Governor’s Opioid State Action Accountability Taskforce · 2018/7/17 · Governor’s Opioid State Action Accountability Taskforce July 17th 2018 9:00 AM Place of Meeting: Old

Governor’s Opioid State Action Accountability Taskforce

July 17th 2018

9:00 AMPlace of Meeting:

Old Assembly Chambers Capitol Building101 North Carson Street Carson City, NV 89701

This meeting will be video conferenced to the following location:Grant Sawyer Building

Governor’s Office Conference Room 555 E Washington Avenue, Suite 5100 Las Vegas, NV 89101

Track 1PRESCRIBER EDUCATION AND GUIDELINES

Track 1 Progress Update

Dave Wuest, Deputy Secretary

Nevada Board of Pharmacy

Overview of Milestones Completed April – July, 2018

• Regulations - The State worked with the public and prescribers to promulgate Regulations to clarify AB 474. The majority of these have become effective.

• Regulations - All of the Boards that over see prescribers of controlled substances have addressed opioid continuing education by Regulation or Policy.

• The Board of Pharmacy has collected controlled substance prescription data via the PDMP.

• Preliminary analysis of the PDMP date has been completed.

National Safety Council Prescription Nation 2018: Facing America's Opioid Epidemic

• The National Safety Council is a 501 (3)(b)nonprofit, nongovernmental public service organization promoting health and safety in the United States of America.

• Independent review of each State’s fight against the opioid crisis.

• Nevada is one of three states to meet the six key actions to save lives.

• Mandating prescriber education, implementing opioid prescribing guidelines, integrating prescription drug monitoring programs (PDMPs) into clinical settings, improving data collection and sharing, treating opioid overdose, and increasing availability of opioid use disorder treatment.

https://www.nsc.org/Portals/0/Documents/RxDrugOverdoseDocuments/RxNation-2018-web.pdf?utm_campaign=Prescription%20Nation%3A%20Addressing%20America%27s%20Drug%20Epidemic&utm_medium=email&_hsenc=p2ANqtz-9VuVYEQRWXX7ZD5YGJXfEXD-FiCGdV-d0GOF-V8b39YqoNoWdzvLwYsmi8frI8cRZ-lc2BqV4pCfRklECulZ7-hVH3aQ&_hsmi=61703185&utm_content=61703185&utm_source=hs_automation&hsCtaTracking=3a0e08ed-1013-4ecf-a23d-2774c0d439ef%7C5a5359db-00ce-43e8-ac8e-53bba253eb91

https://www.nsc.org/Portals/0/Documents/RxDrugOverdoseDocuments/RxNation-2018-web.pdf?utm_campaign=Prescription%20Nation%3A%20Addressing%20America%27s%20Drug%20Epidemic&utm_medium=email&_hsenc=p2ANqtz-9VuVYEQRWXX7ZD5YGJXfEXD-FiCGdV-d0GOF-V8b39YqoNoWdzvLwYsmi8frI8cRZ-lc2BqV4pCfRklECulZ7-hVH3aQ&_hsmi=61703185&utm_content=61703185&utm_source=hs_automation&hsCtaTracking=3a0e08ed-1013-4ecf-a23d-2774c0d439ef%7C5a5359db-00ce-43e8-ac8e-53bba253eb91

Overview of Prescription Drug Monitoring Program Data (PDMP)• PDMP data is collected from all of the dispensers of controlled

substance to the residents of Nevada.

• This data is housed at the Board of Pharmacy.

• Prescribers are required to view the PDMP prior to prescribing most controlled substances to determine the appropriateness of the medication.

• The Board of Pharmacy (BOP) and the Nevada Department of Health (DHHS) utilizes the data to improve the health of the residents of Nevada.

Early Results from Implementation of AB 474:Opioid Prescription Patterns

• The BOP and DHHS have completed an initial review of PDMP data prior to January 1st 2018, the effective date of AB 474 compared to the same data sets after the effective date.

• We looked at monthly prescription totals from January 1st 2017 to May 31st 2018.

