Rx Summit: Local solutions to crisis require collective effort

Several northern California counties are making inroads in reducing opioid overdoses through the “collective impact” of groups that include a health insurer and community coalitions, two leaders told an overflow audience today at a workshop session of the National Rx Drug Abuse & Heroin Summit.

The presenters told the pre-conference workshop audience that the most dramatic results have occurred in counties in which both Partnership Health Plan (which serves the Medi-Cal population) and the Opioid Safety Coalition Network have a presence. The outcomes have included guidelines that have reduced improper opioid prescribing, and increased capacity to offer medication treatment for opioid dependence.

“Collective impact is an evolving science,” said presenter Matt Willis, MD, MPH, public health officer with Marin County Health and Human Services. “We're developing an evidence base as we work. The goal is significant and lasting social change.”

Willis and Robert Moore, MD, MPH, chief medical officer for Partnership Health Plan, also gave credit to the California HealthCare Foundation, which in 2014 launched an opioid safety initiative designed to promote safer prescribing and expanded availability of naloxone for overdose reversal and buprenorphine and other medications for treatment. Thirty-two California counties have established local safety coalitions, which have been a source of community problem-solving and prescriber mentoring.

Advice for communities

Willis said some basic actions by the safety coalition in Marin County have helped to build momentum for responses to the opioid crisis. “If you just find a way to describe [the problem], people will come,” he said.

One way to start: show the data, he said. In Marin County, narcotic prescriptions had increased from just over 41,000 in 2004 to nearly 105,000 in 2013—those numbers didn't need much additional explanation. “One of the other ways to get people to the table is to talk about mortality,” Willis said. “We had families that were willing to talk about what happened to them.”

Safer prescribing has been the earliest success story for the coalitions, the presenters said. Expanding medication treatment has been more difficult to come by in some communities, however. Typical responses from the medical community on offering buprenorphine treatment in some locations have included, “We're not set up to handle criminal people,” Moore said.

Insurer's role

The actions that the insurer took in communities such as Marin County clearly captured the interest of the audience in Atlanta, with many local community leaders from across the country represented. Moore said Partnership Health Plan instituted prior-authorization changes that “probably were the biggest reason we were successful.”

These included requiring physicians to provide justification for high-dose prescriptions and dosage escalations, and limiting new prescriptions of short-acting opioids that could be approved without prior authorization. “We didn't say, 'You can't do it,'” said Moore. We said, 'You have to explain.'”

At the same time, the health plan expanded coverage for non-medication treatment alternatives such as osteopathic manipulation therapy and chiropractic care, although Moore acknowledged that the latter ended up being a high-cost item as well and didn't demonstrate a direct effect on reducing prescribing.

Moore's comments left some in the audience asking how they might convince commercial insurers to be as proactive about responding to the opioid crisis as the California Medi-Cal plan has been.