According to a CDC report published on October 21, 2016, during the first three years after Blue Cross Blue Shield of Massachusetts (BCBSMA) implemented a new prescription opioid utilization policy, the average monthly prescribing rate for opioids decreased almost 15%, from 34 per 1,000 members to 29.
Overdose deaths involving opioid pain medications are an epidemic in the United States, in part because of high opioid prescribing rates and associated abuse of these drugs. In 2014, nearly two million U.S. residents either abused or were dependent on prescription opioids. In Massachusetts, unintentional opioid-related overdose deaths, including deaths involving heroin, increased 45% from 2012 to 2013. In 2014, the rate of these deaths reached 20.0 per 100,000, nearly 2.5 times higher than the U.S. rate overall.
On July 1, 2012, Blue Cross Blue Shield of Massachusetts (BCBSMA), the largest insurer in the state with approximately 2.8 million members, implemented a comprehensive opioid utilization program after learning that many of its members were receiving new prescriptions with a greater than 30-day supply of opioids. This program included treatment plans, risk assessments, patient-provider agreements, requirements for dispensing from a single pharmacy, prior authorizations, quantity limits and a ban on mail-order opioid prescriptions.
The CDC analyzed BCBSMA prescription claims data for the period 2011 to 2015 to assess the effect of the new utilization program on opioid prescribing rates. During the first three years after policy implementation, the average monthly prescribing rate for opioids decreased almost 15%, from 34 per 1,000 members to 29. The percentage of BCBSMA members per month with current opioid prescriptions also declined.
The temporal association between implementation of the program and statistically significant declines in both prescribing rates and the proportion of members using opioids suggests that the BCBSMA initiative played a role in reducing the use of prescription opioids among its members. Public and private insurers in the United States could benefit from developing their own best practices for prescription opioid utilization that ensure accessible pain care, while reducing the risk for dependence and abuse associated with these drugs.
In 2012, BCBSMA analyzed its 2011 pharmacy claims data to determine the number of members receiving large quantities of opioid prescriptions from multiple providers. In 2011, approximately 30,000 members received new prescriptions of short-acting opioids with a greater than 30-day supply; 25% of these members obtained opioid prescriptions from multiple providers. BCBSMA’s opioid utilization program was developed collaboratively among an extensive network of stakeholders, including physicians, nurses, pharmacists, actuaries, lawyers, data analysts, medical societies, medical and pharmacy boards, the Massachusetts Pain Initiative, and the top 10 opioid-dispensing pharmacies in Massachusetts.
The BCBSMA prescription opioid utilization program was designed around expert-defined best practices for opioid prescribing that include formal agreements between patient and provider, a requirement for BCBSMA approval prior to dispensing new opioid prescriptions, and quantity limits. The program requires providers to conduct a risk assessment for abuse that the patient must sign. Physicians and patients work together to develop a treatment plan that considers options other than prescription opioids. When the decision to prescribe opioids is made, a formal agreement between patient and prescriber outlines specific behaviors expected of both parties. In addition, the prescriber must provide a diagnosis and rationale for prescribing an opiate as part of the prior authorization process. BCBSMA coverage requires prior authorization (including review by a BCBSMA clinician who then notifies the pharmacy) before dispensing new short-acting opioid prescriptions with a greater than 30-day supply and for all new long-acting opioid prescriptions. Pharmacy mail orders are not permitted. If opioid misuse is suspected or if coordination of care among multiple providers is indicated, patients might be assigned a single pharmacy to dispense all opioid prescriptions. Identified patients with chronic pain are referred to case managers who advise on non-opioid therapies. Oncology patients and terminally ill persons are exempt from the requirements for prior authorization for new prescriptions. Members continue to have coverage for physical therapy, pain management, addiction treatment, chiropractic services, and cognitive behavioral therapy.
