AmeriHealth Caritas Opioid Blueprint Demonstrates Benefits of Managed Care in Preventing and Combating Substance Use Disorders
Medicaid initiatives reduced opioid use by more than 25 percent in some of America's most challenged communities
AmeriHealth Caritas, a national leader in Medicaid managed care and other health care solutions for those most in need, announced today the impact of its proprietary Opioid Blueprint, a comprehensive, multipronged approach to preventing and combating substance use disorders.
From 2013-2017, the company saw in its Pennsylvania markets a 39 percent decrease in opioid prescription claims and a 38 percent increase in utilization of medication-assisted treatment (MAT). Across all of its markets from 2015-2017, the company continued to see a 26 percent drop in opioid use and a 12 percent jump in utilization of MAT — reducing the potential for substance use disorders and increasing the total number of members engaged in recovery. Additionally, AmeriHealth Caritas has seen a significant increase in the number of opioid users engaged through its integrated care management program and other wrap-around support services.
“AmeriHealth Caritas is driving improved health outcomes to some of the most challenged communities in the country,” said Dr. Andrea Gelzer, senior vice president, medical affairs for AmeriHealth Caritas. “This frontline approach and personalized interface have given us a deeper understanding of the opioid crisis and helped to fully inform the best practices in our blueprint that are leading to our successes.”
The AmeriHealth Caritas Opioid Blueprint has three core focuses: pharmacy interventions, provider support, and member engagement strategies. To date, the company’s successes have been driven by:
- Interventions at the time of dispensing aimed at appropriate duration and strength of prescribed opioid medications.
- Removal of prior authorization requirements to enhance access to many MAT therapies.
- Amplified care management of high-risk populations.
- Increased access to naloxone (Narcan).
- Effective interventions with members and providers to isolate and impact high usages.
Pharmacists are often the most accessible health care provider and can be a frequent point of contact between patients and the health care system. As a result, pharmacists play a critical role in helping health plans combat the opioid crisis because they can directly identify patients who may be abusing opioids and intervene to prevent further abuse. By offering more intensive coordination and educational tools for better prescribing, AmeriHealth Caritas is making inroads in preventing fraud, waste and abuse and progressively lowering maximum allowed dosing of opioid medications.
Key aspects of this approach include:
- Implementation of Centers for Disease Control and Prevention (CDC) and state prescribing guidelines: AmeriHealth Caritas has implemented recommended prescribing limits on day supply and maximal dosing allowed for members new to opioids in our markets.
- Analytics: The company’s data analytics capabilities are being optimized to identify inappropriate prescribing and utilization patterns. This process includes standardizing data reporting across the enterprise and responding to geographical data trends.
- Pharmacy lock-ins: In all of its jurisdictions, based on utilization patterns, AmeriHealth Caritas is identifying members receiving opioid prescriptions from multiple providers in order to maximize referrals to lock-in programs, which align patients to one specific pharmacy and prescriber to better monitor services and reduce inappropriate use of controlled substances.
“Our company keenly understands the importance of contributing to viable solutions to this crisis. Maximizing pharmacy lock-ins, using analytics to better understand the problem, and successfully working to decrease new starts are providing the right foundation for progress,” said Mesfin Tegenu, president of PerformRx, a pharmacy benefits management company wholly owned by AmeriHealth Caritas. “While we will continue to explore all avenues to help decrease opioid misuse in the nation, it will take a concentrated, holistic approach to successfully tackle this problem.”
Providers face the challenge of minimizing the potential for misuse of medications, while balancing a patient’s access to appropriate prescriptions and adequate pain control. New and comprehensive education pathways for providers, including alternate pain treatment modalities and cognitive support, along with identification of high-risk prescribing patterns are important to help stem the opioid crisis.
Key aspects of this approach include:
- Education: According to a 2011 study in the Journal of Pain, physicians receive just nine hours of training on properly prescribing medications while in medical school. AmeriHealth Caritas is ensuring access to comprehensive training programs for providers in our networks to promote evidence-based prescribing, as well as alternative therapeutic options for opioids.
- Systematic Analysis: AmeriHealth Caritas is also using data analytics to further identify predictive risk factors for prescribing and to more meaningful, effective and efficient conversations with our providers. The company uses data to proactively address patterns of overprescribing and clinically inappropriate utilization, and more importantly, make sure its provider networks are aware of the availability of care management resources, cognitive therapy support, in-network multidisciplinary pain centers, and covered non-opioid and alternative pain therapies.
- Expanding access to care: AmeriHealth Caritas is making comprehensive, multi-disciplinary addiction and recovery services more accessible to its members. The company partners with specialized treatment and recovery providers to expand access to evidence-based treatment and recovery services, thus increasing the likelihood of member success.
"One of the biggest challenges in fighting the opioid epidemic is increasing access to treatment for the disease of addiction,” said Gregory Marotta, CEO and president of CleanSlate, a pioneer and leader in outpatient addiction medicine. “CleanSlate is grateful for the active relationship with AmeriHealth Caritas to help us reach, educate and treat people who are in need of assistance. The strong support of AmeriHealth Caritas is the kind of alliance that helps save lives in communities across the country which have been hard-hit by this health crisis."
AmeriHealth Caritas encourages its members to make safe choices about opioids through its education materials and outreach. By raising awareness about prescription opioid misuse and overdose, the company helps members understand risk reduction strategies as well as available non-opioid treatment options. Additionally, AmeriHealth Caritas is optimizing its care management capabilities by proactively identifying and engaging at-risk members and wrapping them with intervention and follow-up services through its care management program. Nearly half of all opioid users in AmeriHealth Caritas’ member population have been impacted in some way by its integrated care management program.
Key aspects of this approach include:
- Engagement: AmeriHealth Caritas is actively engaging members who have been prescribed high-dose opioid therapy and tailoring personalized interventions and education efforts based on the member’s level of risk. The company is also making naloxone available to those who need it, and as a result, has seen naloxone use increase by 270 percent.
- Peer recovery specialists: AmeriHealth Caritas uses peer support specialists for several special populations, including pregnant women and very high utilizers of medical services. Peer support specialists provide face-to-face engagement with members in their communities and ongoing support.
- Specialized programs: AmeriHealth Caritas has enhanced the identification and intervention process for its Bright Start® maternity care management program, which provides comprehensive maternity care management services to reduce the incidence of pregnancy-related complications and improve birth outcomes. The company also offers specialized support services to members to address opioid use during pregnancy. AmeriHealth Caritas has seen maternal opioid pain medication use decrease over the course of a pregnancy by 11.2 percent.
“The collaboration between Crozer-Keystone Health System and AmeriHealth Caritas has resulted in a robust program that has improved the standard of care for an at-risk population in a meaningful and tangible way. Our goal is to provide support and education for pregnant women who may need substance use treatment options and community resources to deliver the best outcomes for the mother and her baby,” said chair and vice president of psychiatry and behavioral health, Crozer-Keystone Health System, Kevin P. Caputo, MD, FAPA.
The care of members remains at the heart of the AmeriHealth Caritas blueprint. As a national health care leader, the company will continue providing further insights on how it is working to improve health outcomes for members and making impacts in the communities where its associates live and work.