EXECUTIVE SUMMARY
Healthcare organizations saw a disturbing trend of opioid addiction among some Medicaid plan members. The challenge was to address this problem and reduce its resulting increase in ED utilization.
- An interrelated trend was of Medicaid patients not seeing their primary care providers and overusing EDs.
- A solution was a one-pharmacy rule as part of a safety initiative.
- Patients with the highest ED visits in a six-month window were targeted for the program and provided telephonic case management, as well as visits by outreach teams.
Case management programs are accustomed to handling high-risk patients with social determinant of health issues, including Medicaid populations.
But, in recent years, the opioid epidemic has created new challenges for healthcare organizations seeking to improve population health.
“We’re seeing an increase in overutilization of prescribed substances — the opioid epidemic,” says Cindy Colligan, BSN, MBA, CCM, director of operations for clinical care services government programs at Optima Health in Virginia Beach, VA.
“We saw that trend rising, and we saw ER utilization going up,” she adds.
The organization also has seen these interrelated trends of Medicaid patients not visiting their primary care providers and not following their medication treatment plans. Its case management program was telephonic, but helping patients who did not want to help themselves proved challenging.
As a result, the organization started a safety initiative in 2016 that addresses the opioid epidemic, says Tonya M. Palmer, RN, MSN, CCM, manager of government programs for the clinical care services division of Optima Health in Virginia Beach.
One strategy was to identify patients with opioid use problems by the most conservative measures. Those selected for the program were people who, within 90 days, filled 10 prescriptions for controlled substances, written by four or more prescribers and filled at four or more pharmacies, Colligan says.
Telephonic case managers would make the initial phone call and try to connect with the member. They would say, “We see you might have a problem with pain. Can we help you get into pain control? Do you need assistance with substance use?” Colligan says.
“We would say, ‘You’ll be limited to one pharmacy,’ and we’d let them choose the pharmacy if they wanted,” she adds. “Then we’d follow up with a certified letter, stating they are locked into one pharmacy. They could appeal it or complain.”
Once locked in, all prescriptions would be filled and reviewed at the one pharmacy. If patients obtained prescriptions from multiple providers, this pattern would be reviewed.
If patients attempt to fill a prescription at a different pharmacy, they’re told to call their Medicaid contact.
The one-pharmacy policy has two useful benefits. The first is that it makes it much easier to ensure plan members do not abuse the system by getting more prescriptions than they need. The second is that it usually results in their re-engaging in case management — if even just for one phone call.
Often, case managers would have difficulty reaching members or even finding them. But when the one-pharmacy policy began, there was a large response rate from members being denied their medications from additional pharmacies.
“We found the easiest way to find someone was to lock them from a pharmacy,” Colligan says.
These calls typically involved anger, so case managers were trained in motivational interviewing and listening to de-escalate aggression.
“We had people listening to what patients were saying, reflecting on what the underlying problem is, and letting them know you’re there to support and help them,” she says.
For example, a case manager would let the person yell for a few minutes and get it out of their system.
“Then, the case manager would calmly say, ‘I understand your concerns. Let me see how I can assist you today,’” Palmer says. “They’d be as positive as they can be and talk in a calm voice, letting them get it out, but not interrupting.”
The opioid epidemic also has increased ED overutilization, pushing up expenses. The safety initiative and case management could help with this issues, as well.
“Since we’re 100% telephonic, we’d use an outreach team to go to their homes and have a face-to-face visit,” Colligan says. “They would use an educational piece we helped put together, where we’d educate them on the appropriate use of the emergency room and focus on getting them care from a primary care provider [PCP].”
The outreach team member would help patients schedule a PCP visit and arrange transportation, if that was an issue. “So, they’d have that in place before they left home,” Colligan says.
The goal was to get patients into a pain management program or a substance abuse treatment program. It didn’t work with every person who needed the intervention, but for those who were receptive to changing their lives, it worked well.
“We definitely had some success with some of the membership,” Colligan says. “We saw great success with the members who wanted to change. There were fewer who wanted help than didn’t.”
The change in behavior in even a minority of people with opioid abuse issues made a significant difference. “We saw a decrease in emergency room visits, and we saw some improved behavior and success,” Colligan says.
ED visits declined, in part because patients attempting to obtain pain medications could no longer get those prescriptions. So, they stopped going.
“The ERs stopped prescribing, so it was an overall success — but the individual successes were fewer,” Colligan notes.
The patients who did change behavior made for uplifting examples.
“We had people who came back after going into pain management treatment, and they said it was a vast change in their quality of life, and we saw people who got back into substance abuse treatment.”
One man, who previously had been in substance abuse treatment and then relapsed, was locked out of a pharmacy. “He said it was a wake-up call, and he got back into treatment,” Colligan says. “He said it saved his life, and his wife said she thought it saved their marriage.”
The following are additional ways the safety initiative program works:
• Case managers are in contact with at-risk patients more frequently. “We coordinate their care, follow up with them, check on their status, and ask whether they need help or transportation to clinics for treatment,” Palmer says. “We coordinate all of that and encourage them.”
Case managers also keep the opioid cases open as long as the patients are restricted to one pharmacy. They are reviewed annually, Colligan says.
• Use automated phone messaging. “Every household that had an ER visit during the month would receive an automated phone message, saying we saw that someone in their household had been in the ER in the last 30 days,” Colligan says. “Then we’d give them instructions on when it was appropriate to go to the ER and when to see their primary care physician. We still do that.”
• Alert patients to telephone case management. Patients who visited the ED several times in six months would receive a home visit and are advised of case management follow-up by phone.
“The case manager would call and make sure the person saw a primary care provider,” Colligan says. “They’d work with them on whatever issue they had going on.”
For instance, if patients repeatedly went to the ED because they could only get transportation on the weekends and were unable to get a ride to their doctor during the week, the case manager would help them fix this problem.
“Some people felt the ER was appropriate for routine care, and they didn’t want to schedule a doctor’s appointment,” Colligan says.
The case manager would inform the patients of the Medicaid transportation benefit that could help them get to doctors’ appointments.
“The case manager would help them get transportation to see the primary care provider and help them coordinate their care,” Palmer says.
In recent years, the opioid epidemic has created new challenges for healthcare organizations seeking to improve population health.
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