• We will review this data during our Track 3 presentation.

Priorities and Next Steps

1. Analyze PDMP data. Unit of use view.

2. Provide stakeholders and public with the data.

3. Identify policies needed to enhance current laws.

Questions and Contact Information

Nevada Board of Pharmacy

Dave Wuest

Deputy SecretaryNevada Board of Pharmacy [email protected]

Track 2TREATMENT OPTIONS AND THIRD PARTY PAYERS

Track 2 Progress Update – Stephanie Woodard

Initiatives Updates

Overview of Grants/Spending Obligations

Overview of Milestones Completed April – July, 2018

• Integrated Opioid Treatment and Recovery Center development

• Ongoing outreach and expansion by Mobile Recovery Teams into Emergency Departments

• Expansion of naloxone distribution statewide

• Needs Assessment published

• Establishment of webpage for STR information: casat.org/str

• STR year 2 RFAs were released and reviewed

Update on Track 2 Initiatives

Integrated Opioid Treatment and Recovery Center (IOTRC) Updates

• Between February 2018 and April 2018,

• 2,582 individuals accessed treatment through the IOTRC’s• 101 individuals received Peer Recovery Support Services• 300 naloxone kits were distributed• 1 opioid overdose reversal was reported back to us • 2 mobile recovery outreach teams were established


Naloxone Distribution• Between May and June 2018, the following quantities of

naloxone were distributed through the STR project:• Law Enforcement received 806 2-dose naloxone nasal kits• Integrated Opioid Treatment and Recovery Centers received

500 new doses of the 2-dose naloxone nasal kits• Community Based Organization Distribution Sites:

• Established one new CBO, Ridge House, Reno, NV; received 30 2-dose naloxone nasal kits

• Trainings with prevention coalitions: 3 trainings distributing 95 2-dose nasal kits


STR Project Expansion for Year 2 include the following category areas:

• Category 1: Outpatient Clinical Treatment and Recovery Services• Category 2: Mat Expansion for SAPTA Certified Providers• Category 3: Tribal Treatment and Recovery• Category 4: Criminal Justice• Category 5: Community Paramedicine• Category 6: Neonatal Abstinence Syndrome • Category 7: Recovery Support Services• Category 8: Community Preparedness Planning

Overview of Grants and Spending Obligations

Past and Current Funding based on Priorities

• Harold Rogers (BJA)

• STR (SAMSHA)

• PFS (CDC)

• ESOOS (CDC)

• SUBG (SAMSHA)

• STR (SAMSHA)

• Settlement (AG)

• SUBG (SAMSHA)

• General Fund

• PFS (CDC)

• Harold Rogers (BJA)

• STR (SAMSHA)

• SUBG (SAMSHA)

• General Fund

• NROOR (HRSA)

• STR (SAMSHA)

• PFS (SAMSHA)

• PFS (CDC)

• SUBG (SAMSHA)

• NROOR (HRSA)

• Settlement (AG)Prescriber Education

and Guidelines

Treatment Options and Third Party

Payers

Data Collection

and Intelligence

Sharing

Criminal Justice

Interventions

16

State Targeted Response to the Opioid Crisis (STR)• Grantor: Substance Abuse and Mental Health Services Administration

• Current funding period: 5/1/17- 4/30/19

• Current amount: $5,663,328

• Budget update:• To date, we have spent $3,062,243.93 of the first year of the opioid grant. This leaves a remaining

balance of $2,601,084.07. The total of the first year of the opioid grant is $5,663,328. According to the carry forward request this will leave a remaining projection for the first year opioid grant at $573,656.88.

