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Payers Have Important Role in Reducing Opioid Harm

Health insurance companies can play a central role in limiting the harm of opioids, according to a 2017 white paper by the Healthcare Fraud Prevention Partnership (HFPP). In “Healthcare Payer Strategies to Reduce the Harms of Opioids,” the HFPP encourages appropriate care and prescribing practices for patients; identifying and eliminating fraud, waste, and abuse within the healthcare system; and supporting dissemination of information about effective opioid misuse strategies. The HFPP is a voluntary collaboration among major health insurance companies, the Department of Health and Human Services, and several state-level agencies concerned with Medicaid fraud.

The white paper describes 5 “specific actions that should be strongly considered for implementation by all payers as soon as possible.”1 Detailed examples and potential strategies for each action are included. The recommended actions are:

  1. Train providers on the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain. The HFPP suggests that incentives might be offered to providers to achieve knowledge of and adherence to the guideline. The authors recommend developing Continuing Medical Education (CME) materials to educate providers about the guideline, adding, “One option payers can take to increase the use of CME is to actively encourage all network providers, with enhanced outreach to those with high prescription rates, to take an approved course on opioid prescribing guidelines.” Outreach visits to providers may offer additional benefits.
  2. Promote access to and usage of medication-assisted treatment (MAT). “MAT, in combination with behavioral therapy, is more effective in treating [opioid use disorders] than behavioral therapy alone, and its use should be widely promoted and reimbursed,” the authors write. Increased use of MAT faces numerous hurdles, they note, including limited knowledge about the option among patients and families, “limited attention to MAT among many abstinence-only advocates and organizations,” and insufficient supply of behavioral health and treatment services and physicians with MAT experience, especially in rural areas. As part of the strategy to increase availability of MAT, they recommend use of the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach, which has been widely used for alcohol use disorder. Recently passed federal legislation has expanded the number of MAT waivers to physicians and other healthcare providers to allow more non-physician specialists to prescribe MAT.
  3. Promote the availability of naloxone. The authors recommend “reducing unnecessary barriers to the availability of, and reimbursement for, naloxone,” calling it “a responsible and ethical response to a significant public health crisis.” In response to multiple concerns about increased naloxone use, the HFPP states, “While there may be concern that liberal access to naloxone results in moral hazard in the form of excess opioid misuse in the face of fewer consequences, studies have shown that heroin users consistently report that they are not more comfortable using heroin frequently or in higher doses because of naloxone availability. Providers may have concern as to whether co-prescribing naloxone for patients with pain increases provider liability. In fact, researchers have reported that prescribing naloxone is not associated with legal risks any greater than prescribing for any other medication.”
  4. Encourage the use of data to identify fraudulent, wasteful, or abusive practices associated with opioids to target corrective actions. Data analysis and sharing within and across payer entities should be encouraged, they write, in order to identify at-risk patients, and prevent non-prescribed use and diversion of opioids. “This information can help direct investigative resources and appropriate interventions.
  5. Identify and disseminate effective practices across the healthcare sector. The report recommends that every action taken be accompanied by data collection, allowing analysis of different strategies for development of best-practices recommendations.

“The HFPP strongly supports and promotes collective and coordinated action to combat the crisis of negative health consequences that result from the intended and unintended misuse of prescription opioids,” the authors conclude. “The consequences of inaction on this issue are dire in terms of public health impact and increased medical costs…These priority actions should be strongly considered for implementation.”


1Healthcare Fraud Prevention Partnership. Healthcare Payer Strategies to Reduce the Harms of Opioids. Center for Medicare and Medicaid Services. 2017.