In the fight against opioid addiction and abuse, many health plans and PBMs are turning to data

Health Care Current | May 22, 2018

This weekly series explores breaking news and developments in the US health care industry, examines key issues facing life sciences and health care companies, and provides updates and insights on policy, regulatory, and legislative changes.

My Take

In the fight against opioid addiction and abuse, many health plans and PBMs are turning to data

By Sarah Thomas, Managing Director, Deloitte Center for Health Solutions, Deloitte Services LP

We recently saw some good news on opioids—that the rate of prescribing is down significantly.1 To the extent that some of the problem lies with too many prescriptions, fewer prescriptions could lead to less addiction, treatment, and mortality over time.

Despite this good news, I think the legacy of the opioid epidemic will be with us for years. Many industry observers agree that the rates of addiction, overdose, and death will probably get worse in the coming years before they start to improve.2

The toll this epidemic has taken on individuals, families, and communities is absolutely heartbreaking. Addressing the problem will likely take the combined efforts of many stakeholders—from governments at all levels, health care stakeholders, and human services agencies.

The Center for Health Solutions recently conducted research to find out what health plans and pharmacy benefit managers (PBMs) are doing to help address the opioid epidemic. Health plans and PBMs have a stake in improving care outcomes, and they have key assets—especially data—that could be used for diagnosis and treatment.

We interviewed 35 clinical, pharmacy, data analytics, and policy leaders from health plans and PBMs across the country. We found that a growing number of health plans are taking a data-driven, evidence-based approach to help change patient and physician behavior. Although data analytics is a core part of their strategy, the health plan and PBM executives we interviewed cited a number of barriers that kept them from using data to its full potential. One critical challenge is the need for evidence-based standards and stronger quality metrics to define successful treatment. Quality metrics and standards could help advance value-based care payment models for prevention and treatment.

Treatment gaps can be mapped
There are evidence-based treatments for opioid-use disorder. Medication-assisted treatment (MAT) is defined by the Substance Abuse and Mental Health Services Administration (SAMHSA) as the use of medications in combination with counseling and behavioral therapies. The medications used in MAT could help block other narcotics or help ease withdrawal symptoms—they do not cause the euphoric high associated with opioid misuse. However, these treatments are often underused.

Deloitte developed an interactive map using data to highlight where MAT treatment gaps persist in the US. We found that just over half of the treatment facilities that offer opioid-addiction treatment do not offer any form of MAT.

Our interviewees emphasized the importance of patients having access to some form of MAT. Many of them said that the lack of standardized quality outcome measures for opioid treatment can make it challenging to secure high-quality treatment for members. Some health plans are working with community and quality-focused organizations and researchers to validate treatment-outcome measures. These health plans are sharing their medical, pharmacy, and behavioral health data and intend to develop quality measures for treatment.3

Moving forward, our research shows that many health plans and PBMs want to evolve value-based payment models along with the rest of the health care system. Value-based payments for behavioral health issues—including opioid disorders and substance-use disorders—have traditionally lagged behind medical and surgical conditions. One major challenge is often the lack of standardized quality measures. Some health plans are piloting programs around prevention and treatment and are advocating for policy changes to address the limitations in data.

Despite some limitations in the availability and completeness of data, many health plans and PBMs are using the information and evidence they do have to develop leading practices. Technology is also playing a key role in their strategies, and many stakeholders expect emerging technologies to have an increased role in the future. For now, virtual care, including telehealth to improve access to MAT treatment, is a strategy that appears to be growing more common. Digital therapeutics, such as mobile apps to help with prevention and treatment, are also being used. Many health plans, however, seek further evidence regarding which apps work for specific populations, and at which point on the prevention-and-treatment spectrum.

For many health plans, addressing opioid misuse among their members and within communities is an important strategy for improving health outcomes. Many PBM stakeholders told us that taking on this challenge is a critical part of their mission, and it is an opportunity to mitigate future financial risk while maintaining their reputation.

While we are only beginning to understand how to address root causes of opioid abuse and addiction, and how to improve long-term outcomes, I found the results of this study to be optimistic.

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1 New York Times, April 19, 2018 (
2 Max Blau, STAT forecast: Opioids could kill nearly 500,000 Americans in the next decade, June 27, 2017
3 Shatterproof Launches Substance Abuse Use Disorder Treatment Task Force, April 18, 2017


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In the news

Beyond the blueprint: HHS releases plans to address drug prices

On May 11, the president and the secretary of the US Department of Health and Human Services (HHS) proposed several initiatives targeting drug prices. The administration simultaneously released its blueprint, American Patients First: The Trump Administration Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs (see the May 15, 2018 Health Care Current). As discussed in a recent RegPulse blog, the blueprint’s proposals include both immediate actions and longer-term solutions to help make drugs more affordable, such as reducing out-of-pocket costs and increasing competition in the market. On May 14, HHS Secretary Alex Azar spoke in more depth about the first of these proposed initiatives, which focus on payment reform and price transparency.

