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By Sarah C. Threnhauser, MPA

Sometimes, our headlines seem strangely at odds with each other. I had that reaction when I read our recent coverage of two studies—One In Three Medicare Part D Beneficiaries Prescribed Opioids In 2017 and Over Half Of Adults With Opioid Use Disorder Report Criminal Justice Involvement. The quick summary: Medicare is paying $3.5 billion per year for opioid prescriptions and $347.6 million a year for medications to treat opioid addiction (see Updated Medicare Part D Opioid Drug Mapping Tool Unveiled); while at the same time, over half of people who develop an opioid use disorder end up involved with the criminal justice system. It’s an expensive use of resources all around.

First, a surprising new study showed that one in three Medicare Part D beneficiaries was prescribed opioids during 2017—14.1 million (31.2%) of the 45.2 million beneficiaries. About 460,000 beneficiaries (1.0% of all Medicare Part D beneficiaries in 2017) received high amounts of opioids, with a morphine equivalent dose (MED) of greater than 120 mg a day for at least three months (FYI, the Centers for Disease Control and Prevention recommends that the MED for people with chronic pain be no more than 90 mg per day). Other findings from the study are equally troubling. Approximately 4.6 million (10%) Part D beneficiaries received opioids continually for three months or more. And, the study was able to identify the proportion (a little less than 1%) of the 53,933 total Medicare prescribers with questionable opioid prescribing patterns, including prescribing for beneficiaries who appeared to be doctor shopping.

Certainly not every Medicare beneficiary receiving opioid medications will become addicted. But overprescribing opioids contributes to that condition. At the same time, beneficiaries using opioids for chronic pain conditions that are non-responsive to other interventions are concerned about policies that will limit their access to pain relief (see Medicare Is Cracking Down On Opioids. Doctors Fear Pain Patients Will Suffer and Pain Patients Beg FDA For More Options, Easier Access To Opioids). Using analytics to find the right balance and manage practice outliers is key (see Population Health Management In A Value-Based Market: Using Pharmacy Analytics To Increase Consumer Engagement & Improve Outcomes).

On the other hand, the second study, which showed the incredibly high proportion of adults with opioid use disorder that end up involved with the criminal justice system is not at all surprising. In 2016, about 51.7% of adults with opioid use disorder report a history of criminal justice involvement, compared to just 15.9% of adults with no opioid use who are involved in the criminal justice system (see Over Half Of Adults With Opioid Use Disorder Report Criminal Justice Involvement). This overlap of addiction and the criminal justice system will likely become greater with the growing number of states using involuntary commitment of opioid addiction (see our market intelligence report on the topic, Is Involuntary Commitment The Right Solution For The Opioid Crisis?) and with the recent court decision allowing incarceration of probationers for drug use (see Massachusetts Court Rules Defendants On Probation Can Be Jailed For Drug Relapse).

To address the alarming number of Medicare beneficiaries being prescribed opioids, the Centers for Medicare & Medicaid Services (CMS) has drafted new rules for Medicare Part D plans (see Advance Notice of Methodological Changes for Calendar Year (CY) 2019 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2019 Draft Call Letter). The pending policy changes include:

  1. Plans to cease paying for long-term, high-dose prescriptions
  2. Limiting initial opioid prescription fills for the treatment of acute pain to no more than a seven days’ supply
  3. Mandatory case management for Medicare beneficiaries considered ‘high risk’, defined as using high levels of opioids from multiple prescribers and pharmacies
  4. Real-time alerts to pharmacists about duplicative opioid therapy and concurrent use of opioids and benzodiazepines
  5. Use of a new Pharmacy Quality Alliance (PQA) performance measure: Concurrent Use of Opioids and Benzodiazepines

What do these pending changes mean for service provider organizations? Payers and their health plans are looking for actions to curb the misuse of opioids and for low-cost, long-term treatment and maintenance programs for opioid addiction. And, given the high rate of involvement with the criminal justice system, it seems likely that the “high value” treatment program will need to address to criminal justice involvement as part of the care management plan.

For more resource on addiction and opioids, check out these resources in the OPEN MINDS Industry Library:

  1. BCBS Reports Decrease In Member Opioid Prescriptions
  2. San Francisco Creates ‘Street’ Public Health Team To Offer Medication Assisted Treatment
  3. CMS Clarifies Funding Streams For Opioid-Related HIT
  4. Kenton County Detention Center Partners With Aetna, Betty Ford Foundation For Treatment, Re-Entry Program
  5. Pennsylvania’s City of Philadelphia Seeks Naloxone Distribution Services
  6. Opioid Use In Medicare Part D Remains Concerning
  8. An Update On States With Medicaid 1115 Waivers For Addiction Treatment
  9. The Stigma Of Addiction Treatment Medication
  10. The State ‘Crazy Quilt’ Of Opioid Treatment Policy

For more on tracking changes in the market, join me on September 20 at The 2018 OPEN MINDS Executive Leadership Retreat for my session, Leadership Lesson #1 – Don’t Be Surprised!

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