• $5,663,328.00 – Total Year 1 funds

• $3,062,243.93 - Spent

• $2,601,084.07 – Remaining Authority

• $573,656.88 – Remaining Projection

• $2,027,427.19 – Requesting carry forward

• The program is currently drafting the carry over request; it is due to SAMSHA on 7/31.17

Opioid STR Carryover DollarProposed Expenditure

Activity Amount

Medication Assisted Treatment Services Expansion (through competitive RFA Process)

$1,664,000

Neonatal Abstinence Syndrome Expansionand Expansion of Services for Pregnant Women and Women with Dependent Children (awarded to organizations through a competitive RFA process)

$363,472 *

Total Federal Request for Treatment Costs $2,027,472.19

*This is the amount allocated in the carryover, additional funding in the year 2award has also been marked for this category

MAT Services Expansion

• Through a competitive RFA process, organizations will be identified that can provide MAT expansion services and work collaboratively with an Integrated Opioid Treatment and Recovery Center (IOTRC).

• Funding will be allocated to each “spoke service” delivery organization in an effort to establish a coordinated system of care through the build-out of a referral network that is inclusive of the following services:

• Peer Recovery Supports, Criminal Justice Partners, Community Paramedicine, Mobile Recovery Outreach Teams, and expansion of Residential and Transitional Housing services.

NAS Expansion and Expansion of Services for Pregnant Women and Women with Dependent Children

• NAS has been identified as an area of need to be addressed with STR funding. Continued funding will be provided to support Nevada’s first Pre-natal to Three Program for pregnant mothers who are identified as having OUD and in need of comprehensive medical and behavioral health care to reduce the incidence of NAS and provide a continuity of care.

• STR funds will continue to support trainings for SUD providers in order to build competence with working with pregnant and parenting women with OUD.

• STR funds will additionally support the expanded implementation of Nevada’s Plan of Safe Care by readying treatment providers to provide services as outlined within the plan.

Strategic Framework Partnership for Success (PFS)

• Grantor: Substance Abuse and Mental Health Services Administration

• Strategic Prevention Framework Partnership for Success (PFS)

• Current Funding Period: 9/30/13-9/29/2018

• Current Amount: $2,207,505

• Primary Activities: • Reduce the nonmedical use of RX drugs among persons 12 and older and the

consequences that result from such use, with a focus on persons ages 12-25• Implement a comprehensive prevention strategy through community education,

social marketing, media, physician training and drop boxes/take back events through funded coalitions.

Note: A new application for an additional 5 years with a potential start date of 10/1/2018 for PFS has been submitted for $2,260,000 annual budget to address Alcohol, Marijuana, and Methamphetamine prevention in Nevada.

21

Prevention for States (PFS)• Grantor: Centers for Disease Control and Prevention

• Current funding period: 9/1/17-8/31/18

• Current amount: $1,158,632 (plus $123,388 carryover from 9/1/16-8/31/17)

• Primary Activities:• Expand and improve proactive reporting• Conduct public health surveillance with PMP data and publicly disseminate reports • Identify and provide technical assistance to high-burden communities and counties to address

problematic prescribing• Conduct a rigorous evaluation on a law, policy, or regulation designed to prevent opioid overuse, misuse,

abuse and overdose• Maximize broadcasted messaging• Educate citizen of Nevada and bring awareness to the risks and signs of opioid addiction and provide

assistance in prevention and early intervention• Coordinate with local authorities to collect and track relevant criminal justice data• Improve PDMP utilization and reporting• Create an opioid data dashboard• Link deaths, hospitalizations, and prescriptions of individuals• Create mapping of funded activities to find gaps• Policy analysis and implementation• CDC’s statewide media campaign• Link health data sets and law enforcement data sets

22

Enhanced State Surveillance of Opioid-Involved Morbidity and Mortality (ESOOS)

• Grantor: Centers for Disease Control and Prevention

• Current funding period: 9/1/17-8/31/19

• Current amount: $387,763

• ESOOS Primary Activities:• Improve the timeliness of fatal and nonfatal opioid overdose surveillance.

• Identify the hospital discharge data and ED (syndromic surveillance) data for opioid incidents defined by the Injury Surveillance Workgroup.

• Develop and disseminate a report template to key stakeholders.

• Abstract data from Vital Statistics.

• Maintain relationships with statewide medical examiners and coroner’s offices.

