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The Opioid Crisis and your Health Plan

Tuesday, December 5, 2017
The Opioid Crisis and your Health Plan
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Authored by Fred Garfield, CEBS, CFP®, CHFC, CLU, RHU

In a recent federal study, the opioid crisis in the United States deeply affects our economy by as much as $500 million annually.  This represents a six-fold increase in cost over just the past five years.  

The number of opioid painkillers prescribed in the U.S. actually peaked in 2010 and has slightly declined each year through 2015, according to the Centers for Disease Control.  However, the CDC also said in July that opioid drugs are still being prescribed about three times more than they were in 1999. 

An analysis published this week by OM1 Inc., a company that uses artificial intelligence to improve health outcomes, found that in the second quarter of 2017, one out of every six emergency room visit in the U.S. was opioid-related.  According to the National Institute on Drug Abuse, more than 33,000 Americans died from opioid overdoses in 2015.  Most of those deaths were linked to prescription pain pills, though the use of heroin was already growing rapidly, accounting for almost 13,000 fatalities that year.

One common starting point stands out – the prescribing and use of narcotic painkillers through employer-sponsored and financially subsidized medical plans.  Although managing chronic conditions such as diabetes and expensive specialty drugs are common significant emergent financial concerns, it is shocking to see this class of opioid medications consistently listed in the top five therapeutic drug cost categories on many of our health plans.

Our employer health plans, while protected under HIPAA, are becoming a large part of the problem.  Medication prescribing by physicians is often well intended, and necessary palliative care for their patients, but often poorly managed and supervised.  Prescribed pain management related to employee injuries under workers compensation complicates this.

Inappropriate and extended prescribing of these medications can result in serious addiction and performance risks, leading some to use illegal replacement drugs such as heroin.  Our pharmacy claim reporting shows that many of these medications can fall into the wrong hands, as we often see opioid abuse in “households” as a common outcome.

Every plan member who is under the influence of opioid medications is a potential risk to themselves and others.  In this regard, “OSHA tops HIPAA” on the legal, workplace safety, and financial obligations of the employer.

Employees under the influence are a risk to others in the workplace and to the property of the employer.  This is especially critical if they operate machinery; drive forklifts, trucks or other vehicles; or handle critical engineering, operational or financial activities on behalf of your company.  Use of these medications can also increase employee theft and/or fraud.  OSHA has made it critical in many occupations to identify and intervene as needed if employees are under the effects of drugs at the workplace.

In light of updated FDA recommendations, we are suggesting that plan sponsors confirm PBM policies or require they make changes to their self-funded prescription drug plans related to opioid prescribing:

1.    Supply Limits:  We recommend imposing a 7-day maximum supply limit for any new prescriptions related to acute care, especially any time a member is not in any maintenance program.  A physician can submit a prior authorization should the need require more than a 7-day limit.  This policy should also be applied to transdermal immediate-release fentanyl products.

2.    Dosage Strength Limitations:  We recommend that any opioid or morphine equivalent prescription be limited to no more than 90 milligrams without a medically appropriate prior authorization being approved for their physician.  Some pharmacy benefit managers currently apply a 47 milligram per dose limitation without prior outside validation.

3.    Step Therapy and Extended Release:  We recommend the use of “immediate release” formulas for any pain management needs before allowing a patient – through prior authorization – to move to any “extended release” form of a medication.  Extended-release medications tend to have a significantly higher addiction risk than normal immediate release forms of these drugs.

4.    Reporting Requirements: For OSHA compliance, detailed reporting at least annually to confirm plan members who are on opioid medications to verify they are medically compliant, and if necessary, reassign them to positions that are not a risk to themselves or others.  

5.    Special Investigations and Pharmacy Audits:  Confirm your PBM has active fraud detection, investigation, and prevention services.  Confirm they audit to identify or prevent members who are accessing multiple physicians and/or pharmacies to obtain opioid or narcotic medications, or control distribution through a limited, specific distribution process.  This reduces waste and potential abuse of these medications.

6. Pharmacy “Soft Edits”:  Point-of-sale automated checks should be available to alert a pharmacist of any potential inappropriate use or medical contradictions before the medication is dispensed.  Examples of this include duplicate therapies, dosage or duration issues, use by pregnant women or members on other psychotherapeutic medications, and potential toxicity risks.  This would include catching prescriptions that are outside of the normal supply limits, excessive dosage limitations, or use of inappropriate extended-release drugs.  

Finally, we recognize it is our sincere responsibility to help manage the benefits and overall costs of a health plan, and inform plan sponsors where concerns arise, to assure that their programs will remain sustainable and affordable.  

We also must respect the overall health of the member and keep them in the highest regard, knowing well that in some cases – such as with potential abuse of opioid medications – the treatment may actually be worse than the cure.

Material posted on this website is for informational purposes only and does not constitute a legal opinion or medical advice. Contact your legal representative or medical professional for information specific to your legal or medical needs.

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