Responding to the Opioid Epidemic

By Jessica Altman, Pennsylvania Insurance Commissioner | Joel S. Ario, Managing Director, Manatt Health | Patrice Harris, M.D., President-Elect, AMA | Susan Kansagra, M.D., Section Chief, Chronic Disease and Injury, North Carolina Division of Public Health

Editor’s Note: With the number of opioid deaths six times higher in 2017 than in 1999, the opioid epidemic is continuing its rampage across the country. What can be done to solve the epidemic? What steps have states taken that are showing meaningful progress? What needs to come next? To uncover the answers, Manatt Health and the American Medical Association (AMA) performed an in-depth analysis of how four hard-hit states—Pennsylvania, Colorado, Mississippi and North Carolina—are addressing the epidemic. We shared our findings in a recent webinar. In part 1 of our article summarizing the program, published in the April “Health Update,” we looked at the top-line findings from our state analyses and shared a deep dive into how North Carolina is responding to the epidemic. In part 2 of our summary, below, we provide insights into how Pennsylvania is dealing with the epidemic and a look at key points around efforts to end the epidemic. Click here to view the webinar free, on demand—and here to download a free copy of the presentation, as well as the spotlight analyses for Pennsylvania and Colorado.

_________________________________

Pennsylvania’s Three-Pronged Approach

In Pennsylvania, Governor Tom Wolf has been laser-focused on solving the opioid epidemic that has hit the state so hard. Pennsylvania has worked across agencies to develop a three-pronged, comprehensive approach to combatting the crisis: prevention, rescue and treatment.

Prevention efforts focus on opioid stewardship. Initiatives include integrating education around opioid prescribing into medical school curricula and driving provider training through continuing education credits, including training on the Prescription Drug Monitoring Program (PDMP). Pennsylvania also makes sure that drug take-back boxes are available across the Commonwealth for those who have extra prescription opioids they no longer need for treatment.

Rescue efforts focus on expanding access to naloxone. Initiatives include having a standing order in place to make naloxone accessible at pharmacies without a prescription, providing emergency medical services agencies with free naloxone, and making sure that first responders are enabled with naloxone. Pennsylvania also has naloxone giveaway days to optimize distribution of the lifesaving medication. In addition, the state has implemented an overdose information network (ODIN), which tracks naloxone utilization, including the lives that were saved, how many times naloxone needed to be used, how many overdoses naloxone reversed, whether the person had to be transferred to the hospital following treatment, and other key information. Pennsylvania also provides free training to emergency responders on treating opioid-associated overdoses.

Treatment efforts include launching the PA Get Help Now hotline for those struggling with addiction and their families. The state also is focused on driving “warm handoffs”—ensuring that those coming to emergency rooms with opioid-related issues are taken directly into treatment in the most effective and efficient manner, with the patient’s needs always top of mind. In addition, Pennsylvania works to support clinical integrity, implementing best practices for creating facilities and optimizing access to treatment.

Pennsylvania also has created Centers of Excellence and the PA Coordinated Medication-Assisted Treatment (Pac/MAT) Program—a Pennsylvania-coordinated MAT program intended to serve both the Medicaid and commercial insurance populations. The Centers of Excellence and the Pac/MAT program offer a holistic approach to treatment that includes not only medication but corollary services, as well, including counseling for other mental health needs. Patients can have all of their treatment needs met in one place through one comprehensive treatment plan.

Additional Tools to Fight the Epidemic

In January 2018, Governor Wolf signed a 90-day declaration designating the opioid crisis an official disaster in Pennsylvania. Since that time, Pennsylvania has been under a series of 90-day disaster declarations without gaps, giving the state important tools for responding quickly and efficiently to the opioid crisis. Additional tools include:

• Creating an opioid command center that coordinates response initiatives, measures progress and milestones, and shares key data across 17 state agencies
• Exempting portions of certain regulations to create more effective processes
• Increasing access to the PDMP across state agencies and programs
• Adding overdoses as a reportable condition for public health reporting
• Waiving birth certificate fees for people with opioid use disorder (OUD)
• Conducting a consumer outreach campaign to educate consumers about mental health and substance use disorder coverage
• Waiving the physician face-to-face requirement for narcotic treatment program admissions

Collaboration to Ensure Best Practices

Pennsylvania convened a group of all the major insurers in the state—on both the commercial and the Medicaid sides—to discuss the opioid crisis and ways they could work collectively to respond most effectively. In particular, the discussion focused on removing barriers to treatment and having a consistent approach to opioid prescribing.