23

Attorney General Volkswagen Settlement• Grantor: Attorney General Volkswagen Settlement

• Current Funding Period: 10/17-6/19

• Current Amount: $250,000

• Primary Activities:• Design and implement a program that promotes awareness and understanding of the

dangers and consequences of RX drugs misuse.• Connect those at risk of developing RX drug dependency or abuse to preventive services• Provide education on the dangers of RX misuse, neonatal exposure, youth accidental

overdose.• Provide resources for chronic pain management and preventative services programs to

avert RX drug misuse and dependency.• Provide the location s of where unused RX drugs can be taken for disposal and destruction• Promote the awareness of proper storage of RX drugs• Naloxone for law enforcement.

24


1. Finalize application for new CDC 2018 Opioid Overdose Crisis Cooperative Agreement Supplement– Due June 30th

Nevada allocation: $2.55 million; new award for 12-months

2. Continue to assess spending for each award; redirect where needed

3. Continue to coordinate between funding streams to ensure no duplication

Questions and Contact Information Nevada Division of Public and Behavioral Health

Stephanie Woodard, Psy.D.Licensed [email protected]

DHHS Senior Advisor on Behavioral Health State of Nevada, Division of Public and Behavioral Health 4126 Technology Way, Carson City, Nevada 89706

Julia Peek, MHA, CPMDeputy [email protected]

Division of Public and Behavioral Health 4150 Technology Way, Carson City, Nevada 89706

mailto:[email protected]


Health Plan of Nevada Opioid Initiatives

Governor’s Accountability Task Force

Laurine Tibaldi, M.D.

Timothy Justice, M.D.

Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

Introduction

Health Plan of Nevada is committed to:

- Preventing opioid misuse and dependence

- Connecting people to effective, timely treatment for opioid dependence

- Providing support to help individuals sustain recovery

- Supporting providers with evidence based pain management modalities

28


Health Plan of Nevada & UnitedHealthcare Sites-Opioid Community Partnership

29

• Little Rock, AR

• Phoenix, AZ

• Palm Beach, FL

• New Orleans, LA

• Winston-Salem, NC

• Las Vegas, NV

• Dayton, OH

• York, Hanover,

Lewisberry, Gettysburg,

Columbia, PA

• Nashville, TN

• Dallas, TX

Five Interventions Selected

Physician Practice Modification

Prescription Over-utilizers

Neonatal Abstinence Syndrome Reduction

Naloxone Promotion

Medication-Assisted Treatment (MAT)

Physician Interventions


Pain ManagementOpioid Prescribing Trends

A 38% decrease in total prescriptions and average unique utilizers

was identified over the past two year years.

30

8,000

10,000

12,000

14,000

16,000

18,000

20,000

Prescriptions Unique Utilizers

Prescribing rates of Opioids trend Q3 2016 vs Q2 2018


Pain Management Policies

31

• On all opioid prescriptions

• Limit early refills and stockpiling

• Threshold increased from 75% to 90% on opioids and other controlled substances CII-V

Narrowed Refill

Window

New to therapy

short acting

opioid dispensing

limits

Opioids + Prenatal

Vitamins point

of sale alert

• Dispensing limits for short-acting opioids for opioid naïve members (opioid naïve defined as members with no paid opioid claims in the past 60 days)

• 7-day limit

• Max dose of less than 50 morphine equivalent doses (MED)

• Point of sale alert for patients that have concurrent claims for short acting opioids

• Point of sale alert for concurrent use of opioids and buprenorphine products

• Point of sale alert for patients that have concurrent claims for long acting opioids

• Higher risk for overdose in patients taking both opioids and benzodiazepines

• Point of sale alert for concurrent use of opioids and benzodiazepines

Drug Interaction

• Point of sale alert for concurrent use of opioids and prenatal vitamins

Opioids +

Benzodiazepines

point of sale alert


Pain Management Policies (cont.)

