Quality & Science

One Insurer’s Efforts to Assist in Massachusetts’ Opioid Overdose Crisis

by ASAM Staff | March 11, 2016

The Payer Relations Committee seeks to build a working relationship with health insurers and other payers across the country. One way that we will be engaging with payers is by featuring in the ASAM Magazine health insurers that are working to increase access to treatment for plan members with addiction. This will be the first in a series of articles that will highlight payers working to improve access to substance use disorder treatment.  

Massachusetts, like many other states, has been dealing with an increase in people with opioid use disorder and opioid-related deaths. Between 2012 and 2014, seventy-five percent of the cities and towns in the state have reported at least one opioid overdose death1.  The death rates from opioid overdoses have been steadily rising, from 10.1 per 100,000 people in 2012 to 18.6 per 100,000 people in 20142. The state Department of Public Health, the Governor and other state officials are treating this increase in opioid use as a public health crisis. Some health insurers are responding with a similar sense of urgency. ASAM staff recently spoke with Jay Gonzalez, CEO of CeltiCare Health, a Massachusetts-based Medicaid managed care plan owned by Centene, to discuss some of the efforts that CeltiCare Health has undertaken to try to ameliorate the effects of opioid misuse.

CeltiCare Health, as a managed care plan focused on the expanded Medicaid population, has many members that have many serious physical and mental health conditions, including substance use disorders. A recent analysis of their inpatient admissions showed that 23% were related to substance misuse. The number one prescribed medication to members was Suboxone. Clearly, substance use disorder was a pressing health issue in the state and for their members, so the company decided that the best way to help the state tackle this issue was to focus on helping patients with addiction get treatment and to prevent addiction in high-risk patients.

To address the needs of their members and the state, CeltiCare Health has developed a three point strategy to address opioid use disorder. First, they are identifying members who have addiction or are at high risk of becoming addicted to opioids. Second, they want members with addiction to access treatment and maintain recovery. The final part of the strategy is working with prescribers to reduce the number of opioids available and able to be diverted.

By identifying members who have a substance use disorder or are at risk of developing one, CeltiCare Health is trying to keep members engaged in the health care system, even if they are not yet ready for treatment for their addiction. Case managers and social workers reach out regularly to members, including through trips to homeless shelters, to connect them to services they may need. CeltiCare Health is also partnering with a datamining firm to use other information, besides claims data, to find members who may be at risk of developing a substance use disorder but whose claims data are unclear. 

CeltiCare Health has partnered with a mental health social service provider to reach out to members that have serious behavioral and mental health needs, including substance use disorder, to encourage them to access treatment and support them through recovery. CeltiCare Health pays this organization a per-member-per-month fee to find this difficult-to-engage population and intends to share savings from reduced hospitalizations with the organization.

When members are identified as having opioid use disorder or at risk of an overdose, CeltiCare Health requests to connect with family members or friends to let them know about state-sponsored trainings to use naloxone and reverse an opioid overdose. These efforts to prevent overdoses are aimed at keeping members alive and out of the hospital so they can get treatment for their substance use disorder.

The second strategy to tackle the public health crisis related to opioids is to help members with addiction to access treatment and maintain recovery. One of the first efforts to increase access included reviewing the prior authorization process for all behavioral health services including inpatient, outpatient and pharmacy. More than 99% of prior authorization requests were being approved, so the company eliminated them in most cases. This elimination occurred before MassHealth (Medicaid) mandated it for managed care plans in the state. Only buprenorphine without naloxone has a prior authorization requirement for use longer than seven days. The prior authorization process was seen as a barrier to care, even if most of the requests were being approved, so eliminating it removed a perceived barrier for members and providers.

In an effort to engage members at a critical point, a hotline staffed by substance use disorder experts is being set up to help primary care and emergency department providers help patients who would like to access treatment. Hotline staff will determine which level of care the patient needs and help find an available treatment facility that the patient can be steered towards. CeltiCare Health covers all ASAM levels of care.

Plan members with mental health needs, including substance use disorder, have case managers that help integrate and coordinate mental and physical health care. These case managers technically work for an outside company, but one owned by Centene, the corporate parent, so there are no competing financial incentives. A substance use disorder (SUD) expert is being hired to serve as a resource specifically for case managers of plan members with addiction. Members in recovery have fewer emergency department visits, fewer hospital admissions and lower health care costs, so spending money on resources to get members into recovery is seen as a long-term benefit, both financially and for the health of members. While helping members get treatment is one way to improve their health, another way to improve health is to prevent overuse of opioids in the first place by reducing the supply available for diversion.

The final part of the strategy to tackle opioid overuse is focused on prescribers. Many stakeholder groups in Massachusetts have come together to have policy discussions about appropriate prescribing of opioids. Using these discussions, research and other insurers’ policies, CeltiCare Health has set a limit of a 15 day supply of opioids for patients. After the second refill, the physician and member must enter an agreement about addiction risk and caution about diversion before more opioids can be prescribed. In February, 2016, the limit will be further reduced to a seven-day supply, excepting oncologists. The Massachusetts Medical Society supports these quantity restrictions. Additionally, CeltiCare Health eliminated prior authorization requirements for all FDA-approved abuse deterrent opioids.

As Massachusetts faced this public health crisis, CeltiCare Health recognized their role as vital to accessing treatment and recovery services for members and decided to remove barriers to access. They see better outcomes when members are engaged in recovery. While many of these efforts have short-term costs related to them, long-term cost savings, such as fewer hospitalizations, as well as improved health of members, make the benefit outweigh the costs. By being a partner in treatment and recovery, CeltiCare Health hopes to play a role in ending the opioid crisis in Massachusetts.
Do you work with an insurance company or other payer that has removed barriers to addiction treatment or increased engagement with providers and patients? Let us know and we may feature them in a future edition of ASAM Magazine.


[1] Rocheleau, Matt, A town-by-town look at the opioid epidemic’s toll in Mass., Boston Globe, October 22, 2015; https://www.bostonglobe.com/metro/2015/10/22/town-town-look-opioid-epidemic-deadly-toll-massachusetts/FJksUU8hlYJN4Yl4mCKwkI/story.html

[2] Massachusetts Department of Public Health,  August 2015 Data Brief: Fatal Opioid-related Overdoses among Massachusetts Residents, http://www.mass.gov/eohhs/docs/dph/quality/drugcontrol/county-level-pmp/data-brief-aug-2015-overdose-county.pdf