The role of health plans in addressing the opioid crisis: A qualitative study

Abstract

Introduction:

Health plans are key players in substance use treatment in the United States, and the opioid crisis presents new challenges for them. This article is part of the HEALing Communities Study (HCS) funded by NIH, which seeks to facilitate communities’ adoption of activities that might reduce overdose deaths, including overdose prevention education and naloxone distribution, medication for opioid use disorder, and safer opioid prescribing. We examine how health plans in one state (Massachusetts) are adapting to encourage and sustain activities that help communities to address opioid use disorder (OUD).

Methods:

We conducted semi-structured interviews with managers of behavioral health services at eight health plans in Massachusetts that that have Medicare, Medicaid, and commercial lines of business. Two plans in this sample contract with a specialized behavioral health organization (“carve-out”). The interviewees also completed a survey on policies regarding access to treatment and opioid prescribing. Interviews were recorded and transcribed and analyzed using thematic analysis. Analysis of the data included intended influence of the policies at three levels: member level (micro), group or community level (meso), and system or institutional level (macro).

Results:

All health plans developed strategies to increase access to treatment for OUD, primarily through eliminating or decreasing cost-sharing, eliminating pre-authorization for MOUD, and increasing supply of providers. Health plans encourage qualified practitioners to offer MOUD, but most do not provide incentives or training. Identifying high risk populations is a focus of health plans in this sample. Naloxone is a covered benefit in all health plans, although with variation in monthly limits and cost-sharing. Most health plans take measures to influence opioid prescribing. Health plans’ activities are predominately aimed at the micro (member) level with little ability to influence at the macro (wider system-level changes).

Conclusion:

This study provides insight into how health plans develop strategies to address the rise in OUD and fatal opioid overdoses, many of which are key in the HCS initiative. How active a role health plans play in addressing the opioid crisis varies, even within the insurance industry in one state (Massachusetts).

1. Introduction

The opioid crisis continues to worsen in the United States, with preliminary data suggesting that more than 75,000 Americans died of an opioid-related overdose in the 12-month period ending May 2021(Ahmad, 2022). Effective treatments are available, in particular medications for opioid use disorder (MOUD). However, fewer than 30% of individuals with an opioid use disorder (OUD) receive any treatment (Saini et al., 2022), and among those who do, many do not receive MOUD (Substance Abuse and Mental Health Services Administration, 2021).

A comprehensive response to the opioid crisis includes a wide range of interventions (Kolodny et al., 2015). One strategy is to expand harm reduction services, including overdose education and access to naloxone, which can reverse an opioid overdose if given early enough and at an appropriate dose. Expanding access to naloxone in communities can be an impactful intervention in decreasing opioid-related overdose deaths. A second strategy is to expand the use of MOUD, which includes three FDA-approved medications that have been established as the first-line treatment option for OUD: buprenorphine, methadone, and naltrexone (National Academies of Sciences et al., 2019). Under current federal regulations, methadone for the treatment of OUD can only be administered in an opioid treatment program (Kampman & Jarvis, 2015). The third strategy is to promote more cautious prescribing of opioids to prevent future cases of OUD. These strategies are typically viewed as complementary, not as alternatives (Pitt et al., 2018; Rao et al., 2021).

To address the crisis nationwide, the National Institutes of Health and the Substance Abuse and Mental Health Services Administration (SAMHSA) have jointly funded the largest substance use disorder implementation study ever conducted, called the “Helping to End Addiction Long-term Communities Study” (HEALing Communities Study, or HCS). The study targets 67 communities in four states (Kentucky, Massachusetts, New York, and Ohio) that have been disproportionately affected by the opioid crisis, with the goal of reducing opioid overdose deaths by 40% in these communities (Chandler et al., 2020; Walsh et al., 2020). As part of the HCS study, communities are using federal grant funding to implement interventions that improve opioid prescribing safety, expand access to MOUD, and increase naloxone distribution (Winhusen et al., 2020). However, federal funding is scheduled to end in 2024, calling into question the sustainability of the implemented interventions, even if they are shown to be effective, and raising the concern of whether other health system actors could play a role in sustaining the interventions in the post-HCS environment. Health plans are one type of entity that could potentially do so.

Health plans play a central role in the structure of the US health care system, primarily through their influence on the payment and delivery system. In 2019, 84% of individuals with opioid use disorder had health insurance coverage, either through private insurance, Medicare, or Medicaid (Foundation for Opioid Response Efforts, 2021). While most health plans do not typically deliver prevention or treatment services themselves, they may use a number of other levers that could potentially impact the services that are available to their members. First, the benefit package can affect the use of medications through utilization management techniques, such as cost sharing, prior authorization, step therapy, quantity limits, and formulary design (Reif et al., 2016). Health plan benefit package is a critical lever since cost sharing and prior authorizations deter the use of MOUD (Bachhuber, 2020; Mark et al., 2020; Morgan et al., 2022). The lever also can influence use of prescribed opioid analgesics (an important contributor to the current crisis), naloxone (a prescription medication that can reverse an opioid overdose), and MOUD (a potential solution). Despite the large number of people in need of treatment, federal, state, and local jurisdictions restrict the availability and accessibility of medications for OUD at opioid treatment programs, the only locations licensed to administer methadone (PEW Charitable Trusts, 2021). Second, health plans similarly determine the availability of other nonmedication services that may address the opioid crisis (e.g., non-pharmacological alternatives to opioids, behavioral treatments to complement MOUD). Third, health plans influence the geographic availability of treatment services by forming provider networks. Finally, health plans aggregate a large amount of utilization data that can be used to profile providers and patients to identify risky prescribing patterns or lapses in OUD treatment.

