Ben Franklin, arguably the most famous resident of Philadelphia, said in 1736, “An ounce of prevention is worth a pound of cure.” Today, Independence Blue Cross—which serves Philadelphia and four surrounding counties—is heeding Franklin’s advice.
More than 2,000 Independence members died due to opioid overdose between 2016 and 2017. But through collaboration and a series of evidence-based strategies, the insurer is working to keep opioids out of its members’ hands, and to get those who suffer from opioid use disorder currently into treatment.
To understand what Independence is doing within the Philadelphia area and as a member of the Blue Cross Blue Shield Association (BCBSA), FierceHealthcare spoke with Rich Snyder, M.D., chief medical officer of Independence Blue Cross, and Kim Holland, vice president of state affairs at BCBSA.
FierceHealthcare: What distinguishes the opioid crisis in the Philadelphia area from other regions of the country?
Rich Snyder: Historically, Philadelphia is a multigenerational heroin-using city, with many families where grandparents, parents and kids are all using. The ties are particularly strong with South America, and that’s where the purest heroin comes from. Heroin purity in Philadelphia runs around 65% to 70%, which is much stronger than most places—so strong that it can often be snorted and/or put into pill form and result in a high. It’s also one of the cheapest cities in the country where you can buy heroin.
Other than that, I think the issues we face are similar.
FH: Have you targeted your efforts differently in the city of Philadelphia versus the surrounding suburban counties?
RS: About 500 deaths occurred in the surrounding four counties. We’ve geomapped the deaths in Philadelphia—not only to where people died or where they were found, but where they were from. About 20 to 25% of the deaths in Philadelphia County are from people that live in surrounding counties who came to Philadelphia to get their drugs.
When you try to alert people that there’s a dangerous substance on the street, it has the unintended consequence of people wanting to get their hands on it because it’s so strong. To get a bigger, better fix, they rush to buy this stuff. We’ve actually refrained from notifying people in this sort of usual, mass-media, social media approach.
FH: How many of your members used prescription opioids at peak?
RS: From my work on the mayor’s task force, we believe there were 55,000 heroin users in the Philadelphia region in 2016, and another 55,000 who abused prescription opioids purchased on the street. But we don’t really know what the numbers are. These numbers are based on how many drugs were interdicted, how many people were overdosing, and so on.
FH: Can you talk more about your work with the mayor’s task force and how that ties into what you’ve done with Independence?
RS: They’re definitely linked. We all knew this was happening. We saw the crisis. There’s a long history, dating back to 1986, when the American Pain Society said we should treat pain as the fifth vital sign. From there, the cascade of events that led us down this path. I think it reached a crescendo over the past few years.
Philadelphia’s mayor pulled together a multidisciplinary task force, including law enforcement, legislators, regulators, providers, health plans—I was the health plan representative—and acute care hospital systems who treat the opioid overdoses. We worked together to understand what was going on, and then at potential solutions.
After hearing a number of stories from relatively young people, I told our head of pharmacy, “Look, I’m really distressed. I want to put a five-day, 90-MED limit on as fast as we can get it on.” We got it in place by July 1, 2017, and in that second half of the year, 25,000 fewer people—22% fewer members—got prescriptions for opioids.
FH: How did physicians respond to that?
RS: The physician response was positive. I got a lot of calls from physicians that I thought would give me a hard time, but said “thank you for putting the target on your back. I didn’t really want to prescribe the drugs, but that’s what people expect, and I didn’t want to expect my patients.” It gave them an out.
FH: Have you done anything to make opioid use disorder treatment more accessible to patients?
RS: We eliminated cost-sharing for rescue medications to the extent that we can. We can’t waive deductibles by law, but after patients exceed their deductibles, they can get them for free, and we eliminated the copay part. We also went public saying we will cover methadone, and we have quite a few patients on methadone now who prefer that to MAT in another form.
FH: What are you doing to address the stigma that keeps many patients from pursuing treatment?
RS: In our warm handoff program, which started in Bucks County, patients who arrive in the emergency room with an overdose are immediately handed off to someone who can be a liaison, most of whom have been through the journey and guide the patients to come into treatment. Then, we find treatment locations for them. We’re looking to expand that program to more counties; Philadelphia probably has the fewest warm handoff programs at this time. But the likelihood that a patient will get into treatment is much higher when there’s a warm handoff program in place.
