured under diagnoses for other conditions such as depression. Indeed, more than half of uninsured nonelderly adults with opioid addiction had a mental illness in the prior year and more than 20% had a serious mental illness, such as depression, bipolar disorder or schizophrenia, according to the Kaiser Family Foundation. The result is that, without sophisticated behavioral analytics, it can be difficult to determine all the patients who are addicted to opioids. And what you don’t know can have a significant impact on care, costs and risk.
Complications, risk, and prioritization
Opioid addiction tends to interfere with the treatment of other concerns, especially chronic conditions such as depression, congestive heart failure, blindness/eye impairment and diabetes. As a result, physicians must first take care of the addiction before they can effectively treat these other conditions.
That is what makes identifying patients with an addiction, and prioritizing their care, so critical. Failure to do so can be devastating, not just clinically but financially – especially as healthcare organizations take on more risk in the shift to value-based care.
Take two patients with an opioid addiction who are on a withdrawal medication. Patient A also has eye impairment while Patient B is a diabetic. If the baseline for cost is 1, analytics have shown that Patient A will typically have a risk factor of 1.5 times the norm while Patient B, the diabetic, will have a risk factor of 5 times.
Under value-based care, especially an Accountable Care Organization (ACO) where the payment is fixed, the organization can lose a significant amount of money on patients who are costing five times the contracted amount. For example, if the per member per month (PMPM) reimbursement for the year is $2,000, this patient — who is using this medication for withdrawal from an opiate dependency and is a diabetic — will end up costing $10,000.
It is easy to see why that is unsustainable, especially when multiplied across hundreds or thousands of patients. Yet the underlying reason for failure to treat the diabetes effectively – the opioid addiction – may not be obvious.
Healthcare organizations that can use behavioral analytics to uncover patients with hidden opioid dependencies, including those on withdrawal medications, will know they need to address the addiction first, removing it as a barrier to treating other chronic conditions. That will make patients more receptive to managing conditions such as diabetes, helping lower the total cost of care.
They can also use the analytics to demonstrate to funding sources why they need more money to manage these higher-risk patients successfully. They can demonstrate why an investment in treating the addiction first will pay dividends in the long term with a variety of chronic conditions.
It’s easy to see that opioid abuse in all forms has reached epidemic levels within the U.S. What is not so easy to see at face value is who the addicts are — or could be.
Despite popular media images, the reality is that opioid addition in America has many faces. Some of them may be closer to us than we think. Behavioral analytics can help us identify with much greater clarity who the likely candidates are so we can reverse the trend more effectively.
As we move forward with winning the war against opioid addiction, it can sometimes be challenging to read the daily headlines and stay positive, especially around the holidays. A December article titled “Drug Abusers May be Injuring Pets to Get Pain Killers” shared how police officers and community leaders informed the Ohio attorney general’s office that people have been abusing drugs rightfully prescribed to pets. The US News HealthDay story titled “Secure Your Prescription Drugs When Hosting Holiday Parties” warned readers about the importance of securing prescription drugs in a safe location before guests arrive. When stories deteriorate to addicts intentionally harming their dogs and to people worrying about holiday guests raiding medicine cabinets, rock bottom isn’t far away.
However, 2013 positioned us well for achieving improved results during 2014. Some of last year’s positive developments include:
1. State law changes establishing clearer standards of care, reporting and tracking of controlled narcotics, bans on abused narcotics, etc.
2. State and federal agencies aggressively prosecuting individuals who prescribe opioids illegally or operate “pill mills,” revoking registrations of some pharmacies and compelling healthcare providers and pharmacies to surrender or forfeit their medical licenses to state medical/pharmacy boards
3. Physician-led education efforts like the Physicians for Responsible Opioid Prescribing
4. Medical boards actively addressing the inappropriate and illegal dispensing of drugs
5. Heightened awareness of the neonatal abstinence syndrome crisis in the U.S.
6. Workers’ compensation insurers leveraging advanced analytics, physician education efforts, evidence-based pain diagnoses and utilization reviews to reduce injured worker reliance on addictive prescription drugs
7. The Food and Drug Administration’s Risk Evaluation and Mitigation Strategy
8. The issuance of the October 2013 Trust for America’s Health report titled “Prescription Drug Abuse: Strategies to Stop the Epidemic”
9. Continuing prosecution and sentencing of healthcare providers
This article will expand on the last two developments and share some thoughts on what may be in our future when it comes to winning the war on opioid addiction and abuse.
Prosecution and sentencing of healthcare providers
2013 was marked by the successful prosecution and sentencing of healthcare professionals involved in various forms of prescription drug diversion. Arguably the most notable of these was the 39-year prison sentence given to David Kwiatkowski, the former New Hampshire hospital technician who caused dozens of people to become infected with hepatitis C when he injected himself with pain killers using syringes that were then used on patients. Kwiatkowski admitted in August to stealing the drugs and leaving used syringes for hospital use for years, despite knowing he was infected with hepatitis C. His case drew national attention to the problem of prescription drug diversion among healthcare workers; caused a number of institutions to finally take a fresh look at their human resource policies and systems being used to detect diversion; and, has, we hope, sent a strong message of deterrence to all healthcare drug diverters — it is only a matter of time before you get caught!