Some have argued that health plans would benefit financially by addressing the opioid crisis, since it is driving up their medical costs in expensive settings such as inpatient hospital units and emergency departments (Elitzer, 2017), which in turn drives up their insurance premiums. Although the impact on overall health care spending may be modest, treatment with MOUD is cost-effective (Fairley, 2021), and preventing one new case of OUD could save the health care system $244,030 and the taxpayer $325,125 on an annual basis (Murphy, 2020). Health plans may also be able to address some barriers more quickly than can be achieved by legislative or regulatory reform, and may be integral in sustaining long-term access to effective interventions. Therefore, the role of health plans in addressing the opioid crisis is particularly salient.

Addiction treatment has historically been separated from the management of other medical conditions, and many health plans “carve-out” their behavioral health benefits, which include most forms of OUD treatment, to specialized behavioral health plans, sometimes known as managed behavioral health organizations (MBHO). Plans that maintain management of behavioral health benefits are said to “carve-in”. In addition, many plans contract with pharmacy benefits managers to operate their drug formularies, interact with pharmacies and process prescription drug claims. Thus, reimbursement for services may be complex and integration of care is difficult (Polsky et al., 2020). Finally, commercial health plans face high enrollee turnover, which may reduce their incentive to invest in care that saves long run costs (Herring, 2010).

1.1. Aim of current study

The specific goal is to investigate the role of health plans in addressing the opioid crisis in Massachusetts and the feasibility of health plans to help sustain initiatives of the HEAL project. Key foci are the ability of health plans to use their data and relationships within their network to implement effective strategies around prevention of OUD and care for their members who have OUD. Research questions for the current study include: (1) How do health plans encourage activities related to interventions implemented by the HCS communities, (2) What reforms are being implemented, (3) What part of the health care system do the reforms target, and (4) What are the barriers to broader application of reforms. These questions are driven by the critical role of health plans in financing interventions to address the opioid crisis. Study findings may inform how health plans impact solutions to the opioid crisis.

2. Methods

Qualitative methods are well-suited to this type of exploratory study (Creswell & Poth, 2018) as the goal is not to document the quantity of initiatives, but rather to develop an initial understanding of the role that health plans do, and could, play in addressing a public health crisis, in this case, the opioid epidemic.

2.1. Study setting

The current study focuses on Massachusetts, one of the four states participating in HCS. In Massachusetts the number of opioid overdose deaths rose more than 250% between 2010 and 2016, and in 2019 the state had one of the highest opioid-related death rates in the United States at 28.9 per 100,000 people (Kaiser Family Foundation, 2019). Due to earlier health reforms and Medicaid expansion, nearly all Massachusetts residents (93.3%) reported at least 12 continuous months of health insurance (Center for Health Information and Analysis, 2021). Massachusetts has the highest rate of individuals with health insurance in the nation, yet residents report that accessing medical care is difficult (Massachusetts Health Council, 2021). The state also is a leader in innovative approaches to the opioid crisis, such as the Blue Cross affiliate’s Prescription Pain Medication Safety Program (Livingston, 2017), bridge clinics, and the Medicaid carve-out’s introduction of recovery support navigators (Hodgkin et al., 2019; Regan et al., 2021).

2.2. Sample selection

A health plan is defined as an individual or group plan that provides or pays the cost of medical care. The researchers selected health plans based on data from the state government’s Center for Health Information and Analysis, which identified 13 health plans that offered Medicare, Medicaid, and commercial products in 2018. From that list the research team developed the sample frame that included health plans that carve-out behavioral health benefits, plans that retain administration of behavioral health benefits (carve-in), and specialized behavioral health plans. Of the 13 plans identified, eight agreed to be interviewed. One hundred percent of Medicaid beneficiaries, over 97% of Medicare beneficiaries, and 91% of commercial beneficiaries are enrolled in the eight plans. Among the eight, two plans carve-out their behavioral health benefits for all or some of their members, two plans are specialty BH plans, and four plans carve-in behavioral health benefits. It was important to interview both the health plan and their specialty BH carve-outs because health plans that carve-out generally retain some influence over the benefit package (Frank & Garfield, 2007).

We interviewed the director or manager of behavioral health services of each plan, because they were most likely to have knowledge about policies regarding prescription opioids, MOUD, and naloxone. In all, 13 persons participated in the interviews including the BH director. The respondents included eight females and five males. Four respondents are MDs, eight are licensed social work clinicians, and one has a bachelor degree in a related field. All but one are Caucasian. All participants have been in the health care field for 25 years or more. We also interviewed three non–health plan stakeholders who have been integral in the health care system response to the opioid crisis in Massachusetts to give additional perspectives.

2.3. Interview protocol

The research team sent health plan respondents a brief pre-interview survey to collect data on items related to member benefits. Topics included OUD interventions they cover or encourage, financial incentives they offer to providers to offer MOUD in primary care or other settings, quality standards they use for OUD treatment, rules they implement around prior authorization, and reforms they have made to influence opioid prescribing or dispensing.

