Published in Health Care
Jody Gembarski, pharmacy manager at Blue Cross Blue Shield of Michigan Jody Gembarski, pharmacy manager at Blue Cross Blue Shield of Michigan Courtesy Photo

BCBS takes steps to respond to opioid abuse

BY Sunday, August 06, 2017 03:47pm

Nearly one in five Blue Cross Blue Shield of Michigan members had a prescription for an opioid filled in 2015. The dispensing rate nationally was higher, at 21.4 percent. Between 2010 and 2016, the 36 Blue Cross Blue Shield plans across the U.S. recorded a 493-percent spike in enrollees diagnosed with a disorder associated with opioid use. Those statistics from the Chicago-based Blue Cross Blue Shield Association reflect the opioid epidemic in America that in 2016 resulted in more than 33,000 overdose deaths. MiBiz spoke with Jody Gembarski, a pharmacy manager at Blue Cross Blue Shield of Michigan who oversees its controlled substance work group, to discuss the association’s analysis and the role the state’s largest health insurer has in responding to the epidemic.

What do you make of the Blue Cross Blue Shield Association data on opioid use?

There clearly is a problem with opioids for our members and across the nation. Michigan definitely has a problem. You can see the statistics. We have a high dispensing rate of opioids and high opioid use disorder. It’s definitely a problem and we are very invested in attacking that and seeing what we can do to improve the situation for everyone involved.

What can Blue Cross Blue Shield of Michigan do?

We try to look at it on multiple different avenues. There’s no one solution that fixes this. We look at it from the providers, our physicians and health care providers that are involved with this. We have educational webinars (and) an opioid toolkit for them to use. We encourage them to check the Michigan Automated Prescribing System that will let them see if the member and their patient has gone to a physician a week before or a month before (for an opioid prescription).

What about from the member perspective?

We have a new pilot program that focuses on overdoses and trying to get those members connected to treatment or help. My controlled substance work group, what we do is we monitor claims and if somebody has a concerning behavior, we try to connect them with appropriate resources, whether behavioral health, case management, a pain management referral, or even treatment of a substance abuse disorder that they have.

Do you have a way of identifying doctors who perhaps are outside of the norm and have a higher prescribing rate for opioids?

We have a corporate and financial investigations unit. They do look at prescribers who are outliers and compare them to their peers and they investigate those prescribers. There is a whole process to evaluate physicians prescribing opioids, and we have a process to remove them from our network. A lot of times we are ahead of the state and federal government because we have our own data. We actually receive reports from the Centers for Medicare and Medicaid Services — it’s a prescriber outlier report — and we take action on that as well.

Is Blue Cross getting more aggressive in identifying outliers prescribing opioids?

We’ve definitely increased our focus there as we’re seeing how much the opioid epidemic is impacting everything. We are looking much more closely at those that are outliers and identifying what’s going on (and) why. It’s definitely a high priority for us.

Why should this be an issue for employers?

The impact of the opioid epidemic is significant. It’s raising health care costs overall with the prescribing of opioids, and then once somebody is addicted, it is very costly for the health care system. The cost for the health care system is definitely going to impact employers and everyone else involved.

What should an employer do?

Ask what type of programs are in place from the health care provider that they have. We have a list of initiatives and programs and things that we do to help identify fraud, waste and abuse. We have initiatives in providing treatment of our members. As an employer, it is worth investigating and asking the question of what’s being done from the health provider perspective? What are you doing to help improve the situation or decrease prescribing?

Is there any consensus out there on what led to the epidemic?

There are a number of factors and we all ask, ‘What’s the root cause?’ Some of the national meetings that I sit on, there is discussions about how in the ’90s there was this push about the ‘fifth vital sign’ and pain management. That was kind of the focus and people shouldn’t be in pain if they’re having pain. Maybe that fueled a little. Everyone you talk to might have a different idea about that, but that is something that is on the table. There was this focus on pain management. It wasn’t being assessed appropriately and it wasn’t given enough attention. That could be the reason that partly led to this, but that’s not the reason. I don’t think there’s one reason. There are multiple things that led to this and it’s kind of hard to point to something.

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