  • Proposal would move Medicare Part B drugs into Part D
    In a May 14 press briefing, Azar discussed moving some expensive medications administered in physician offices, such as cancer drugs, from the Medicare Part B program into the Part D program, which could allow Part D plans to negotiate over their price. 
    • Related: The Pharmaceutical Research and Manufacturers of America (PhRMA), an industry association, said the proposal to shift Part B drugs into Part D might raise patients’ out-of-pocket costs. The association also raised questions about how such a shift might interact with Part D's “protected drug classes" law, which requires plans to cover drugs for certain conditions.
  • Azar suggests restructuring drug rebates
    Azar also discussed preventing pharmacy benefit managers (PBMs) from negotiating discounts with drug manufacturers as a percentage of list prices during his May 14 briefing. Under these arrangements, rebates increase with drug prices. Azar said one option might be to limit PBMs to rebates that would be based on a set amount, rather than a percentage of the drug price. Another option might be to ban PBMs from receiving any payments from drug manufacturers.
  • CMS updates Medicare and Medicaid drug price dashboards
    The US Centers for Medicare and Medicaid Services (CMS) updated its Medicare and Medicaid drug price dashboards on May 15 to improve price transparency for consumers. These interactive databases, launched in 2015, provide information about how much the agency spends on prescription drugs for Medicare and Medicaid beneficiaries. In a press release announcing the dashboard updates, CMS stated that it spent 23 percent of its total budget on prescription medications in 2016—up from 17 percent in 2012.

    During his May 14 briefing, Azar proposed further efforts to improve transparency, such as requiring manufacturers to include the prices of their drugs in direct-to-consumer advertisements. He also proposed eliminating the “gag rule” in some PBM contracts, which keep pharmacists from informing patients that they can get some drugs at a lower price by going outside of their insurance plans.
  • Administration seeks comment on proposed 340B changes
    On Monday, May 14, the administration released a request for information (RFI) seeking comments on the ideas in the Blueprint for changes to the 340B drug-discount program. This program allows certain hospitals and other entities to pay less for drugs than other organizations.

House bill would expand private-sector services to veterans

Bipartisan legislation that would make it easier for veterans to receive care in the private sector passed by a 347-70 vote in the House on May 16, and is poised to win approval in the Senate. The VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (VA MISSION) Act would create new rules about the circumstances whereby the Department of Veterans Affairs (VA) would pay for care for veterans outside of VA facilities. It also could create a process for closing some VA facilities.

The Congressional Budget Office (CBO) estimates the bill would cost nearly $52 billion between 2019 and 2023. The legislation would appropriate $5.2 billion in mandatory funding to the Veterans Choice Program, which allows veterans to seek care at commercial facilities when the services they need are not offered at a VA facility, or when there is no full-service medical facility in their state. About 2 million veterans have used the program since it was created in 2014, but funding could run out by the end of this month. The legislation seeks to keep the Choice Program running for another year before ending it permanently. By then, the new program is expected to be operational.

According to CBO, most of the bill’s expected costs are tied to provisions that would expand community health care to veterans and increase eligibility and benefits for caregivers. The VA would develop the rules for seeking private-sector care following the parameters in the legislation. In a May 15 memo, the president signaled strong support for the bill.

Maryland announces federal approval of all-payer health model

On May 14, Maryland officials announced federal approval for the state’s Total Cost of Care All-Payer Model. The new model starts January 1, 2019 and runs through 2023, with an option to extend the program for an additional five years.

Maryland’s current model, approved in 2014, does not provide comprehensive coordination of services across the health care system. The new model was developed to:

  • Coordinate care across both hospital and non-hospital settings, including mental health and long-term care.
  • Invest resources in care that focus on the patient and enhance primary-care teams to improve individual patient outcomes. 
  • Set a range of quality and care improvement goals and provide incentives for providers to meet them.
  • Concentrate system and community resources on population health goals to help address opioid use and deaths, diabetes, hypertension, and other chronic conditions.
  • Encourage and facilitate programs that focus on the unique needs of Marylanders across geographic settings and other key demographics.

Maryland’s current all-payer model saved Medicare more than $586 million through 2016 (see the April 3, 2018 Health Care Current). Hospitals reduced unnecessary readmissions and hospital-acquired conditions, and per-capita hospital costs decreased. The new model is expected to save an additional $300 million per year by 2023, and a total of $1 billion over five years.

New interactive resource provides detailed city-level population health data

A new online tool from the Department of Population Health at New York University offers interactive health data from cities across the country.

The City Health Dashboard contains maps providing 36 health measures for the 500 largest US cities. Topics include social and economic factors, the physical environment, health behavior, health outcomes, and clinical care. Some maps break the data down by census tract, which can provide insight into disparities within cities.