The research team developed the interview protocol that asked health plans about many of the OUD-related interventions listed in the Opioid-overdose Reduction Continuum of Care Approach (ORCCA), which was the menu presented to community coalitions that participated in the HEALing Communities Study (Winhusen et al., 2020). In all, eight base questions asked about (1) factors that influenced the decision to pay/not pay for activities intended to improve access to MOUD or naloxone; (2) what has been helpful in efforts to promote access; (3) factors that have influenced the decisions about whether and how to encourage providers to meet quality standards; (4) incentive or reimbursement models that have affected care; (5) strategies to encourage providers to offer MOUD; (6) engagement with other stakeholders to address the crisis; (7) measures to influence opioid prescribing; and (8) measures to influence opioid dispensing. The analyses included data collected between February 2021 and April 2021.

Two of the authors conducted the interviews (MD, RB) via web-based video and they lasted approximately one hour. Interviewees did not receive compensation for their time. Expert groups suggest that interviewing is the best model of data collection to gather more in-depth qualitative data (Charmaz, 2014; Cypress, 2017). The study protocol (Pro00038088) was approved by Advarra Inc., the HEALing Communities Study single Institutional Review Board (sIRB).

2.4. Analytic strategy

To answer the study questions, we used thematic analysis (Braun & Clarke, 2006). The thematic analysis method “provides a robust, systematic framework for coding qualitative data, and for then using that coding to identify patterns across the dataset in relation to the research question” (Braun & Clarke, 2014).

Initially, one of the interviewers reviewed the transcriptions for accuracy. Each transcript then was assigned to one of three researchers who separately coded the text using Atlas.ti (v7), a qualitative data software program. A second reader then reviewed coded transcripts and the team discussed if codes should be changed or added. The team identified initial codes from the literature review and interviews with expert stakeholders. As themes developed from the transcripts, the team revised codes, resulting in 23 codes. The team sorted the codes into four categories related to qualitative study questions: what are health plan initiatives related to: (1) increasing access, (2) monitoring opioid prescribing, (3) improving OUD treatment, and (4) reducing overdose. Survey data were categorical and the study analyzed them using frequencies.

The research team presented a preliminary analysis of the findings to the larger HCS study group for feedback that was then incorporated into the ongoing analysis. To understand policy implications of health plans’ strategies, we used a framework that the National Committee for Quality Assurance (Niles, 2021) developed that identifies 3 possible levels of influence. The NCQA framework is often used in analysis of health systems to understand behaviors and interactions on a one-to-one level (micro), on a specific group or community level (meso), and on a broader system or institutional level (macro) (Otiso et al., 2017; Richter & Dragano, 2017; Sawatzky et al., 2021).

3. Results

Generally, we found few differences in approaches to address the opioid crisis among the three types of organizations interviewed (carves-in, carves-out, and specialty BH plans). Across all 8 plans, the study identified 24 initiatives to address the opioid crisis. The larger plans tended to have more initiatives yet the smaller ones also were willing to try new strategies. We found an alignment across plans that the opioid crisis requires targeted strategies and all plans are working to foster better access to care. However, only four initiatives are directed toward system-wide reforms.

Table 1 displays the strategies the health plans discussed and classifies them into the four areas of investigation: (1) improving access to treatment, (2) monitoring and improving opioid prescribing, (3) improving OUD treatment, and (4) preventing overdose. Table 1 also crosswalks the strategies into areas of greatest impact using the NCQA level of influence framework, with some strategies influencing more than one level. Although any change in one level may affect changes in others, the classification is based on the level of immediate impact.

Table 1:

Classification of health plan policies by level of influence

Health plan policy	Level of influence (primary area of impact)
	Member (Micro level)	Provider (Meso level)	System (Macro level)
1. Improving access
Reimburse for telehealth	✓	✓
Reduce or eliminate cost sharing	✓	✓
Increase number of prescribers			✓
Pay for XDEA waiver		✓
Close geographic barriers	✓
2. Opioid prescribing
Provide provider education and trainings		✓
Lock-in pharmacy access	✓
Aligning opioid prescription reimbursement with CDC guidelines	✓
Feedback to providers on prescribing relative to peers		✓
3. Opioid use disorder treatment
Identify members at risk for OUD	✓
Track members across BH and medical visits	✓
Provide case management	✓
Provide pain management consultation to PCPs		✓
Contingency management	✓
Eliminate pre-authorizations for MOUD		✓
Bundled payment structure		✓
Encourage Integration of pharmacy into treatment programs	✓
Pay for OUD screening		✓
Enhanced rate to integrate BH services			✓
Provide self-service apps	✓
Use quality metrics to identify high-quality treatment	✓	✓	✓
4. Overdose prevention
Provide access to naloxone	✓
Train first responders			✓
Identify members at risk of overdose	✓

Notes: BH=behavioral health, DEA=Drug Enforcement Administration. A check denotes that the plan reports this activity. Categories are not mutually exclusive.

3.1. Improving access to treatment

All health plans reported interest in improving access to OUD treatment services. They cited cost to members and the supply of providers and case managers as major barriers to access. One health plan cited “adverse selection” as reason the health plan is cautious about providing benefits.

