With the CDC reporting over 47,000 U.S. deaths due to opioid overdoses in 2017, opioid addiction has become a crisis on a massive scale. It can only be effectively tackled if all stakeholders, from government to pharma, adopt ambitious plans to combat the problem – and that includes health insurance companies.

Withholding Drugs and Providing Treatment

Much of the focus of health insurance companies’ responsibility in stopping opioid abuse has been on their role as gatekeepers. Insurers are increasingly pressured to make certain that patients aren’t able to keep getting access to these highly addictive drugs. This can be done by looking over claims and flagging ones that appear to show evidence of opioid misuse. At that point, the insurance company can either get in touch with the prescribing physician or start denying the claims. 

Some public health experts, however, feel that the health insurance industry should concentrate its efforts on ensuring that opioid addicts can get the professional help they need. In an article in Medical Xpress, Theresa Kreif explains that insurance coverage for addiction treatment during health insurance enrollment is key to stopping opioid deaths and that a lack of insurance coverage is the main determining factor for people who want treatment but don’t get it. 

How Health Insurers Are Helping Their Members

Nerd Wallet published an overview of which steps some of the major health insurance companies are taking to do their part in the fight against opioid abuse, and they found that Aetna, Anthem, Cigna, Humana, Kaiser Permanente, and UnitedHealth Group were all reviewing claims for signs of misuse. All but one (Humana) had also stopped requiring a prior authorization for addiction treatment, which is an important step in making it easier for addicts to get help urgently. Some companies are also requiring prior authorization for opioid prescriptions as a way of monitoring potential abuse. You can also contact a drug addiction help hotline for more information.

Last year, Blue Cross Blue Shield (BCBS) issued a report finding that 241,900 of its members suffered from opioid use disorder. The company has been working to reduce opioid abuse by following CDC guidelines and curbing inappropriate opioid prescriptions, as well as through other initiatives. For example, BCBS of Western New York helps families in addiction recovery with the House of Hope program and BCBS of Michigan sends at-risk patients to an in-network behavior health partner via is Opioid Overdose Monitoring Pilot.   

Many insurers have also adopted pharmacy “lock in” programs, which are a way of stopping opioid users from going around from doctor to doctor to get new prescriptions for opioids. Typically, payment records are used to identify these individuals, at which point they will be locked into only being able to get the prescription via one physician or pharmacy to prevent abuse.

Medicaid has an especially significant role in the battle against opioid addiction in the U.S., given that it covers four out of 10 (non-elderly) adults suffering from opioid addiction. A Kaiser Family Foundation report notes that, “Medicaid facilitates access to treatment by covering numerous inpatient and outpatient treatment services, as well as medications prescribed as part of medication-assisted treatment.” And the expansion of Medicaid, due to the Affordable Care Act, has also helped bring treatment to more opioid users. 

Insurance Companies Working Together to Fight Addiction

The Substance Use Disorder Treatment Task Force was able to bring 16 healthcare payers together (including the nation’s six largest) to adopt “National Principles of Care” in the treatment of addiction. Collectively covering nearly 250 million people, the list of companies includes Aetna, AmeriHealth Caritas Family of Companies, Anthem, Inc., Beacon Health Options, Blue Cross Blue Shield of Massachusetts, CareOregon, CareSource, Centene Corporation, Cigna, Commonwealth Care Alliance, Envolve Health, Horizon Blue Cross Blue Shield of New Jersey, Magellan Health, UnitedHealth Group, UPMC Insurance Division, and WellCare.

The agreed-to principles (explained in greater detail here) are:

• Universal screening for substance use disorders across medical care settings
• Personalized diagnosis, assessment, and treatment planning
• Rapid access to appropriate Substance Use Disorder care
• Engagement in continuing long-term outpatient care with monitoring and adjustments to treatment
• Concurrent, coordinated care for physical and mental illness
• Access to fully trained and accredited behavioral health professionals
• Access to FDA-approved medications
• Access to non-medical recovery support services

In a statement, the founder of the task force and CEO of Shatterproof, Gary Mendell, said, “For the first time in history, leading healthcare insurers and other third-party payers from across our nation have come together and agreed to identify, promote, and reward one core set of evidence-based principles for addiction treatment. Payers will now begin to establish an accountability process that will systemically change and significantly improve the way that treatment for addiction is delivered in our country.”

Innovating and Discovering New Ways to Reach Out

As a part of its commitment to combating addiction, one of the members of that alliance, Centene Corporation, announced that its clinical leadership team developed the OpiEnd™ program. “OpiEnd utilizes Centene’s proprietary business intelligence tools to identify at-risk members for potential opioid misuse,” the company stated. “This proactive approach employs early intervention to prevent opioid misuse and, ultimately, to save lives, one member at a time.” Innovative measures like this, utilizing technology tools, will make a considerable difference in how health insurance companies are able to deal with the challenges of opioid addiction.

Telehealth and telemedicine services are a potentially promising avenue for fighting the widespread opioid crisis as well, and they will receive more support thanks to a new bill, recently signed into law. Eric Wicklund of mHealth Intelligence reports that the legislation includes “provisions to improve Medicare reimbursement for telehealth programs and support an innovative telemedicine-based program that trains rural and remote healthcare providers on how to treat patients with substance abuse and mental health issues.” He also notes that the bill includes other provisions that will utilize connected care platforms to bring treatment to underserved populations.  

Tackling a Complex Problem

The opioid crisis undoubtedly represents one of the greatest healthcare challenges of our time. The amount of destruction that this powerful addiction has wrought, and the number of lives it has taken, has still not been fully understood. But health insurers are recognizing the breadth and depth of the tragedy and taking steps to reduce its damage.

The solutions themselves can be complicated, though. Some critics worry that by trying to crack down on opioid prescriptions, insurance companies are penalizing people who are in great pain and genuinely need these drugs. And some of the measures being taken by insurers might actually make it harder for patients to get access to drugs that are used to treat opioid addiction, like buprenorphine.

As health insurance companies continue to develop their efforts to reduce opioid abuse and save lives, it will be important to share insights with competitors, work on innovative solutions, get regular feedback from medical professionals and patients, and continue improving policies and measures designed to help bring this deadly crisis to an end.