We also worked with Penn State University to create a media campaign to address the stigma. Most people know, or know of, somebody who died from opioid use disorder, but there’s still a stigma. It used real-life examples of real people that have gone through the journey, have survived, have come out the other side, and have a successful, positive life. We want to promote that.
FH: I understand you’ve also used telemedicine in your efforts.
RS: This fall, we plan to launch a screening tool on our website, computer-based cognitive behavioral therapy (CBT) programs, including one for substance use disorder, and tele-behavioral health.
FH: What do you want to do going forward?
RS: A number of things. I think we’re making huge progress on preventing access to opioids. The BCBS Association generally does not allow opioids to be the first line in treatment for any diagnosis. The evidence says they’re not any more effective than alternatives, including local analgesics injected at the time of surgery and so forth that are done to prevent pain.
Not every BCBSA plan has gone quite as strict to five days and 90 MEDs. A lot of plans are at the seven-day level. But seven days gets you 30 oxycontin, and we’re trying to cut that down.
We’re not doing it for patients with cancer, patients in hospice, patients with sickle-cell crises that will have a lot of pain. We still worry about diversion, but when you have hospice patients’ meds being diverted, it’s often through the staff that are taking care of them.
Starting Oct. 1, we’re moving to nonabusable forms of oxycontin, rather than oxycontin or oxycodone. Theoretically, you can crush them a little bit, but you can’t snort them, you won’t get the benefit, and you can’t inject them.
FH: What challenges lie ahead?
RS: Capacity is somewhat limited. Outcomes are extremely variable. There are a host of out-of-network providers “patient brokering,” selling patients to these facilities. We’re working on a campaign to tell our members to avoid the out-of-network cost and often bad outcomes of those facilities. Expanding the capacity of our in-network providers is also important. Rewarding them for better outcomes is important, and we’re doing that through value-based contracting.
Kim Holland (KH): We do feel that treatment is where the rubber meets the road. The healthcare system doesn’t have standards for substance use disorder like it does for other chronic diseases. We want to make sure people get the right care in the right setting at the right time to ensure successful long-term recovery. Our goal as an association is working through our plans to build evidence on, for example, how to treat pain effectively. It can be a little daunting. But we understand this is a long-term problem that will take long-term solutions, and we are committed to it.
FH: You are doing a lot of very extensive, evidence-based work now, but some have criticized insurance companies generally for taking too long to get these efforts going. Why did Independence Blue Cross and BCBSA take until the last couple years to do all these things when the opioid crisis has been building for decades?
KH: I wouldn’t agree from the association standpoint. Like a lot of others, we suddenly became aware of a problem that we didn’t know existed in the magnitude that it did. Plans have dealing with this for years. I think it takes more than a plan to drive a solution. It takes partnerships.
RS: We’ve had a program in place since 2014 to restrict access to opioids—not to the degree we do today—and to notify physicians who are prescribing outside of the CDC guidelines. But I would absolutely agree. We each tried to deal with this problem in our own respective silo until it reached crisis proportions in everybody’s mind. It isn’t that we didn’t recognize it.
FH: What regulations or policies would you like to see come to fruition at the federal, state, or local level?
KH: Access to, and interoperability of, prescription drug monitoring programs. A lot of information, like who pays cash for a drug, doesn’t go into our system, and plans have information they can share with doctors about prescription history. Also, aligning 42 CFR Part 2 with HIPAA to ensure they can pass along important information.
We also think it’s important to reduce the incidence of fraud, mainly by improving state licensure, which currently is nominal at best and not enforced. There are [unlicensed] residential centers that are not properly staffed with qualified people. The federal government elected to defer this to the states, so we’ll work with states in that regard.
RS: I believe in making sure mental health and medical benefit design are equitable. We, as a health plan, can’t work with providers to take care of behavioral health patients the same robust, comprehensive way that we take care of medical patients. Until we address care coordination between providers, data, technology, and more, we will not have mental health parity, period.