I think based on our finance teams they’re concerned with having members with a lot of substance use issues that will pick the health plan because of the offerings and so a lot of times the finance teams say no. They say we’ll get what is called the adverse selection. That we’ll get a lot of people with a lot of substance use issues and then once they’re stable, they’ll go to another health plan because it’s cheaper.

(BH Director, Carve-out)

A recent change has been the expansion of telehealth as a member benefit. All health plans said that since the COVID-19 pandemic started, claims for telehealth services have increased significantly (to more than 80% of behavioral health services in one plan), and said that telehealth is one of the main drivers of improved access to services.

3.1.1. Cost sharing

Most plans have reduced some of the costs patients pay related to OUD treatment. Health plans noted that cost-sharing (e.g., co-payments and deductibles) is a barrier to accessing care, especially among members who use multiple services. Regarding the delivery of methadone treatment at an opioid treatment program, one director said,

If you have a $20 to $30 copay a day when they’re coming in every single day, that’s not going to be sustainable for your members. So, based on feedback from the providers, we worked with the providers to really shape our benefit to make sure that we as a health plan aren’t putting up any barriers for our members accessing treatment. I think we have demonstrated quite clearly that on methadone you can dramatically increase access by adjusting the copay and deductible.

(BH Director, Carve-in)

However, directors said that changing the cost-sharing structure is a complicated issue because conflicting rules can prevent health plans from eliminating copays. One example they cited was that there are many benefits that health plans are required to offer in the Medicaid line of business, which they may not offer in other benefit packages, reflecting the preferences of the payer/purchaser (e.g., employer) that chooses which product they want to offer their employees.

We have so many high deductible health plans where the rules around what can be zero copay are tight if it’s not a preventive medicine or a preventive service; and MAT, while yes, it’s preventive it really is treatment. So, getting around some of those rules to allow a zero-dollar copay or to not change the deductible have been difficult in the high deductible health plan world that many of our employers live in.

(BH Director, carve-in)

Directors said another barrier is that most health plans sell policies to self-insured groups (e.g., employers) that may have their own preferences regarding what services to subsidize and how much of the cost the member will have to assume.

There are some accounts, self-funded accounts that control our pharmacy and benefit structure, that exclude one or all of these treatments because they have a belief system that doesn’t allow medication assisted treatment so it’s something we – I -- have actively struggled against but it’s still out there, there’s stigma and it’s in some of the benefit structure in certain self-funded accounts.

(BH Director carve-in)

3.1.2. Supply of providers

All health plans report working to increase the supply of providers, especially ones qualified to prescribe MOUD. Directors said that increasing the supply of providers reduces wait times, but increasing the number of prescribers is challenging and that many of these initiatives have been unsuccessful. Interviewees said that workforce shortages are an issue in the health care field generally, but they are especially acute in the addiction sector. A director with one of the largest provider networks noted that primary care physicians do not want to become “addictionologists” because they have limited capacity to conduct the necessary treatment regimen for clients on MOUD. Directors noted that stigma is also a barrier to recruiting providers, because providers do not want what they perceive as treatment-resistant “addicts” in their waiting rooms.

Acknowledging that treatment for addiction is not a one-size-fits-all endeavor, one of the larger plans added an in-home recovery model—Aware—into its provider network so that anyone can have access, even members covered under some of the more restrictive self-funded accounts.

Directors said that the fact that many providers are in multiple health plan networks presents unique challenges. Directors said that providers do not want to change practices or procedures unless an initiative occurs across all payers, which limits the plan’s ability to recruit new providers as well as limit the ability to restructure care and reimbursement. As an example, one stakeholder talked about the value of integrating addiction treatment into all medical care, “so that it would be much like diabetes, or heart disease, or depression that are identified and managed by primary care doctors,” but the providers need to be willing to buy into a different model of care that may not be covered by all health plans.

Some health plans are trying to increase their network of providers by offering “hefty” incentives to prescribers to offset cost of buprenorphine waiver training. They also incentivize providers to see patients within five days of initial contact to reduce waiting time, and offer increased reimbursement for behavioral health visits. Health plans will try to recruit providers who provide out-of-network care to members, but Directors said this strategy has moderate success. Plans that carve-out their behavioral health benefits leave the recruiting of providers to the specialty carve-out plan.

Some health plans adopt a targeted approach to increase the supply of providers. One of the larger plans and a BH specialty plan talked about “heat mapping” (a process where the plan reviews claims data to identify geographic areas of high concentrations of opioid-related harms and checks the local availability of providers). Health plans can identify areas where more providers are needed.

We do heat maps of where’s our membership and where are those MAT clinics and where are we seeing overdoses and complications of substance use compared to where are our treatment providers. We try and make sure our treatment providers are in the neighborhood or in the markets close to where our customers are who are struggling with substance abuse issues.

(Director, Specialty BH plan).

3.2. Opioid prescribing

All plans are concerned about safe prescribing of opioids, and all plans interviewed offer some type of education for providers on safe prescribing, regardless of size of plan or carve-out status. Information is also available to network providers on the plan’s website. Most initiatives to monitor opioid prescribing patterns are done in conjunction with the pharmacy benefit manager. Regardless of type or size of the health plan, the respondents talked about the need to track pharmacy claims and “lock-in” the member to one pharmacy if they detect “doctor shopping,” where a member sees multiple physicians seeking opioid prescriptions. In addition, using claims data, health plans alert prescribers about their prescribing patterns relative to peers in that marketplace.