An average of 1.5 million commercial members with pharmacy benefits were enrolled in BCBSMA each month during the study period. The average monthly prescribing rate for all opioids decreased 14.7%, from 34 per 1,000 before implementation of the program to 29 after implementation. Although the average monthly prescribing rates for long-acting opioids remained constant at three per 1,000 members before and after program implementation periods, the average monthly prescribing rate for short-acting opioids decreased 16.1%, from 31 to 26 per 1,000 members. Similarly, while the percentage of all members with a long-acting opioid prescription decreased 8.3%, from 0.24% per month to 0.22%, the percentage of members with short-acting opioid prescriptions decreased 12.9%, from 2.49% per month to 2.17% after program implementation. The number of members with cancer diagnoses was not available to calculate opioid prescribing rates. However, the average monthly number of opioid prescriptions dispensed to members with cancer diagnoses declined 9% following program implementation, which was less than among all members.
Results of the interrupted time series analysis showed a 6%–9% annual decline in the percentage of members on short-acting and long-acting opioid prescriptions and in opioid prescribing rates after implementation of the opioid utilization program compared with the pre-implementation period. All differences were statistically significant, regardless of medication type. Overall, the estimated quantity of opioids dispensed before and after implementation of the program indicate that approximately 21 million fewer opioid doses were dispensed in the first three years after implementation.
After implementation of the opioid utilization program in July 2012, the number of opioid prescriptions and the percentage of members with an opioid prescription significantly decreased among BCBSMA members. However, it is possible that other events, such as changes in policies and media coverage, contributed to the decline. Although the declines in average monthly prescribing rate and the percentage of BCBSMA members with opioid prescriptions appear modest, these data represent significant changes for a 2.8 million-member health plan. The decreases in dispensed opioids were highest for short-acting opioids, which also account for most of the opioid prescriptions.
Although oncology patients were exempt from prior authorization requirements for new prescription opioids, the number of opioid prescriptions also declined among these patients following program implementation. Insurers frequently observe a sentinel effect following a new drug utilization program in which provider behaviors extend to their entire patient populations. Effective management of pain is a core component of quality end-of-life care and care for patients with serious advanced illness. To avoid unintentionally limiting access to pain medication for these patients, insurers can evaluate how policies affect this population to ensure that comprehensive care addresses their specific needs, including pain management. Data are not available on the impact of the decrease in prescribing among BCBSMA oncology patients on their pain management and functioning. However, in the four years since program launch, the only appeal of a claim related to the insurer’s policy resulted from a clerical error, suggesting that these members continue to receive medically appropriate access to pain medication.
State and federal initiatives to address the opioid epidemic in the United States have been implemented in the past several years, with some resulting in reduced opioid prescribing. The U.S. Department of Health and Human Services initiative targets three priority areas: improving opioid prescribing practices, distribution of naloxone to reverse overdoses, and access to medication-assisted treatment. The significant decrease in dispensing of opioids immediately after the implementation of the BCBSMA opioid utilization program suggests that this intervention played a role in the reduction of the observed monthly prescription rate. As part of quality improvement efforts, public and private insurers can implement policies that promote best practices in opioid prescribing to reduce risk among their members while ensuring access to appropriate pain management. The CDC Guideline for Prescribing Opioids for Chronic Pain, released March 2016, supports this effort and provides a comprehensive list of recommendations that can inform insurer opioid utilization programs and policies.
See the CDC Report
See also Medical Law Perspectives, September 2015 Report: Arthritis Pain and Inflammation: Diagnosis and Treatment Risks
See also Medical Law Perspectives, October 2014 Report: Backaches and Court Battles: When Chronic Back Pain Leads to Litigation
See also Medical Law Perspectives, January 2014 Report: Prescription Painkillers: Risks for Patients, Pharmacists, and Physicians
See the Medical Law Perspectives February 16, 2015, Blog: Pharmacy Owes Duty To Patient Not To Fill Excessive Prescriptions for Opioids
See the Medical Law Perspectives October 8, 2014, Blog: Opioid Pain Pill Abusers Switch to Heroin; Heroin Overdose Deaths Double