An Opioid Overutilization Management Program uses state-of-the-art data mining and targeted case management to reduce opioid claims.

  • The program works by having trained pharmacists interact with prescribers, plan members, and pharmacies to facilitate members’ pain management.
  • The overarching goal is to facilitate appropriate care coordination.
  • The program mines data from pharmacy and medical claims, looking for members who have had repeated ED visits and who had an opioid overdose diagnosis within the last 24 months.

Healthcare organizations could learn a great deal about developing an opioid management program by following some of the best practices created as a result of the federal Medicare mandate for health plan sponsors.

For example, Anthem’s Opioid Overutilization Management Program has state-of-the-art data mining and targeted case management to address opioid dependency. As a result, it has successfully reduced opioid claims, and expects also to reduce ED visits by opioid-dependent plan members.

“While we have seen a reduction in opioid claims in our case management population, we are still evaluating the impact of case management on overdose and ED visits,” says Devanshi Sheri, PharmD, BCGP, a clinical pharmacist who leads the Anthem program.

“We feel that we have seen such a positive success rate due to two main reasons: We are always trying to understand our members better by incorporating as much information as we can, and our case management is completed by trained pharmacists who interact with the prescribers, members, and pharmacies to facilitate the member’s pain management,” Sheri says. “The most important goal is to facilitate appropriate care coordination.”

The following is how Anthem’s opioid management program works:

Collect good data. Intricate data mining is the key component to why the program has been successful and remains adaptable, Sheri says.

“We have a good analysis for identifying our members,” she explains. “We use pharmacy claims to extract information about members who meet preset criteria for what we define as overutilization.”

The program mines data from pharmacy and medical claims, looking for members who have had an opioid overdose diagnosis within the last 24 months. Another red flag is repeated ED visits.

“It’s picture-building,” Sheri says. “The more we know about the member, the better we can understand the member’s pain needs and take the appropriate course of action.” Data about health plan members who are identified as having an opioid dependency issue go to the case management program.

Refer members to case management. “We have a responsibility to our patients and are taking these steps to keep them safe,” Sheri says. “We give their providers as much information as we can.”

The case management program is pharmacist-driven. Pharmacists contact ER doctors, orthopedists, pain specialists, dentists, and other prescribers.

“We identify the decision-maker who is making pain management decisions for this patient,” Sheri says. “We want to understand if there’s been diversion or abuse or mismanagement. We inform prescribers of all other opioid claims the member has in a given time frame that the prescriber might not be aware of.”

For example, the plan member’s pain specialist might not be aware that the person is going to the ED once a month to supplement medicine the pain specialist prescribed.

The program’s pharmacists call physician offices until they receive a return call. Their phone script typically is, “Hi, I’m a pharmacist and I’ve been working with your patient. We’ve done a utilization review, and we see that the member has seen a number of doctors and pharmacists and had these ER visits,” Sheri says.

“We give doctors information about whether the patient is taking non-narcotics as well, and we answer their questions,” she adds. “We find out if there is a diagnosis that needs to be treated with pain medication, and we let them know that these are some courses of action we can take.”

Pharmacists ask physicians what course of action they would like to take, including the option of monitoring patients or placing a medication restriction if patients pose a threat to themselves.

Once confronted with data about their patients, physicians usually change the prescription to one with more limited quantity and renewals. They’re more aggressive and aware than they were before they were contacted through the program, Sheri says.

The case management program works closely with behavioral health experts, nurses, clinicians, and others at Anthem.

“We’ve had compassionate interview training, and we also work closely with behavioral health case managers who listen in on calls,” Sheri says. “We use their experience and guidance.”

Limit at-risk members’ access to opioid prescriptions. Each opioid dependence case is unique, Sheri notes.

“We have a standard operating procedure, letters, and protocols, and it all builds into our making a final decision about that member,” she says. “Should we limit the member at point of sale?”

A member could be fully restricted from opioid prescriptions, meaning the member is cut off from the prescriptions and referred to opioid addiction therapy. This is only done to stop opioid use for the patient’s safety, she says.

The program sends members a decision letter, stating what is happening — whether monitoring or restricted access to opioids — and, sometimes, referring them to a behavioral health program.

“The pharmacist will call the member, saying, ‘You have this medical benefit through your health plan for substance use disorder treatment,” Sheri says. “Our pharmacists are trained to be very sensitive, with the goal of opening members’ minds to the possibility of enrolling in a medication-assisted treatment program.”

The case management program pharmacist opens the communication channel by introducing the behavioral health program, and then it’s up to members to decide whether to enroll.

“CMS has included this point-of-sale drug-level restriction as a key tool in the Opioid DUR [drug utilization review] mandate,” Sheri explains. “We can stop the purchase of the opioid at the time of sale, denying payment for the prescription. The pharmacy gets a point of sale rejection, informing them that the member’s access to the opioid medication is restricted and will not be paid for through the plan benefit.”

But this step is limited in its effectiveness because members might access opioids on a cash basis — meaning their prescription is not picked up in the health plan sponsor’s claims data. Or, the person could be using illegally obtained opioids.

“That’s one of the largest roadblocks, as an industry, in managing this epidemic,” Sheri says.

Often, the plan is to educate members about opioid dependence and to continue to monitor them to see if they have cut back on their opioid use.

“We give the member an opportunity for behavioral change for six months,” she says. “On the seventh month, we re-review the case against the same criteria. If the member doesn’t meet the threshold criteria, we know that the overuse is resolving.”

So far, the plan is working well, she says.

“We have seen over the course of the past few years that members are inclined to change their behavior when their pain management needs are better coordinated,” Sheri says.