Our pharmacy benefit vendor sees if the member is filling multiple prescriptions or if they are doctor shopping. And then they identify those members to us, and then we reach out to the member and we put them in the lock-in program basically where we reduce and limit what pharmacy that they can go to pick up their opioids that are prescribed.

(BH Director, Carve-in)

In the survey, six health plans reported they take measures to influence opioid prescribing (e.g., limiting quantity, academic detailing, tier placement of opioid medications). In the interviews the directors generally reported success with their initiatives to educate providers about safe prescribing.

Probably 5 years ago now, when we really started getting more aggressive with managing the opioids, and opioid prescribing, we’ve seen significant decrease in opioid prescribing. Obviously, there have been lots of state mandates about prescription limits and all sorts of things that have happened along that time as well, but we’ve certainly seen significant improvements in the number of people who are prescribed opioids for more than seven days, and then the number of people who are on a high dose of opioids.

(BH Director, Carve-in)

A stakeholder, who is a medical provider, cautioned that health care institutions, including health plans, need to be aware that primary care doctors are bearing the burden treating patients with chronic pain. Often, PCPs feel overwhelmed and “out of their depth” treating “legacy” patients who have been on prescription opioids for pain for a long time and have no desire to reduce their dosage.

Making them (primary care physicians) feel bad or that they’re doing something wrong or having insurance companies say they won’t pay for it anymore, is not a supportive way to approach either the patient experience or the provider experience.

(Stakeholder)

3.3. Opioid use disorder treatment

Directors talked about improving treatment by improving engagement and retention, and through system-wide reforms.

3.3.1. Improving treatment engagement and retention

All the health plans interviewed focus on ways to proactively engage members in treatment using data to identify high risk individuals. Health plans that are carve-in said they have the advantage of being able to track patients across treatment engagements through analysis of medical, behavioral health, and pharmacy claims.

Directors talked about the value of case management to increase access to initial and ongoing care. Across the board, directors said that case management was a valuable resource but in low supply. Health plans that carve-out sometimes keep case management services in-house to closely monitor the patient’s progress. Case management includes recovery support services (a Medicaid benefit in Massachusetts) and care management. Health plans employ case managers to reach out to high-risk individuals and follow members throughout treatment engagement. In some of the health plans, case managers are available to members who are admitted to a hospital or emergency department for medical conditions that are related to opioid use, (e.g., overdose, opioid-related infections).

A stakeholder talked about confusion that patients sometimes experience with case managers. Often the relationship is remote as opposed to in-person. “And what I’ve heard from patients is, ‘I don’t know why this person keeps calling me like I don’t understand who they are They say they’re from the insurance company that doesn’t make any sense to me.”

One specialty BH plan supports primary care physicians who are treating patients with chronic pain or have SUD, by offering consultation with an addictionologist. Other medical staff are available to members in some benefit packages. One health plan includes nursing care to medically monitor detox in the medical unit. In addition, in some plans, members who are admitted to emergency departments are able to begin induction with a qualified prescriber.

So, there’s a team that actually sits in the emergency room, and their physicians are all waivered so they can do induction while the member is in the emergency room, or if they’re medically admitted, they’ll start the induction there. Then, the triage team sets up an appointment for them with a community medication assisted treatment provider prior to discharge. So, there’s really a smooth transition when the member leaves the emergency room or the inpatient setting.

(BH Director, Carve-in)

Directors talked about other strategies to improve treatment engagement including contingency management (i.e., client incentives) if the member enters the next level of care. Plans monitor patient progress through claims data and offer additional case management and/or cash payment. One plan tried incentive payment in a pilot program and said it was unsuccessful, probably due to “inadequate financial incentive.” In addition, health plans said they use claims data to identify members who have an OUD diagnosis but have not received MOUD treatment.

The director of a carve-out said that during the COVID-19 pandemic, members released from jail could not see probation officers in person, so the plan provided them with recovery coaching as a link until they were connected to a provider in the community.

The survey data indicate that all health plans in the sample have eliminated requirements for prior authorization for MOUD, and two of the plans require prior authorization for other SUD services. One respondent said that after eliminating co-pays and pre-authorizations, outpatient retention increased, and provider satisfaction improved due to the elimination of administrative burdens.

We have, we actually have, we’ve definitely seen longer lengths of stay in the ambulatory world, and providers love it because it’s less administrative burden on them collecting a copay, finding out the benefit. You know, they just want to provide treatment.

(BH Director, Carve-in)

Survey responses also indicate that most health plans pay providers for screening members for opioid use disorder in primary and/or specialty care practices. If OUD is detected, health plans reported that they encourage the provider to prescribe MOUD.

One of the newer innovations is a “self-service app” or digital therapeutics that plans provide as a benefit. Apps can be guided imagery or self-guided cognitive behavioral therapies that patients access on their mobile devices. These apps are used to bridge the gap between discharge and outpatient care, and directors said they were especially useful during the early COVID-19 pandemic when individuals were not able to connect in person with 12-step programs or other support groups.

