2019 Year in Preview

Why the new opioid bill won’t really change the way insurers approach the epidemic

Which is not to say that health plans will not attempt some innovative things on their own. One such innovation: an addiction recovery medical home.

Frank Diamond
Managing Editor

The big development in fighting the opioid crisis in 2018 was the massive Support for Patients and Communities Act signed into law by President Trump on October 24. Eric Bailly, the business solutions director at Anthem who oversees that insurer’s substance abuse program, says that the law probably won’t “have a dramatic impact on our continued strategies.” He adds: “The legislation helps solidify many of our current strategies, such as support for expanding the use of telehealth for comprehensive medication assisted treatment.”

Keith Humphreys, drug policy expert at Stanford University, notes that the law’s payer policy changes focus mostly on Medicaid and Medicare, although commercial health plans will be more closely monitored on how well they provide mental health parity.

The emphasis in 2019 will be on early intervention and increasing access to nonopioid treatments, but that’s a continuation of what plans have been doing for the last few years.

There’s a lot to like about the bill, says Kate Berry, AHIP’s senior vice president of clinical affairs, including provisions that make telehealth more flexible. That could conceivably lead to telehealth counseling sessions with substance use disorder (SUD) patients that allows for them to better avoid the stigma of addiction. But, again, just how that will work on the ground is still unknown.

“This is fairly new, right?” asks Berry.


It’s no mystery why the law garnered bipartisan support. Although the number of overall drug overdose deaths seems to have (arguably) gone down in 2017, the number of deaths from opioids laced with fentanyl actually increased, from about 29,000 in 2017 to a projected 30,000 in 2018. The National Institute on Drug Abuse says that there were 49,068 opioid deaths in 2017. It’s a huge problem and will remain one for some time.

National overdose deaths

Number of deaths involving opioids

*2017 data are provisional

Source: National Institute on Drug Abuse

Berry likes the way the legislation cracks down on so-called sober homes, which are supposed to be safe places for people who are addicted and who want to get their lives back on track. Instead, HHS investigators have found that many of them take advantage of vulnerable patients and make their drug-related and other problems worse.

Credible allegations of fraud

She also likes that the law allows suspension of payment for prescription drugs in Medicare Advantage and Part D when the dispensers are being investigated for credible allegations of fraud.

Insurers can also better monitor opioid prescribing for things like lower back pain. “We’re looking at other kinds of treatment for that,” says Berry.

For the most part, though, health plans in 2019 will continue to do what they did in 2018, which is to investigate innovative approaches to dealing with the problem. One such approach is an addiction recovery medical home model developed by the Alliance for Recovery-Centered Addiction Services. Anthem’s a member, and so are some other heavy hitters such as Leavitt Partners and the National Council on Alcoholism and Drug Dependence. The model includes bundled payments and performance bonuses, nationally recognized quality metrics, and the placement of treatment and recovery providers close to where SUD patients live.

“Going into 2019, it’s our intent to launch at least one, if not several, pilots within our Anthem markets, to give this a shot, and to take a look and see if we can make this work,” says Bailly at Anthem.

Meanwhile there’s the opioid legislation. Health insurers are still sorting through its ramifications.

“We are partnering with others in the Blue Cross Blue Shield Association to really take a look at what’s been passed and what wasn’t,” says Bailly.

Some of the main provisions include cracking down on mailed shipments of drugs like fentanyl. It also provides more inpatient treatment beds, allowing payments for Medicaid beneficiaries for five years. In addition, it frees up money for demonstration medication assistance programs, a crucial step, many in the medical community believe.

However, the law doesn’t give health plans access to information in state-run prescription drug monitoring programs (PDMPs). “Allowing health plans access to PDMP data would help existing PDMPs reach full potential for efficacy in addressing opioid misuse,” says Bailly.

Berry at AHIP points to privacy concerns and “a lack of understanding by many about why patients can benefit from plans having access to this data and what plans do with it,” as a couple of the reasons that health plans can’t so far convince policy makers to let plans get a hold of PDMP data.

Even when states have recognized the benefit of plans having access to such data, technical barriers on granting optimal access remain, says Berry. “We strongly advocate for policy that will allow integrating of the PDMP data with claims data to give a more complete picture of people’s controlled substances prescriptions,” says Berry.

What about utilization management?

What to do about utilization management seems to also have been left unaddressed. A study in June in JAMA Network Open that looked at opioid prescribing in Medicaid, Medicare Advantage, and commercial insurance plans garnered some headlines because it concluded that those plans rely too heavily on utilization management that excludes non-pharmaceutical treatments for pain.

Kate Berry

“The CDC opioid prescribing guidelines that were released a few years ago say that opioids should not be the first thing that you try for pain,” says AHIP’s Kate Berry.

Berry counters that nearly all insurers cover, for instance, chiropractic and physical therapy. “But this is a really complex area,” she adds. “The evidence is limited for some of those other types of care. There are not a lot of studies that say what type of treatment works best for what type of pain.”

Berry hopes that real-world evidence might step into the void where, so far at least, clinical studies have not ventured. “A lot of work needs to be done; we don’t really have a consensus on how to measure pain,” says Berry. “Patients might have high expectations to be pain free and that may not always be the realistic answer.”

Cultural change has to accompany changes in treatment. It is far easier to pick up a prescription than it is to go to six or eight physical therapy appointments, Berry observes. Patients need to be educated about the different options for pain relief.

“The CDC opioid prescribing guidelines that were released a few years ago say that opioids should not be the first thing that you try for pain,” says Berry. “Sometimes stretching and other kinds of things can be just as effective.”

Or ibuprofen, says Berry—something found in every drug store in America.

She sees health plan benefit design and utilization management in 2019 evolving as more is learned about approaches to pain management. Health plans will continue to struggle to strike the right balance, says Berry. “We don’t want patients to go without treatment for pain. We don’t want them to be in danger of addiction.”

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