Medicaid and the opioid epidemic

While the opioid epidemic impacts individuals and communities throughout the country, regardless of socio-economic class, the impact seen within Medicaid programs is profound.

As the opioid epidemic presses on across the country, those who rely on Medicaid for coverage and access to health care are disproportionally impacted. In the June 2017 Medicaid and CHIP Payment and Access Commission (MACPAC) report on Medicaid and the Opioid Epidemic, MACPAC highlighted research that demonstrated individuals on Medicaid are prescribed opioids, develop dependency, overdose and are treated for opioid use disorder (OUD) at higher rates than those covered by other insurance.¹

Each individual comes to use opioids because of a unique set of circumstances and factors.

Across the country, states are looking for ways to slow and end the epidemic while also addressing the significant challenges of access and resource limitations. It is clear that no silver bullet exists. This complex societal challenge has taken a significant toll on individuals, families and communities — and its impacts will be felt for generations. Collaboration, partnership and innovation must be central to any approach that seeks to substantially address the opioid epidemic.

UnitedHealthcare Community & State efforts to address the opioid epidemic

Each individual comes to use opioids because of a unique set of circumstances and factors. While the specifics of the individuals’ journey to recovery is based on their particular situation, we recognize that a comprehensive strategy to combat the opioid epidemic must include components that support prevention, treatment, recovery and harm reduction.

Prevention

Our prevention efforts include education, prior authorization and monitoring activities. Throughout UnitedHealth Group, we are working to raise awareness and educate our members, our staff and our provider partners on appropriate use and disposal, warning signs and resources for treatment. We have also extensively leveraged prior authorization to change provider and pharmacy prescribing and dispensing patterns — implementing or enhancing requirements for authorization to certain medications while removing or reducing barriers where enhanced access to services are needed. Additionally, UnitedHealthcare has implemented several monitoring tools that support efforts to identify inappropriate prescribing and utilization patterns.

Treatment 

The foundation of our treatment efforts is a robust person-centered approach to care that integrates physical, behavioral and social services. Our care teams include behavioral health specialists — many of whom have experience working with individuals who have substance use disorders. While the care team represents an important component and a potential pathway to treatment, providing access to treatment – specifically Medication Assisted Therapy (MAT) – is essential. We have worked diligently to expand our MAT network and continue to develop strategies that build capacity to provide treatment and recovery supports.

Recovery 

Recovery services and supports is an essential piece to a comprehensive strategy for addressing the opioid epidemic. UnitedHealthcare has intensely focused on developing strategies that integrate care and overcome the social barriers that often stand in the way of improved outcomes. These efforts are critical to supporting individuals in recovery and helping them find stability and resiliency. The recovery journey is not monolithic so the strategies to support recovery should not be. Working with those who are in recovery, we leverage an array of evidence-based approaches to recovery supports.

Harm reduction 

Because the path to recovery and stability look different for everyone and because opioid use has impacts on families and communities, harm reduction needs to be considered as part of a comprehensive strategy. Our harm reduction strategies to date have primarily focused on collaborations that have been driven by community need and local collaborations. For example, in North Carolina UnitedHealthcare collaborated with the Greensboro Police Department, Walgreens, Triad Adult & Pediatric Medicine (FQHC) and a large church to host a Drug Take Back Day which collected over 100 lbs of medications.

For all markets, UnitedHealthcare leverages data analytics to identify individuals who may be at-risk for opioid dependency or misuse.

Robust use of data

Underpinning our strategy is the robust use of data to identify needs, target interventions and evaluate impact. For example, in states with integrated pharmacy benefits, UnitedHealthcare has established extensive monitoring and reporting processes to track and evaluate opioid prescriptions and fill rates. Our Chief Medical Officers and pharmacy leads leverage these reports to determine physicians, pharmacies and members that would benefit from outreach, education and support. Furthermore, we are committed to using this data to identify, investigate and terminate (when appropriate) top opioid prescribers in each market.

For all markets, UnitedHealthcare leverages data analytics to identify individuals who may be at-risk for opioid dependency or misuse. Building on the vast data resources across the commercial, employer, Medicare and Medicaid lines of businesses, we are identifying common conditions and utilization patterns that may not only indicate misuse, but signal potential for misuse.

