Changing Course: The Role of Health Plans in Curbing the Opioid Epidemic

By Donna Laverdiere, Margarita Pereyda, Jason Silva, Margaret Tatar

Health plans have a critical role to play in curbing the opioid overuse epidemic — both through prevention (lowering the rates of addiction and complications from long-term opioid use) and treatment (ensuring affected members get the care they need). As primary payers for prescription drugs, health plans are in a position to influence the behavior of providers and patients.

Although some health plan actions are relatively easy to implement — such as restrictive formulary changes — this approach, if taken in isolation, risks harming members and alienating providers. Instead, Changing Course: The Role of Health Plans in Curbing the Opioid Epidemic argues that health plans need to invest broadly in four areas to make a lasting difference in prescribing culture, and ultimately, in the health of the population:

  1. Supporting judicious prescribing practices through formulary changes and provider education
  2. Focusing on improved member outcomes, especially for those at highest risk: members on high doses of opioids, those taking high-risk medication combinations, and members with addiction
  3. Identifying and acting upon overuse, misuse, and fraud
  4. Supporting safe communities through participation in opioid safety coalitions, and promoting naloxone

This report also highlights three California health plans that launched major opioid safety initiatives to address the threat to public health and to the health of their members, each reducing opioid prescribing by 25%-50% through a series of coordinated activities. A companion paper, Case Studies: Three California Health Plans Take Action Against Opioid Overuse, reviews these programs in depth. A second companion paper, published in 2017, reviews the case for health plans to expand access to addiction treatment: Why Health Plans Should Go to the “MAT” in the Fight Against Opioid Addiction.

The full report and the case studies paper are available as Document Downloads.

There are additional resources available for payers and providers at Smart Care California, a public-private partnership working to promote safe, affordable health care in California.