3.3.2. Reforms to the treatment system

A stakeholder talked about perverse discrimination that is built into the health care system as it relates to individuals who inject drugs, and suggested that health plans can play a role in minimizing harm by offering an enhanced treatment program for select patients discharged from the hospital. The stakeholder laid out a typical scenario below.

Let’s talk about people who are not sick enough to stay in the hospital, but they need some sort of stepped down level of medical care. We see patients who inject drugs, who need IV antibiotics, and if they were a person who didn’t inject drugs would just go home with a PIC line and get IV antibiotics at home. If they don’t have a home and/or because of their recent history injection drug abuse, often it’s very hard to get home infusion services set up for a person, and so they end up going in nursing homes. But because of discrimination, nursing homes don’t want to take people who inject drugs, so they get rejected from every nursing home across the state, and end up with these very limited options of where they can go. Many of these patients are young and actually don’t need a nursing home. They just don’t have anywhere to go to get their IV antibiotics.

Directors talked about reforms they have attempted to encourage better care for patients with OUD. These include (1) initiating collaborative care, (2) changing reimbursement structures, (3) eliminating differential payment between BH and medical care, and (4) tracking better metrics of care. Each is discussed below.

Health plan directors said reforms are not easy to implement across the system, especially if a limited number of plans want to pay for it. Directors said that since health plans are only one actor in the system, they have limited ability to make system-wide innovations. As an example, one plan incentivized collaborative care, but provider groups did not want to participate due to the steep learning curve involved in changing billing, coding, and documentation procedures.

A stakeholder explained that MassHealth, the Medicaid program in Massachusetts, has been a driver of some of the system-wide changes, including requiring payers to reimburse an enhanced rate for residential care. The purpose of the enhanced rate is to integrate BH into the recovery home setting, with the expectation that BH providers would be able to prescribe, initiate, and maintain people on MOUD. Additional funding is built into the daily rate. However, changing the reimbursement structure within the network has proven challenging for health plans.

We’ve interviewed a number of providers about the possibility of a value-based payment structure, where they keep patients out of detox and hospitals, and we pay them for that. We’ve had discussions with three or four different groups, and we have not had a yes with any of them.

(BH Director, Carve-in)

There’s not a lot of BH providers who want to engage in an alternative payment method, because even if you say there’s no risk at the beginning, they’re fearful that at some point they will share a risk in the future, and I think that’s very scary to them.

(BH Director, Carve-out)

Directors noted that a barrier to system-wide change is that currently, reimbursements for medical care are higher than for BH care. They see claims from a psychiatrist coded as medical even though the service was BH. A stakeholder said that residential programs are not motivated to take more complicated cases if they get paid the same rate for “easier” patients. There’s no incentive to keep people in treatment who are “resistant” and don’t show up. A stakeholder said that one of the biggest challenges to changing the treatment system is that care is siloed and providers are not incentivized to make changes to their practices.

There are really 3 silos, or 4, there’s the mental health silo, the substance use silo, the medical silo, and the pharmacy silo. People with addictions cross all the silos, so we’re in a company that doesn’t carve-out mental health or substance use to another company, so we try to be one big silo but there’s still silos within the silos.

(BH Director, Carve-in)

Stakeholders and directors said better quality metrics are needed. Most use HEDIS measures and rely on ATLAS, a tool from Shatterproof (a national nonprofit organization focused on addiction) that monitors outcomes and identifies high-quality treatment facilities in select states including Massachusetts. Many providers embed screening modules into the electronic health record, and health plans are encouraging this through reimbursement policies. Health plans look at quality metrics to determine which providers are higher performers and will steer their members to those practices.

So, I think we really need to do more of those things to improve the frequency of assessments in the primary care world. It’s hard to do it on the commercial side because unless you have some bigger providers that you’re working with it’s more difficult, because a lot of them don’t have the capacity to offer that or to change their electronic health record to accommodate it.

(BH Director, Carve-out)

One stakeholder said no matter how integrated and rational the treatment system becomes for providing care for people with OUD, the biggest barriers are the social determinants of health, such as food insecurity and housing.

Then the last piece is that probably the biggest barrier to delivering care to our patients who are most vulnerable is the fact that they don’t have housing. I think if I could prescribe housing, that would be probably one of the most important things that we could possibly do.

(Stakeholder)

3.4. Overdose prevention

Few health plans that we interviewed have initiatives to engage the community in overdose prevention and other opioid-related interventions, which is one of the goals of the HCS (Sprague Martinez et al., 2020). Rather, plans see community engagement as a state and local government responsibility. However, some plans do reach out to community groups. For example, one plan encourages their recovery coaches to build relationships with police departments and with residential programs. Another plan uses their foundation grants to help support the work of first responders and police departments.

All health plans in the sample include naloxone as a covered benefit, and most place quantity limits on it per member per month. A stakeholder said that MassHealth was ahead of the curve regarding access to naloxone. “That was the message from MBHP [a carve-out contracted by Medicaid] that if you were prescribing opioids, provide a naloxone prescription along with them.” Directors said that once the naloxone benefit was offered by public insurers, they added the benefit for commercial products, too.

Almost all of the health plans said the cost of naloxone is a barrier for their members, though pharmacy-based naloxone was usually more accessible for Medicaid members. However, they noted that stigma prevents patients from obtaining naloxone at a pharmacy.