The group developed best practice recommendations for what should be covered to ensure that all the different modalities of treatment are readily available. The Pennsylvania Medicaid program then implemented those recommendations comprehensively. The Pennsylvania Insurance Commissioner built on those efforts to work with commercial insurers to drive consistent coverage and encourage access to treatment. The agreed-upon guidelines include:

1. Removing prior authorization for MAT

• Covering at least one buprenorphine/naloxone combination product
• Covering methadone as MAT
• Covering injectable and oral Naltrexone
• Covering at least one form of nasal naloxone without quantity limits
• Ensuring MAT is covered at the lowest patient cost tier on the plan’s pharmacy benefit

2. Aligning prior-authorization requirements for prescription opioids

• Implementing consistent thresholds for prior authorization for long- and short-acting opioids and morphine milligram equivalents
• Establishing consistent exceptions for active cancer, sickle cell crisis, palliative care and hospice patients           

Creating consistency really helped shape a common understanding of appropriate prescribing. It is important to note that prior-authorization requirements are not the same as limits. Prior-authorization requirements are meant to say there should be a medical reason to prescribe more than a set amount. They are an additional set of checks and balances in the system.

We need to remember that there is a need for adequate pain treatment, including appropriate opioid prescribing, as well as pain management alternatives that are not opioids. The next frontier is providing improved coverage of non-opioid alternatives.

Enforcing Behavioral Health Treatment Parity Through Market Conduct Exams

The Pennsylvania Insurance Department is strengthening its enforcement of behavioral health treatment parity through market conduct exams of individual, small group and large group commercial payers—not public programs, such as Medicaid and Medicare, or self-insured large employers. The commercial payers being examined cover about 25% of Pennsylvanians.

The exam is really a compliance audit to evaluate a company’s adherence to all provisions of the Affordable Care Act (ACA), as well as associated state law. For example, in Pennsylvania, mental health parity is both a federal law and a state law. The goal of the exam is to make sure that companies are complying with all the consumer protections that are guaranteed under state and federal laws. The Pennsylvania Insurance Commissioner is authorized under state law to conduct the market exams, which cover the period from January 1, 2015, through March 31, 2016.

It is important to stress that the exams do not just involve looking at a piece of paper to see that a benefit is covered. The exams look at how the benefit is enacted and practiced, including whether an insurance company denies or pays a claim and how it determines what is or is not medically necessary.

Pennsylvania has so far released two exams, and both found issues related to mental health parity. When it finds a compliance issue, the state goes back at a later time to make sure the problem gets addressed. The exams result in three important steps:

1. Corrective action—committing first and foremost to fix the problem
2. Restitution—reimbursing people for their expenses if the insurance company denied a claim that it should have paid
3. Financial penalties—paying appropriate financial penalties for noncompliance

Pennsylvania is a leader among regulators in its rigorous approach to evaluating mental health and substance use disorder treatment parity through market conduct exams.

Outreach Through Educational Videos for Consumers and Providers

All insurance is complicated—and it’s especially complex for mental health and substance use disorders, which are regulated by different laws that affect different types of coverage in different ways. For example, there are essential health benefits under the ACA that apply to individual plans and plans sold to small businesses but not plans sold to large businesses.

To guide consumers through the maze, Pennsylvania created a series of short, easy-to-understand videos. The videos are geared to consumers, but, to an even larger extent, to those helping consumers navigate the healthcare system, such as providers, advocates and local government officials.

Summary

There are three final points to remember when thinking about the efforts to end the opioid epidemic:

• There is significant work being done at the state level to improve patient outcomes and remove barriers to high-quality, evidence-based care for patients with an OUD.
• Effective solutions need to be comprehensive and systemwide.
• There is a lot more work to do to end the epidemic—and we must all work together to achieve that goal.