How Cigna reduced opioid use 12% in 12 months

In 2016, as the opioid epidemic continued to escalate and as tragic stories about the misuse of opioids proliferated, it became obvious to Cigna that this issue needed focused leadership.

Drug overdose is the leading cause of accidental death in the U.S., with 52,404 lethal drug overdoses in 2015, according to the CDC. Opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin in 2015.

Since announcing its commitment to combat the nation’s opioid epidemic last year, Cigna has made significant inroads toward reaching its goal. Since last year, Cigna customers’ use of prescribed opioids has declined nearly 12%, and the plan is now halfway to its goal of a 25% reduction by 2019.

Nemecek

Managed Healthcare Executive (MHE) recently spoke with Cigna’s Chief Medical Officer for Behavioral Health Doug Nemecek, MD, about Cigna’s efforts, outcomes, and how it plans to reach its goal.

MHE: Describe your efforts. When did it all begin?

Nemecek: In May 2016, Cigna took a public stand as the lead sponsor of a Washington Post  forum on “Addiction in America,” during which Cigna CEO David Cordani spoke about prevention and treatment. The forum convened policymakers, thought leaders, advocacy experts, and government officials, including the U.S. Surgeon General.

At the same time, a cross-departmental team at Cigna began laying the groundwork for Cigna's response to the epidemic, which includes the following elements:

1. Work with organizations like Shatterproof and the Association for Behavioral Health and Wellness to end the stigma associated with substance use and treat substance use disorders as a chronic disease.

2. Collaborate with the American Society of Addiction Medicine (ASAM), to establish national evidence-based measures for treating substance use disorders.

3. Identify and encourage alternative treatments for chronic pain that don’t rely on opioids.

4. Establish “Centers of Excellence” that are preferred sites for substance use disorder treatment, equivalent to Cigna's Centers of Excellence for surgery.

5. Encourage physicians to follow CDC prescribing guidelines, including adoption of Cigna's pledge.

6. Reduce Cigna customers’ opioid use by 25% by 2019 by:

• Analyzing integrated claims data across pharmacy and medical benefits to detect opioid use patterns that suggest possible misuse by individuals, and then notifying their healthcare providers. 

• Alerting doctors when their opioid prescribing patterns are not consistent with the CDC’s guidelines for opioid selection, dosage, and duration. 

• Implementing additional customer safety measures in support of the CDC guidelines. Effective July 1 2017, most new prescriptions for a long-acting opioid that are not being used as part of treatment for cancer or sickle cell disease, or for hospice care, will be subject to prior authorization, and most new prescriptions for a short-acting opioid will be subject to quantity limits.

• Establishing a database of opioid quality improvement initiatives for doctors that can help them determine next steps for improving patient care, including referrals into chronic pain management or substance use disorder treatment programs.

Next: The cost savings

MHE: What are the cost savings?

Nemecek: This initiative is not about cost savings, that’s not something we’re considering. This is about improving the quality of care and reducing the risk of opioid misuse that can result from overprescribing.

MHE: What is Cigna doing about prior authorization for drugs for opioid use disorder such as Suboxone (buprenorphine and naloxone) and probuphine?

Nemecek: Cigna has removed the prior authorization requirement for all medications used for medication assisted treatment (MAT), such as Suboxone.

MHE: If a patient is identified with a pharmaceutical use pattern that is aberrant, and the doctor says “so what,” what does the plan do next?

Nemecek: We don’t expect that reaction. We expect doctors to be receptive to the information about their patients because it likely is information that they don’t have. We operate on the premise that doctors want to deliver the best care possible and want their patients to have a positive outcome, and by working together with doctors we can help them accomplish that.

MHE: Are physicians with inappropriate prescribing patterns terminated from the provider network?

Nemecek: No, because there may be a valid reason for the physician prescribing the way he or she does. We prefer educating the physician through our prescribing profiles and by promoting the CDC prescribing guidelines. However, we would take steps to terminate a doctor who prescribes illegally or who engages in fraudulent activity.

MHE: To date, 158 medical groups and 62,000 doctors have pledged to reduce opioid prescribing and to treat opioid use disorder as a chronic condition. What percentage of these represent your network? What are you doing about the remainder of doctors in your network?

Nemecek: The doctors affiliated with a group that has signed the pledge represent about 7% of our total network physicians, but they are among the most engaged physicians because of their participation in Cigna Collaborative Care. We will continue to communicate with physicians about the importance of following the CDC prescribing guidelines, provide them with their prescribing profiles, and encourage them to use our database of quality improvement programs so they can evaluate what they might adopt in their own practice.

MHE: How real time is Cigna’s analysis of medical and pharmacy claims?

Nemecek: In some situations, we review data in real time; for example, when we alert a pharmacist that a prior authorization is needed for a new opioid prescription. Other algorithms, such as those used in our narcotic therapy management program to detect patterns of fraud or abuse, are run monthly.

Tracey Walker is content manager for Managed Healthcare Executive.