So, I would say there are some of us who have fought and said maybe we should eliminate the cost share completely for naloxone as well, we haven’t been able to do that but we’ve tried to get it lowered and more affordable.

(BH Director, Carve-in)

4. Discussion

In this study, we found that health plans in Massachusetts are conducting a variety of activities intended to address the opioid crisis in the areas of (1) improving access to treatment, (2) safer opioid prescribing, (3) removing barriers to increase MOUD engagement and retention, and (4) naloxone distribution. Below we review the implications of the findings and how they compare to reported health plan activities in prior research. We also assess what barriers may inhibit greater plan involvement with different levels of the health care system, and sustainability of community engagement developed through HCS initiative.

4.1. Improving access to treatment

In the area of improving access to treatment, Massachusetts plans reported a variety of initiatives. Some of the initiatives matched prior reports from other states, such as the use of case managers to reach out to high-risk individuals through the treatment episode. Case management has also been used in Virginia’s Medicaid program (Bachireddy & Terplan, 2021). In the case of Massachusetts, plans reported that increasing case management was somewhat constrained by workforce shortages. Similarly, plans in many states have faced shortages of providers who are federally approved to prescribe buprenorphine (X-waivered), and plans in California too have offered bonuses to get the waiver (California Health Care Foundation, 2016), as was reported by at least one plan in the current study. Prior literature has reported that payers eliminate copayments for other chronic diseases (e.g., for diabetes and high cholesterol, under the label of “value-based insurance design” (Frank et al., 2012)), but rarely for SUD treatment.

As many of the respondents in the current study mentioned, eliminating or reducing co-payments is a complicated issue in SUD treatment, especially for commercial health plans. A few reasons may exist that health plans find changes to cost sharing difficult. Under federal rules, high-deductible plans may only allow zero copayment for services classified as preventive. Many plans classify MOUD as treatment, thus requiring a copay. In addition, although the BH Directors report they want to remove co-payments, the pharmacy benefits manager needs to agree it would be cost-effective. With so few members on MOUD (as compared to cardiac medicines), the plan may not see a return on their investment. Adverse selection may also be a factor where a health plan does not want to attract high-risk members who seek lower cost structures. Stigma is also an issue and some employers do not want to subsidize what they perceive as replacing one drug habit with another. Commercial health plans had more discretion in covering certain medications, like MOUD or naloxone, and applying utilization management strategies to those medications, which was oftentimes influenced by the purchaser (e.g., employer), whereas public health plans, like Medicaid, may be mandated by federal or state policy to cover these medications at no cost.

4.2. Safer opioid prescribing

Some of the approaches reported by Massachusetts plans have also been used by health plans elsewhere, including prescriber education and for data analytics to identify and reduce doctor-shopping (Beaton, April 5, 2018). However, the plans in the current study did not report using community-level opioid prescribing initiatives employed by health plans elsewhere, such as community-level opioid risk education (Beaton, April 5, 2018; Waddill, 2020).

It is worth noting that the proliferation of payer policies brings its own problems, as well as solutions. In Michigan, one study found that during 2014–2018, commercial and Medicaid payers implemented a large number of policies to address opioid prescribing, in addition to federal laws, and differed in the content of their policies (Arfken and Lehr, 2021). In Massachusetts too, we observed differences across health plans in which policies they adopted. Thus, a provider who is in multiple networks is bound to multiple standards. Navigating these different sets of rules can be time-consuming for both clinicians and pharmacists (Comerci et al., 2018). Relatedly, health plan policies that support one strategy may frustrate another. For example, pharmacy lock-ins reduce doctor-shopping for opioids but may also hinder access to buprenorphine among patients who use multiple pharmacies for reasons like housing instability.

4.3. Removing barriers to improve retention

In the area of improving MOUD treatment, plans that we interviewed had a number of policies that were previously observed in other states. Bundled payment per episode of SUD treatment was reported by at least one Massachusetts plan, while in other states health plans reported developing additional fee-for-service payments on top of primary care capitation (California Health Care Foundation, 2016). Similarly, plans elsewhere have also implemented interventions to increase treatment retention, such as leveraging data analytics to identify treatment disruption and then providing additional support to ensure continuation of treatment, and other forms of care coordination and case management (Bachireddy & Terplan, 2021). These initiatives are important given that around half of patients discontinue medications for MOUD within one year after initiation (O’Connor et al., 2020).

4.4. Naloxone distribution

In the area of overdose prevention, the chief activity that plans reported was encouraging providers to accompany their opioid prescriptions with a prescription for naloxone. Dual prescribing has been reported for health plans in California, too (California Health Care Foundation, 2016). In addition, some states have co-prescribing mandates as part of their naloxone access law to increase naloxone dispensing among high-risk individuals (Green et al., 2020). Plans appear to have less involvement in collaborating with community coalitions on interventions such as safe opioid storage/disposal campaigns that health plans elsewhere have promoted (Berry, 2019).