32

• Our programs have a strong focus on preventing progression to opioid misuse and abuse

Track opioid usage

& identify high-risk

individuals

Supply limits on

long-acting

opioids

Cumulative

morphine

equivalent dose

(MED) limit in place

• For non-cancer pain, supply limits adhere to CDC recommendations of 90 MED daily

• No quantity ceiling limit for cancer or end-of-life diagnoses

• Appropriate use criteria (non-cancer pain)

• Step through short-acting opioid (non-cancer pain)

• Step through preferred long acting opioids

• Less than 90 morphine equivalent dose (MED) supply limit (non-cancer pain)

• Quarterly identification of members who are getting multiple opioid prescriptions from multiple prescribers and filling at multiple pharmacies

Prior

authorization on

all long acting

opioids

• Point of sale dosage limit for all opioid products

• Prevents cumulative opioid doses above a preset threshold from processing

• Prior authorization required for doses above a preset threshold

Pharmacy

Lock In program


Pain ManagementCoverage for Non-pharmacological Treatment for Pain

Health Plan of Nevada recommends alternative treatment options for common pain

conditions, in accordance with clinical guidelines. While these options may not be

appropriate in all clinical situations, we do encourage members and their doctors to

consider non-pharmacologic and non-opioid alternatives when deciding on the best

course of treatment for chronic pain.

• CDC guidelines recommend the consideration of non-opioid medications

before an opioid medication is prescribed for pain management.

• Before considering prescription drugs for the treatment of pain, it’s important

to first explore the use of a non-pharmacologic treatment, or an approach

without medication.

33


Medication Assisted TreatmentPrescribing Trends

34

Prescribing rates for Medication Assisted Treatment (MAT) have

increased 115% over the past two years.

0

50

100

150

200

250

300

350

400

450

500

Prescriptions Unique Utilizers

Prescribing rates of MAT Q3 2016 vs Q2 2018


Medication Assisted Treatment

35

• Removed prior authorization requirements for Vivitrol

• Effective, August 1, 2018 pharmacy removing prior

authorization requirements for MAT oral therapy

(Buprenorphine and Buprenorphine combination

products)

• Removed Behavioral Health services prior

authorization requirements

• Increased the number of MAT Providers

- Educating Suboxone providers on new expanded

capacity rules

Behavioral Healthcare Options has developed

educational information for members and providers

• Education on use of STAT-line

• Assist PCP’s in differentiating patients that have a

tolerance from those that have developed a

substance use disorder

• Liveandworkwell.com (Addition Recovery Tools)

Individuals Participating in Methadone

Clinic Medication Assisted Treatment

Unique Members

2017 1,549

2018 1,190


Co-Prescribing Naloxone Trends

36

Total Naloxone prescriptions over the past two years.

0

10

20

30

40

50

60

70

201

6-7

201

6-8

201

6-9

201

6-1

0

201

6-1

1

201

6-1

2

201

7-1

201

7-2

201

7-3

201

7-4

201

7-5

201

7-6

201

7-7

201

7-8

201

7-9

201

7-1

0

201

7-1

1

201

7-1

2

201

8-1

201

8-2

201

8-3

201

8-4

201

8-5

201

8-6

Naloxone Prescriptions

0

1

2

3

4

5

6

7

8

9

201

6-7

201

6-8

201

6-9

201

6-1

0

201

6-1

1

201

6-1

2

201

7-1

201

7-2

201

7-3

201

7-4

201

7-5

201

7-6

201

7-7

201

7-8

201

7-9

201

7-1

0

201

7-1

1

201

7-1

2

201

8-1

201

8-2

201

8-3

201

8-4

201

8-5

201

8-6

Naloxone Prescriptions for Non-Opioid Users

(Co-prescribing trends Q3 2016 vs Q2 2018)


Co-Prescribing Naloxone

37

HPN’s website includes Co-Prescribing Naloxone education

HPN provider advocates provide education to providers

Physicians and Emergency Departments (EDs) may want to consider

prescribing Naloxone along with the member’s opioid prescription*

With proper education, patients on long-term opioid therapy, and others at

risk for overdose, may benefit from having a naloxone kit prescribed in the ED

to use in the event of overdose

Candidates for kits include those who are:

• Taking high doses of opioids for long-term management of chronic malignant

or non- malignant pain

• Receiving rotating opioid medication

If you identify a patient who is abusing prescribed opioids:

• Develop a plan for managing the patient, typically involving work with the

patient and the patient’s family.