Strategies that are regionally, culturally and clinically appropriate 

Through detailed exploration of prescribing patterns, done in partnership with Optum Labs, we are also exploring the regional differences contributing to the epidemic. These regional differences inform our provider and member education strategies as well as our local partnerships. The opioid epidemic is too large of an issue for any one organization to solve alone. For this reason, UnitedHealthcare is working in collaboration with organizations throughout the country to understand, develop and launch strategies that are regionally, culturally and clinically appropriate. From collaborations with other health plans on best practice sharing through organizations like the Institute for Medicaid Innovation, to on-site drug disposal events with community-based organizations, we seek to engage and enhance local efforts as part of our approach to providing comprehensive strategies to support our members and state partners in combating the challenges of the epidemic.

Medicaid covers 72 million Americans and nearly 50% of the births in the country.

Strategies that support pregnant women

Pregnant women who are using opioids represent a significant need and acute opportunity to reduce harm and improve outcomes for both mom and baby. They face a unique set of challenges and barriers as they seek treatment and recovery. For these reasons, we are working diligently to pilot, test and build strategies that support pregnant women. In addition, we are working closely with care providers and local organizations to ensure that our existing prenatal outreach efforts are enhanced to educate and reduce stigma that often makes the already difficult decision to seek treatment even more complex for pregnant women.

While we have made progress to prevent and treat opioid misuse, there is more work to be done. We have numerous initiatives underway as we continue to build an increasingly robust approach to addressing this complex and overwhelming epidemic. As we know, this is not an issue that can be solved with one approach or pilot. We must constantly seek to innovate, evaluate what works and be prepared to move forward as our knowledge and the epidemic evolves.

Considerations for states 

States across the country are working to leverage available tools, funding and support to help combat the opioid epidemic. Health plans and Medicaid contractors should be a significant partner in this work. To maximize the benefit of Medicaid managed care partners, we encourage states to:

• Integrate contracting for physical, behavioral and pharmacy benefits to leverage health plans in identifying at-risk individuals and getting those individuals the necessary supports, services and treatment.
• In lieu of integrated pharmacy benefits, provide health plans access to real time prescription utilization to perform analytics that identify at-risk behavior (e.g. individual taking prenatal vitamin and opioid) or utilization patterns that would indicate opioid use disorder (OUD). This data is also important for monitoring prescriber patterns necessary for managing provider network and education efforts.
• Explore using waiver authority to expand access to treatment for OUD inclusive of MAT and when appropriate in-patient treatment options. These benefits should be included as part of the contracted services offered by Medicaid managed care plans.
• Leverage prior authorization and prescribing guidelines that reinforce CDC recommendation and reduce the oversupply of prescription opioids.
• Establish or expand a Controlled Substances Reporting System to include cash purchase prescription data for health plans and state use in combating the opioid epidemic. For health plans, this will assist with developing interventions that capture prescription data that may not be billed through insurance.
• Explore alternative pain management treatments such as acupuncture and mind-body therapies. Coverage for new services will need to be carefully considered in the development of managed care capitation rates to ensure they are sufficiently funded.
• Require health plans to review data on provider prescribing and report outlier providers who do not follow prescribing guidelines for narcotics/opioids. This should be coupled with health plan flexibility to terminate providers from the network and network adequacy exceptions for provider terms based on opioid prescribing practices. Having real-time access to prescription and utilization patterns is a necessary tool for this activity to be conducted by the health plans.
• Remove any limits on number of members in prescriber lock-in models and lengthen the duration of enrollment in the program. Exploration of automatic lock-in policies would also be encouraged as a way to immediately trigger lock in for extreme situations. For example, auto lock-in post overdose for a pregnant mom with evidence of opioid and/ or narcotic prescription during pregnancy could constitute an extreme situation.

In addition to leveraging Medicaid health plans, State should begin or continue strong engagement strategies to impact the opioid epidemic by: 

• Working across agencies to leverage state resources and communication channels to educate the general public and providers on the dangers of opioids, proper handling and disposal of opioids. Working in partnership with medical and hospital associations to enhance public health and health delivery education on topics such as stigma associated with OUD, workforce development, evidence-based practice protocols for Medication Assisted Therapy (MAT), and emergency medicine education.
• Evaluate and educate on Good Samaritan laws to ensure there is sufficient safe harbor for reporting and that any real or perceived punitive damages for seeking help are removed.
• Create credentialing guidelines and certification for addiction counselor to be Medicaid certified providers and eliminate any licensure barriers to creating a sufficient work force in the state.

Our commitment

UnitedHealthcare Community & State is committed to improving the health and wellbeing of those we serve and our communities. We are committed to partnering with states and the federal government to combat the opioid epidemic through a comprehensive strategy that prevents misuse, treats addiction and supports recovery. We believe that this must be approached in a person-centered, trauma-informed, non-judgmental manner to foster long-term recovery and resiliency.