In this section we describe how health plans can ensure their members receive appropriate treatment, including safer pain management, care coordination, and communication between the health plan, member, and the member’s care team.
- Augment benefits: How to support safer pain treatment options
- Coordinate services: How to coordinate services and improve communication among members, providers, and the health plan
Health plans should review their benefit packages to ensure they include nonpharmacological approaches to pain management, such as acupuncture, physical therapy, counseling, or hypnosis. It is important that members have access to these treatment options without copayments or other provisions (e.g., authorization requirements) that may discourage their use. In this section we include examples of health plans offering nonpharmacological benefits for pain.
How to Do It
- Review benefits for comprehensive approaches to chronic pain management.
- Identify and remove obstacles or disincentives (e.g., remove copays and authorization requirements for physical therapy).
- Educate the provider network and work with it to ensure that members access benefits.
Health Plan Stories
Central California Alliance for Health
Inland Empire Health Plan
Oregon-based Samaritan Health announced in 2016 it would remove prior authorization requirements and session limits for patients seeking physical therapy to treat pain. The change was in response to emerging evidence showing movement therapy and exercise could improve back pain. Prior to this, Oregon Medicaid altered its Medicaid plan to allow beneficiaries to access physical therapy and other nonsurgical and nonpharmacologic approaches to back pain as the priority treatment.
- America’s Health Insurance Plans: STOP Playbook: How Health Plans Are Tackling the Opioid Crisis (PDF)
- Aetna News: “Aetna Announces New Policies to Improve Access to Narcan, Combat Overprescribing“
- California Health Care Foundation: “Changing the Approach to Pain Treatment” (video)
- California Society of Addiction Medicine
- Camden Coalition
At-risk members can often feel lost and unsupported when navigating the health care system. Health plans can support at-risk members through care management and coordination services. Health plans can also be proactive in alerting providers about at-risk members and ensuring providers are part of a larger care team working with members. In this section we share stories that show the impact of communicating with providers about their patients’ overdose events and include a template for communicating with providers about available resources for safer pain management and medication-assisted treatment (MAT).
How to Do It
- Identify at-risk members and their providers (see first step in the Provider Network section).
- Assess members’ needs.
- Coordinate necessary services.
- Monitor progress and close the loop with providers, including communication about overdose events.
Health Plan Stories
Aetna’s Behavioral Health Medication Assistance Program works with physicians to counsel and manage patients with or at risk for addiction. These patients receive behavioral health services, and the Aetna team develops and tracks treatment plans for opioid dependence. The program has shown a 30% improvement in opioid abstinence rates, 35% reduction in hospital admissions, and a 40% reduction in total paid medical costs.
Blue Cross Blue Shield of Massachusetts
As part of its Prescription Pain Medication Safety Program, Blue Cross Blue Shield of Massachusetts hired social workers to contact plan members admitted to detox facilities to coordinate next steps for treatment.
Partnership HealthPlan of California
PHC developed an Outreach and Understanding Can Help (OUCH) team of case managers trained to work with members with opioid use disorder (OUD). The case managers supported members as they tapered and/or transitioned to medication-assisted treatment. Although these specially trained case managers were initially dispersed throughout the care coordination department, today all PHC case managers are trained to work with members who have OUD.
Washington State Health Care Authority
San Francisco Health Plan (SFHP) is using the PreManage ED communication tool to link to most San Francisco hospitals. Through this tool, SFHP case managers receive near real-time notifications of admissions and insights into shared care planning.
Prescriber Resource Letter
The following letter was developed by the California Department of Public Health in March 2017 and contains guidance for prescribers in addressing prescription opioids with their patients. We recommend reviewing the letter, adjusting it to reflect additional guidance and resources your health plan offers, and providing a health plan contact who can assist and provide additional information as needed. Download below.
Download this tool: Prescriber Resource Letter (PDF).
- Centers for Disease Control and Prevention: Quality Improvement and Care Coordination: Implementing the CDC Guideline for Prescribing Opioids for Chronic Pain