4.5. Barriers to wider engagement

Health plans’ benefit packages and initiatives most frequently target the member (micro) and provider (meso) level and few are aimed at the system level. A few reasons may explain why reforms that target the broader system are difficult to implement and sustain. Across these content areas, several barriers appear to constrain greater health plan activity to combat the opioid crisis. One barrier is the fragmentation of organization in health plans, with many plans outsourcing their behavioral health benefits to a carve-out entity, and/or their prescription coverage to a pharmacy benefits manager. Oftentimes, initiatives addressing complex problems will require coordination across these multiple entities, increasing the challenges to make broad reforms. Another barrier is the dominant fee-for-service reimbursement system, which impedes health plans from funding novel services until they obtain a recognized procedure code in the Current Procedural Terminology (CPT), which may take years to arrange. Bundled payment and capitation are ways to address that barrier. However, in this sample of health plans bundled payment and capitation have been unsuccessful or not attempted, because, as one respondent said, providers do not want to assume the risk especially if alternative payments are not provided by all insurers. Finally, stigma remains a challenge in terms of attitudes among some health plan officials, providers and others not wanting to provide care for individuals with OUD.

The current structure of health care reimbursement can frustrate attempts to engage system-wide strategies, and may play a role in constraining innovation and equity in treatment for SUD. Health plans pay providers a higher rate for medical care than for behavioral health, which can be a disincentive for providers to specialize in addiction. In addition, reimbursement for “dosage” of care is the same for clients who need more intensive care than for those who do not. Thus, residential programs and treatment centers are disincentivized to accept the “treatment-resistant” population. If all payers are not reimbursing for a service, it is hard for treatment centers to provide novel care when only a fraction of the patient population has insurance coverage for it. Additionally, health plans that carve-out behavioral health benefits are more constrained in implementing initiatives across medical, mental health, substance use, and pharmacy silos.

4.6. Sustainability of community engagement developed through the HCS initiative

Community engagement is an essential component of the HCS for ensuring the adoption and sustainability of evidence-based interventions (Chandler et al., 2020; Walsh et al., 2020). However, we found very little collaboration among health plans with stakeholders beyond the healthcare system. Building new partnerships with community-based organizations may be promising areas for health plans to engage in to improve population health. For example, health plans could partner with law enforcement to develop initiatives to link members involved in criminal justice system to treatment, which one health plan endorsed, and work with recovery community centers to improve outcomes for members after treatment. In addition, health plans may benefit from enhancing existing partnerships within the healthcare system to encourage the delivery of evidence-based MOUD at critical touchpoints, such as nonfatal opioid overdoses presenting to emergency departments or injection-related infections leading to hospital admissions (Larochelle et al., 2019).

As noted, the focus on the micro level may be because community-level initiatives may not conform with the traditional health insurance model, thus raising concerns regarding sustainability of many community-level interventions implemented by the HCS, such as linkage to treatment from community-based settings, prescription drug drop boxes, and community distribution of naloxone. It appears that Massachusetts communities will need to look for funding sources other than health plans to financially sustain community-level initiatives that are being implemented during the period of HCS funding and is likely to be true in other HCS states too. However, some health plans also operate nonprofit foundations, which could be a potential funding source for community initiatives, although this funding may not be permanent.

4.7. Study limitations

The study findings are subject to several limitations. First, the health plan officials’ responses could reflect a desire to portray their organizations in a positive light (social desirability bias), and their responses were not cross-checked against other sources such as plan documents or interviews with consumers or providers working with those plans. However, many of the questions asked whether a plan was or was not conducting a certain activity, which implies a yes/no answer, and we think respondents would have been reluctant to misreport on that type of question. Second, the number of responding plans was small and located in only one state, limiting generalizability. Nonetheless, the plans we spoke with accounted for 100% of Medicaid beneficiaries, over 97% of Medicare beneficiaries, and 91% of commercial beneficiaries. We did not have full participation of all respondents in completing both the survey and interview, making systematic data collection on some variables difficult. As in any analysis, the study had unmeasured variables that potentially affect outcomes more than we realize.

5. Conclusion

Some variability exists in how active a role health plans play in increasing access to care, even within the insurance industry in one state (Massachusetts). The current study identified a wide range of activities, 24 in total, that Massachusetts health plans are conducting to address the opioid crisis by targeting four strategy areas: access, opioid prescribing, OUD treatment, and overdose prevention. Additional research regarding financing of strategies to address the opioid crisis will foster better understanding of health plans’ motivations to concentrate their efforts in certain areas of the health care system. Specifically, more research should address why health plans appear to be most active on the member level and were generally not engaged in systemic or community-level initiatives. Looking beyond the end of HCS funding, these plans appear more likely to sustain HCS activities that target individual patients and providers, and less likely to continue the HCS focus on community-level initiatives such as community coalitions.

The health system itself is undergoing a period of transformative change, partly due to changes related to the COVID-19 pandemic that are likely to remain in some form. These innovations are happening now and will impact the delivery of OUD, as well as other addiction and mental health services. Innovations are underway to develop alternative ways of structuring the workforce, to deliver services in nontraditional settings, to deal more explicitly with social determinants related to housing and food, and to creatively use digital technologies. New opportunities are emerging to improve the quality of care and improve the lives of persons with OUD and to tame the opioid crisis in this country. Health plans are well poised to be contributors that make this happen.

Highlights.

There is a high degree of variability in how active a role health plans play in increasing access to care.

Plans appear to be more active in encouraging individual-level interventions to prevent and treat OUD and less active in promoting community-level initiatives.

We found very little collaboration among health plans with stakeholders beyond the healthcare system.