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Opioids: Managing costs by managing risk

OptumRx Opioid Risk Management.


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While all prescription drugs have some risk of misuse, prescription opioids have a high abuse potential. Opioids, whether taken alone or in combination with other drugs, can lead to misuse, dependency, and even life-threatening adverse events.1 The fact that millions of Americans have routine access to these powerful painkilling drugs has created a tremendous problem with many kinds of costs.2

The epidemic of opioid misuse and abuse is having a profound economic impact on individuals, employers and other groups that sponsor health insurance plans, as well as on the care delivery system. Costs associated with opioid abuse have increased dramatically in recent years, including drug abuse treatment services and lost productivity. In just five years, the claims charged to insurance companies to treat opioid dependence or abuse grew from $72 million to $722 million — an increase of almost 1,000%.3



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At the individual level, (chart below), note the vastly different amounts paid by insurance companies for non-opioid-abusing patients ($3,435) compared to the average $19,333 for patients with an opioid abuse or dependence diagnosis. Notice also that the cost to treat patients suffering from opioid dependence or abuse is already over 450% higher than for ordinary patients. And treatment costs are rising fast, up over 25% between 2013 and 2015.3

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In the graph above we can see that the average per-patient cost for treating someone with an opioid abuse diagnosis was recently just under $20,000 ($19,333). While we commonly see estimates of around 4.5 million people suffering from opioid abuse, recent estimates say that the total number of Americans suffering from opioid addiction may actually exceed 5 million people.4 A simple calculation based on these figures gives us a cost estimate for treating 5 million or so opioid-dependent persons: around $100 billion dollars.

In addition to the direct medical costs, opioids make up one-quarter of all workers’ compensation prescription drug costs. In fact, workers who take opioids for longer than three months usually never return to work at all, due to dependence or other side-effects.5

Leaving aside medical costs, prescription painkiller abuse is costing employers an estimated $25.5 billion per year in missed workdays, lost productivity, and lost earnings from premature death.5

At OptumRx, we believe that solving such a complex, deeply-embedded problem cannot be accomplished by looking only at its individual parts. Rather, it will require a comprehensive approach that we call OptumRx Opioid Risk Management.

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This is a true end-to-end solution that uses extensive education and advanced analytics to confront opioid misuse before it occurs, while also supporting the chronic opioid user and those with documented opioid use disorder in their sustained recovery. OptumRx Opioid Risk Management drives increased opioid safety and prevention through engagement, smart prescribing, and ongoing monitoring. Ultimately, our goal is to improve health outcomes and reduce overall health care costs for all of our clients.

Managing cost by managing risk

We recognize that there will always be a legitimate need for pain relief. But with millions of people receiving opioids, we need to make sure that they are receiving care in accordance with the most current guidelines. From there, we need clear and actionable data to know who is most at-risk to develop abuse or dependency problems and support anyone who does become chronic.

The OptumRx Opioid Risk Management has specific strategies aimed at limiting the risk posed by improper opioid use. We divide the problem into two parts: treating at-risk and high-risk populations, and supporting impacted populations and those in recovery.

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The graphic below illustrates how OptumRx uses sophisticated claims analysis to track opioid use and flag the sub-set of members who may be at-risk for misuse or abuse:

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Unfortunately, out of all the people who are prescribed opioids, a substantial number can end up in trouble. The key is to identify those most at-risk before that happens. OptumRx has comprehensive retrospective (“look-back”) drug utilization review (RDUR) capabilities specifically designed to look for problem patterns and intervene with prescribers closer to the point of a member’s care.

When it comes to identifying at-risk patients, we get maximum leverage out of our claims-paying role as a PBM. In this capacity, we have direct insight into which patients are getting which drugs. This insight feeds our RDUR capability.

The RDUR clinical opportunities directly contribute preventing progression to chronic use. For example, retrospective data helps identify “shoppers,” those that are using multiple physicians, pharmacies, and/or multiple prescriptions. This is key, because when patients are using multiple prescriptions it is not uncommon to see dose escalation over time, putting them at higher risk for overdose.

The system is also looking for other patterns of high risk behavior, such as early refills, or those who are using dangerous combinations of products.

But the real value lies in what we do after we’ve uncovered the unhealthy behavior patterns. With these high risk members, we understand that more high touch interventions are needed. Therefore, we offer an intensive case management program to intervene with providers caring for these individuals.

These interventions feature clinical consults with our on-staff pharmacists from our own clinical call center. They conduct intensive case management consults to address potentially dangerous activity with dispensing pharmacists and prescriber physicians. These consultations drill down into key details for individual opioid users, including overutilization, proper morphine equivalent dosing (MED), high-risk drug combinations, and instances when prescribed quantities exceed the threshold limits set for individual care providers (both pharmacies and prescribers).