The website also includes an extensive list of links to resources—on everything from activity programs to zoning regulations—for people who want to improve health in their communities.

The City Health Dashboard website notes that more than 80 percent of Americans live in urban areas, and about one-third of the population lives in the 500 largest cities.

AHRQ: Not enough research exists to say apps for diabetes are effective

Countless mobile apps claim they can help individuals manage diabetes. However, few of these apps have been studied, and even fewer have been associated with improved patient outcomes, according to a review by the Agency for Healthcare Research and Quality (AHRQ).

AHRQ identified 15 studies that researched 11 apps. Of those apps, five were associated with reduced HbA1c levels, two targeted Type 1 diabetes, and three were used for Type 2 diabetes. None of the studies found any apps that improved blood pressure, weight, body mass index (BMI), or quality of life. Moreover, AHRQ did not consider any of the studies to be high-quality due to methodological problems.

Overall, the agency said it could not draw conclusions about whether diabetes-management apps help patients without independent support from a health care provider. Stronger, longer-term studies are needed on this topic, according to AHRQ.

(Source: Agency for Healthcare Research and Quality, “Mobile Health Applications for Self-Management of Diabetes,” May 2018)

Depression diagnoses in adolescents, millennials have increased, study finds

Between 2013 and 2016, diagnosis rates for major depression increased by 33 percent among adults, according to results of a study from the Blue Cross Blue Shield Association (BCBSA). During the same period, diagnosis rates increased from 1.6 percent to 2.6 percent among adolescents and from 3 percent to 4.4 percent among millennials. The report, Major Depression: The Impact on Overall Health, is part of BCBSA’s Health of America initiative. According to the study, which is based on medical claims data from the Blue Cross Blue Shield Health Index, 4.4 percent of BCBS members have had a diagnosis for major depression. Women are diagnosed with major depression at a rate of 6 percent, which is double the percentage for men.

The report also shows how major depression diagnoses are linked to other chronic health conditions. According to the Health Index, 85 percent of people diagnosed with major depression also have one or more serious chronic health conditions, and nearly 30 percent have four or more other health conditions. Additionally, those diagnosed with major depression use more health care services than others, which results in double the spending on health services, according to the report.

Breaking Boundaries

Telehealth combined with AI could help patients and clinicians

Health care is starting to catch up with other industries. Consumers no longer have to travel to brick-and-mortar buildings to receive top-notch health care services. Some mobile apps are diagnosing and monitoring conditions, and are providing critical information to consumers that traditionally could only have been delivered by a clinician.

ResApp Health, an Australian start-up, recently created an app that can listen to people’s cough and breathing to diagnose and measure the severity of a wide range of chronic and acute conditions, such as pneumonia, asthma, bronchiolitis, and chronic obstructive pulmonary disease. Instead of a physician or nurse listening to a patient’s lungs via stethoscope, ResApp can detect sounds and interpret them using machine learning. The app matches the sounds to a large database of recordings that are associated with clinical diagnoses. Studies indicate that the algorithm developed by the company is precise enough to offer an accurate diagnosis based on sound alone, without a physical exam.

A recent study in the Journal of the American College of Surgeons shows high rates of satisfaction among patients and physicians who use a smartphone app to monitor post-operative wound recovery and to detect wound complications. Patients used the app to transmit digital images of their surgical wounds and answered a series of questions about their recovery. Preliminary results indicate the app gave patients the ability to detect and intervene on wound complications in a way that is more convenient than traveling to the hospital or physician’s office.

Many digital companies focus on heart-disease monitoring apps and devices. Heart disease is the most common cause of death around the world, so these tools could make a huge impact. People can have dangerous heart irregularities, but not notice symptoms. Smartphones that can diagnose these irregularities could prevent cardiac events and trips to the emergency room. The trick is to figure out which of these apps and wearables offer real value to clinicians.

Children who receive chemotherapy are prone to heart conditions and need to get an ultrasound every two weeks to monitor dosage. Engineers at the California Institute of Technology are working on an app that can accurately measure how much blood the heart pumps with each beat—as arteries expand and contract. Patients hold their smartphone camera up to their neck for less than two minutes. The camera measures the expansion and contraction of the artery walls, and an algorithm analyzes the information to calculate the blood flow from the heart. Early studies show the app is as accurate as an ultrasound.

Analysis: The challenge for patients and physicians is that the technology is advancing faster than researchers and clinicians can gather the evidence they need to incorporate these devices into clinical practice. According to the May 2018 AHRQ study referenced in the story above, few of the countless apps on the market to help manage diabetes have been studied and even fewer have shown improved patient outcomes. But as research continues, many more people could gain access to diagnostic and monitoring tools and avoid having to go to a specialist who could be located hours away. If we are able to build a strong evidence base for what apps and devices work accurately in what populations, we also could potentially see lower emergency room use if people monitor their health more proactively.

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