Efforts by national medical organizations (NMOs)
On an extremely positive note, we are beginning to see NMOs join the fight to help stem the opioid epidemic. On Dec. 10, 2013, the American College of Physicians released a position paper titled “Prescription Drug Abuse: A Policy Position Paper From the American College of Physicians.” The goal of the paper was to provide physicians and policy-makers with 10 recommendations to address the significant human and financial costs related to prescription drug abuse. The recommendations include support for additional education, a national prescription drug monitoring program, establishment of evidence-based nonbinding guidelines regarding recommended maximum dosage and duration of therapy, consideration of patient-provider treatment agreements and the passage of legislation by all 50 states permitting electronic prescription for controlled substances.
In turn, in January 2014, the American Academy of Pediatrics (AAP) Committee on Drugs and Section on Anesthesiology and Pain Medicine issued a report titled “Recognition and Management of Iatrogenically Induced Opioid Dependence and Withdrawal in Children.” The clinical report recommended guidelines for prescribers to follow when weaning children from opioids. As noted by lead author Jeffrey Galinkin, MD, “[t]he key reason the AAP was keen to publish this paper and go forward with this guideline is that people are unaware that patients can get drug-specific withdrawal symptoms from opioids as early as five days to a week after having been on an opioid chronically.”
This recommendation was immediately followed by the Centers for Medicare and Medicaid Services (CMS) Jan. 10, 2014, Federal Register Volume 79, Number 7 publication of proposed rules revising the Medicare Advantage (MA) regulations and prescription drug benefit program (Part D) regulations to help combat fraud and abuse in these programs. The proposed rules include requiring prescribers of Part D drugs to enroll in Medicare, a feature that CMS believes will help ensure that Part D drugs are prescribed only by qualified individuals. As reported by Medscape Medical News, CMS is also seeking the authority to revoke a physician’s or eligible professional’s Medicare enrollment if:
• CMS determines that he or she has a pattern or practice of prescribing Part D drugs that is abusive and represents a threat to the health and safety of Medicare beneficiaries or otherwise fails to meet Medicare requirements; or
• His or her Drug Enforcement Administration certificate of registration is suspended or revoked; or
• The applicable licensing or administrative body for any state in which a physician or eligible professional practices has suspended or revoked the physician or eligible professional’s ability to prescribe drugs.
Furthermore, CMS proposes employing data analysis to identify prescribers and pharmacies that may be engaged in fraudulent or abusive activities. In Table 14 of Federal Register Volume 79, Number 7, CMS’ Office of the Actuary estimates the savings to the federal government from implementing its proposed provisions will be $83 million in calendar year 2015, $132 million in 2016, $171 million in 2017, $364 million in 2018 and $589 million in 2019.
In addition to the above efforts, companies continue to innovate and research new ways to address historical challenges.
Vatex Explorations is building a real-time individual-dose monitoring system called Divert-X to reduce drug trafficking, misuse and addictions that result from routine medical care. Divert-X monitors a patient’s individual doses through the electronic transmission of data identifying the time of dose access, location and other measures. The analysis of the data in real time helps physicians and pharmacists identify drug-taking behaviors that fall outside of norms, allowing early intervention before misuse or addiction set in.
In 2012, the Food and Drug Administration approved an ingestible sensor that can be used to track real time data about your pill consumptions habits. The sensor, developed by Proteus Digital Health, was first approved for use in Europe before coming to the U.S. The ingestible sensor is part of the digital health feedback system, which includes a wearable sensor and secure app and is largely focused on serving the transplant population and patients with chronic illnesses. The authors could envision a day when the system could help in the battle against opioid addiction.
Insurance companies are doing a better job of leveraging advanced analytics to understand their opioid-exposed population and the prescribing habits of the physicians treating their injured workers. Through the review of medical bills (e.g., date and types of service and payment, ICD-9 diagnosis codes, CPT-4 procedure codes, etc.) and pharmacy data (e.g., bill frequency, aggressive refills, NDC drug codes, quantity used, generic vs. brand, supply days, use of prescriber, pharmacy name, etc.), insurance companies can identify usage and treatment patterns that fall outside of expectations using cluster analyses, association rules, anomaly detection and network “link” analyses.
Law enforcement continues to push the envelope in finding innovative ways to combat drug diversion. Take, for example, the strategy developed in consultation with the National Association of Drug Diversion Investigators and Oklahoma Bureau of Narcotics to curb false reporting of the loss or theft of prescription drugs in Stillwater. According to a police spokesman, most physicians in Stillwater require patients to obtain a police report before they will write a replacement prescription for lost or stolen medications. This requirement resulted in an increase in the number of police reports filed, but a new problem emerged. How could anyone determine whether those police reports were legitimate? In response, the Stillwater police department created a database to record the names of any individual who reported the loss or theft of a prescription drug. The department now requires the individual to take a polygraph test before it will accept any subsequent report of a lost or stolen prescription drug. Fail that polygraph, and criminal prosecution may follow. Query: If this strategy were employed nationwide, would the medicine cabinet at home be guarded more closely?
There is no doubt we have come a long way in the battle against opioid addiction in a relatively short time. Although there is a lot of road left to travel, 2014 is well-positioned to carry forward the effective efforts from last year. Given the innovative spirit of the U.S. and passion of everyone involved in winning this fight, a better long-term solution could be just around the corner.