In 2013, we saw an alarming trend of mothers using opioids while pregnant in the Upper Cumberland/East Tennessee region. We knew we had to act. And as a mission-driven not-for-profit, we were committed to putting safety first.
“Mothers and children were really suffering,” said Dr. Natalie Tate, VP of pharmacy management. “We felt a responsibility to protect our neighbors from the risks of substance misuse and abuse.”
Our early efforts included partnerships with East Tennessee Children’s Hospital and other to support babies born dependent on the drugs, along with their mothers and pregnant women affected by substance use disorder.
From there, we took a broad approach that began with education – for health care providers, members and the public at large. Our chief medical officer, Dr. Andrea Willis, and Dr. Tate began traveling the state to meet with providers and do public events.
Next, we introduced medical policy changes that led to tens of millions fewer pills in the hands of Tennesseans. And our foundation invested more than $5.4 million in efforts across the state to provide prevention and treatment support. The most visible effort was our support of the Count it! Lock it! Drop it! education and safe drug disposal campaign.
We created an advisory group of health care providers and public health leaders in Tennessee to make sure that our approach would effectively reduce risks while still providing appropriate pain management for our members.
“These clinicians gave us deeper insights into the real-world experiences of members with acute and chronic pain issues,” said Dr. Tate. “And that helped us take a holistic and compassionate approach.”
Gradual policy changes minimized disruption while delivering results
- We introduced quantity limits on all opioids effective Jan. 1, 2016.
- We introduced prior authorization requirements for long-acting opioids for all prescriptions (including refills) on Jan. 1, 2017.
From 2015 to 2018, we saw a 26% decrease in opioid prescription claims and 19 million fewer pills dispensed, along with a drop in the strength of the opioids being used.
We made our last significant medical policy changes with an effective date of Jan. 1, 2019. Those included:
- A seven-day quantity limit for short-acting opioid prescriptions issued to members who are receiving the drug for the first time.
- An enhanced prior authorization requirement for extended use of short-acting opioids. Specifically, this will impact those who use more than 30 days’ worth of short-acting medication in a 90-day period.
- A lower threshold for morphine milligram equivalent dose (MME), with authorization required for more than 120 milligrams of opioids per day.
- Removal of OxyContin from the list of covered drugs, to be replaced with drugs less likely to be abused.
- Drug combination safety alerts for clinical teams and providers, which highlight inappropriate or dangerous drug combinations in order to promote appropriate use.
- Addition of acupuncture as a benefit for alternative pain therapy.
Staying focused led to continued impact
“The intense public focus on opioids began to fade, but we never lost sight of this issue,” said Dr. Tate. “We’ve consistently monitored opioid use in our member population since our last policy changes took effect in January 2019.”
The results show that the numbers of covered drugs has stayed flat since the initial drop caused by those changes:
- Prior to 2013, our average per member using long-acting opioids was around 127 MME. It’s now less than 60.
- Since 2019, our average per member using any opioids (short- and long-acting) has stayed around 35 MME.
- Our total opioids claims (per member per month) decreased by 20%.
Dr. Tate also noted that our opioid policy changes were never about saving money for the company.
“It actually cost us money to put these steps in place,” said Dr. Tate. “That’s mainly because we had an increased administrative burden to manage these limits for medications that are relatively inexpensive. But from the beginning, we’ve simply believed this was the right thing to do for the safety of our members and all Tennesseans.”