Supporting chronic populations & recovery

Next we will look at how OptumRx tracks opioid use to support chronic populations and those who are in recovery. This graphic shows how the intelligent rule engine focuses on this population:

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The risk of becoming dependent on opioids is very serious, although most people do not understand just how serious it really is. A 2015 National Safety Council poll found nearly 90% of opioid users were not worried about dependency, even though 60% of those respondents reported having at least one dependency risk factor (e.g., history of alcoholism or depression, use of psychiatric medications).6

When the occasional misuse of opioid pain relievers crosses over into a more serious opioid use disorder, significant clinical problems can arise. These can include health issues, disability, and the failure to meet major responsibilities at work, school or home.6 The OptumRx Opioid Risk Management program also has a role to play in supporting chronic populations and those who are in recovery.

Our data capabilities are structured in order to flag these individuals using both our own pharmacy claims data plus medical claims data. This is most easily done when the medical and pharmacy care services are bundled within the larger UnitedHealth Group family of companies. But even when the client has chosen to keep their medical health plan separate from their OptumRx pharmacy services, we can still use near-real-time data feeds to integrate medical claims data into our intelligent claims engine to identify members at the right time through the right channel.

Pinpoint interventions

With this data, we are able to know that an individual has been in the emergency room or has been in the hospital as a result of an opioid overdose, confirmed opioid dependency or opioid use disorder. We also can discern from this data those that have had a previous history of enrollment in medication-assisted treatment or admission to a detox/ treatment facility. We also know when they've been discharged from those programs, a point at which they are most vulnerable for relapse.

This knowledge allows OptumRx to support the chronic population in critical ways. For example, many opioid abuse patients enter Medication Assisted Treatment (MAT) programs, where they are prescribed drugs like methadone or buprenorphine to help treat their addiction. We can make sure that when they are in these programs, they are not able to get other opiate prescriptions, which is too often the case today. We also have the capability of monitoring their adherence to these therapies when administered on an outpatient basis and alerting providers when they fall out of appropriate adherence.

We are also able to leverage point-of-sale programs to look for members who might relapse after one of these programs. Our advanced CDUR screens incoming claims through a member claims profile for opioid use after that person has completed Medication Assisted Treatment (MAT) therapy.

Support can extend in various ways. We can monitor and guide those with current or previous high risk status through clinically effective treatment options. These may include referral from our intensive case management program into a “pharmacy home” drug level lock-in, or beneficiary level point-of-sale edits on other controlled drugs when used concomitantly.

Finally, the new CDC opioid management guidelines recommend that clinician treatment plans should incorporate rescue drugs such as Naloxone, a drug used to reverse opiate overdose.7 In cases where there are factors that increase the risk for opioid overdose, we are working to ensure the widest possible access to these drugs.

Accordingly, we have expanded access to emergency/rescue medications to treat overdose. One practical application is that now doctors can prescribe Naloxone in a proactive, preventative fashion, putting it in the hands of the care giver, or a family member, so that if and when that patient does overdose a treatment is on hand immediately.


We have discussed other aspects of the OptumRx comprehensive approach to opioids in earlier articles.

The opioid epidemic is much closer to each of us than we may realize. Hardly anyone has not felt at least some of the impact, whether that be directly, through a family member or friend, or indirectly, among the employee populations of virtually every single client that OptumRx serves. Based upon our own prescription claims data, more than one million patients we serve today through our OptumRx services could be classified as high-utilizers of opioid medications.

At Optum, we recognize that controlling the opioid epidemic will require not just new laws, new guidelines or new administrative rules. More so, we need aggressive steps to change the current mindset and patterns of behavior relative to these drugs. These include patterns of behavior not just at the prescriber and patient level, but also for hospitals and health systems, health plans and PBMs, pharmaceutical manufacturers and educators, addiction treatment specialists and pain management clinics, and among parents and other caregivers as well.

The OptumRx Total Opioid Management approach represents our commitment to execute the massive behavioral shifts required to end the opioid epidemic.

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  1. American Society of Addiction Medicine (ASAM). Opioid Addiction: 2016 Facts & Figures. [PDF].

  2. Johns Hopkins Bloomberg School of Public Health. The Prescription Opioid Epidemic: An Evidence-Based Approach. Nov. 2015. Accessed at: http://www.jhsph.edu/research/centers-and-institutes/center-for-drug-safety-and-effectiveness/opioid-epidemic-town-hall-2015/2015-prescription-opioid-epidemic-report.pdf on 05.02.2016.

  3. FAIR Health Study: The Impact of the Opioid Crisis on the Healthcare System: A Study of Privately Billed Services, September 2016. Accessed at: https://www.fairhealth.org/publications/whitepapers.

  4. Annual Review of Public Health. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction. Vol. 36: 559-574 (March 2015). Accessed at: http://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-031914-122957 on 09.28.2016.

  5. HR Today. Combatting the Prescription Drug Crisis. March 1, 2016. Accessed at: https://www.shrm.org/hr-today/news/hr-magazine/0316/pages/combatting-the-prescription-drug-crisis.aspx on 09.23.2016.

  6. National Safety Council. Prescription Nation 2016: Addressing America’s Drug Epidemic [PDF]

  7. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. Fact Sheet: CDC Guideline for Prescribing Opioids for Chronic Pain. [PDF]
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This article is directed solely to its intended audience about important developments affecting the pharmacy benefits business. It is not intended to promote the use of any drug mentioned in the article and neither the author nor OptumRx has accepted any form of compensation for the preparation or distribution of this article

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