ACAP Prescription Substance Abuse Collaborative National Health Policy Forum June 20, 2014 Deborah Kilstein VP, Quality Management & Operational Support 1
About ACAP About the SUD Collaborative Funded by Open Society Foundations Plan Actions Policy Issues 2
ACAP s Mission To represent and strengthen not-for-profit safety net health plans as they work with providers and caregivers in their communities to improve the health and well-being of vulnerable populations in a cost-effective manner. 3
ACAP Represents 58 Safety Net Health Plans Arizona University Physicians Health Plans California Alameda Alliance for Health CalOptima CenCal Health Central California Alliance for Health Community Health Group Contra Costa Health Plan Gold Coast Health Plan Health Plan of San Mateo Health Plan of San Joaquin Inland Empire Health Plan Kern Family Health Care L.A. Care Health Plan Partnership HealthPlan of California Santa Clara Family Health Plan San Francisco Health Plan Colorado Colorado Access Denver Health Connecticut Community Health Network of Connecticut District of Columbia Health Care Services for Children With Special Needs Florida Prestige Health Choice Hawaii AlohaCare Illinois Family Health Network Indiana MDwise Kentucky Passport Health Plan Maryland Maryland Community Health System Priority Partners Massachusetts Boston Medical Center HealthNet Plan Commonwealth Care Alliance Neighborhood Health Plan Network Health 4
ACAP Represents 58 Safety Net Health Plans Minnesota Metropolitan Health Plan New Hampshire WellSense Health Plan New Jersey Horizon NJ Health New York Affinity Health Plan Amida Care Elderplan & Homefirst GuildNet Hudson Health Plan Monroe Plan for Medical Care, Inc. Univera Community Health VillageCare MAX VNSNY CHOICE Ohio CareSource Oregon CareOregon Pennsylvania AmeriHealth Mercy UPMC for You Rhode Island Neighborhood Health Plan of Rhode Island Texas Children s Medical Center Health Plan Community Health Choice Cook Children s Health Plan Driscoll Children s Health Plan El Paso First Health Plans Sendero Health Plan Texas Children s Health Plan Virginia Virginia Premier Washington Community Health Plan of Washington Wisconsin Children s Community Health Plan 5
ACAP s 58 Plans are in 24 States covering more than 9.5 million people through Medicaid, Medicare, and other public health insurance programs 6
Why a Substance Abuse Disorder Collaborative? Impact of Prescription Drug Abuse Triple Aim Improving care and reducing cost Expansion Population (Medicaid and the Exchange) ACA requirements for Essential Benefit Package Performance measurement (HEDIS, STARS) 7
Participant Overview 16 participating plans Plans are tentatively focusing on the following populations: Medicaid Expansion/Exchange Pregnant women Adolescents Dual Eligibles Mix of carve-in, carve-out Diversity in geography (11 states), team make-up, focus, goals 8
1. Affinity Health Plan 2. Alameda Alliance for Health 3. AmeriHealth Caritas Health Plan 4. CalOptima 5. CareSource 6. Children's Community Health Plan 7. Colorado Access 8. Commonwealth Care Alliance 9. Denver Health Medical Plan Inc. 10. Gold Coast Health Plan 11. Horizon NJ Health 12. L.A. Care Health Plan 13. Neighborhood Health Plan 14. Passport Health Plan 15. Priority Partners 16. Texas Children s Health Plan SUD Collaborative ACAP Participating Plans
Collaborative Activities Action Plan Development/Implementation: Each health plan has put together a team that involves internal staff/external stakeholders (substance abuse treatment providers, PCPs, and/or any other stakeholder they feel necessary). Teams chose an evidence based improvement project and implement a measurable Action Plan for 2014 Quarterly Networking Calls Reporting: Common reporting format and action plan template Quarterly reporting is required using provided template In-person meetings: 10/13, 4/15 Webinars (for all ACAP plans) 10
What Plans Are Doing Members Population focus Consumer engagement Education Screening/Assessment Post treatment support F/U calls, peer support, self help group Family counseling and support Naloxone availability Providers Training Contract requirements PCMH Pay for Performance SBIRT training Medication Assisted Treatment Pain Management referrals and guidelines Patient contracts Integration & co-location (PCP, counselors, BHO)
Plan What Plans Are Doing Care coordination and specialized case management Pain management treatment benefits Formulary Changes Refining poly-pharmacy monitoring Revamp Lock in Evaluation of referral policies Network development centers of excellence & telehealth Data Analytics Data Sharing with providers HEDIS/STARs Systems Needs Assessment ER Usage Better integration physical and behavioral health Aligning reimbursement models Chronic care model Transition to aftercare Health Homes Benchmarking Supportive Housing Community Engagement
SUD Survey Designed to gain a better understanding of how plans are addressing prescription Substance Use Disorder (SUD) Helps inform SUD Collaborative learning Several ACAP plans have developed innovative management programs to prevent, identify and treat SUD 13
Plans with SUD services carved in 10 of 24 plans have Substance Abuse services carved in, 14 carved out Contract with a wide array of providers 14
Formulary Restrictions 20 of 25 plans (80%) have formulary restrictions in place to prevent prescription drug abuse Most commonly in the form of quantity limits and prior authorization restrictions on a number of opioid products, often restricted to a specific diagnosis PBMs are assisting plans in identification Monitoring for dose, dispensing, refill frequency 15
Lock-in Programs A majority of responding plans (16 of 24) use a lock-in program Several are state-run programs (WA,TX, WI) Many lock-in patients are then referred to some type of case management and treatment options Multi-disciplinary teams, PBMs, involved in identification and follow-up work 16
Issue Effective Lock-in Programs Lock-in should be only one step in process Interdisciplinary team meetings Includes referral for substance abuse treatment and behavioral health assessment, as appropriate Specialized care management Includes member education and counseling Use of health advocates and community outreach Pain management Referral, assessment, and patient contracts Data analytics and data sharing (plan, PCP, prescriber, pharmacy) 17
Pain Management 18 of 23 plans (79%) provide access to nonpharmacy pain management services Some of these services included physical therapy, chiropractic care, swim therapy, wellness groups, and acupuncture If required (not all plans require referral), referrals generally come from PCPs or case managers 18
Pain Management Issues Network Adequacy: Lack of pain management providers in geographic area Limited alternative therapies/providers available Telemedicine may hold promise Plans report needing more effective pain management services/well-trained providers who can target their population and needs Need for better and widely-accepted treatment guidelines 19
Other Prescribing Issues Lack of coordination among PCPs, Pain Management providers PCPs need more training Need physician-developed prescribing standards and opiate oversight committees. 20
Medication Assisted Treatment Plans support use of MAT Limitation on suboxone prescribers Limit on number of providers due to the certification requirements and 100 patient panel limit Many refuse to participate in health plan network Unlike other services, often operate on a cash basis Plans responsible for pharmacy benefit, but have no contractual relationship with prescriber 21
Measurement Issues HEDIS measures limited to initiation and engagement do not work in carve-out situations Other than Part D, no measures on opioid prescribing High dosage use Extended use Use in combination with other drugs Need the collaborative development of appropriate measures Measure alignment and prioritization is critical 22
Questions 23