• Refer the patient to an addiction expert for assessment and placement in a

formal addiction treatment program, long-term participation in a 12-Step

mutual help program such as Narcotics Anonymous and follow-up of any

associated medical or psychiatric comorbidities

Source: amhsa.gov > SMA overdose toolkit

The American Medical

Association’s Opioid Task Force

encourages physicians to consider

co-prescribing naloxone when it is

clinically appropriate to do so.


Neonatal Abstinence Syndrome Prevention Efforts in Nevada

38

Prevalence of NAS for 25 states, 2012-2013,

from CDC (Nevada = 4.8)

• Neonatal Opioid Withdrawal Syndrome (NOWS): Withdrawal

symptoms (irritability, seizures, vomiting, diarrhea, fever and

poor feeding) in newborns

• Neural tube defects: Serious problems in the development or

formation of the fetus’ brain or spine

• Congenital heart defects: Problems affecting how the fetus’

heart develops or how it works

• Gastroschisis: Birth defect of developing baby’s abdomen or

where the intestines stick outside of the body through a hole

beside the belly button

• Stillbirth: The loss of a pregnancy after 20 or more weeks

• Preterm delivery: A birth before 37 weeks

2016 CDC study showed:

- In 2013 six in 1000 babies were born with NAS

This has tripled since 1999

- Nevada’s rate at the time 4.8/1000

- The sale of prescription opioids nearly quadrupled

between 1999 and 2014


Neonatal Abstinence Syndrome Prevention Efforts in Nevada

39

• Neonatal Abstinence Syndrome letters

• Inform providers of prescribing to women who were pregnant and if baby was impacted by NAS

• HPN has worked with two large Obstetric groups

• Adopted universal screening to help with early identification and treatment during pregnancy

• Contracted with High Risk Pregnancy Center in Efforts to lower NAS symptoms

• Perinatologists in process of MAT certification to manage patient (Goal to wean off, or reduce to lowest possible dose)

• High Risk Obstetrics Case Management for intervention

• Behavioral Health Complex Case Management for intervention

• NAS treatment pilot – EMPOWERED

• Partnership in program started at St. Rose Dominican Hospital

• Nevada Perinatal Quality Collaborative (5/18 Meeting Launch)

• Key community stakeholders in attendance including providers, universities, health department, and payers; working together

to improve the quality of care for mothers and babies.

• One of the top proposed key initiatives is prevention and treatment of NAS. Funding is a key next step.

• Healthy pregnancy App (Q3 2018 Launch)

2017

Medicaid NICU LOS Avg LOS

No Opioids 606 10383 17.13

Opioids 139 3268 23.51

2016

No Opioids 576 9461 16.43

Opioids 112 2092 18.68

HPN Neonatal Intensive Care

Admissions and Length of Stay


Five Intervention Strategies

40

Intervention Critical Measure 1 Critical Measure 2


Increased rate of compliance with CDC

recommendations (an aggregate measure

of decreased average daily MED and

length of initial script and other CDC

recommendations)

Decreased rate of opioid new start

members

Prescription Over-utilizersReduced rate of high-dispensing

pharmacies

Reduced rate of high-cost opioid

claimants

Neonatal Abstinence

Syndrome (NAS) Reduction

Increased proportion of pregnant women

never exposed to opioids during pregnancy

Increased proportion of pregnant

women with OUD/OD on MAT

Naloxone PromotionIncreased rate of naloxone scripts filled by

members with OD/OUD

Decreased rate

of overdoses

Medication-Assisted

Treatment

Increased rate of MAT in members with

OUD/OD

Increased rate of continuation of MAT

after initiation (follow through with

therapy)



41

Safe use of opioids

Proper Disposal

Treatment Alternatives for pain

Before Treatment

Begins

• Assess pain and function

• Consider non-opioid therapy

• Discuss patient’s treatment plan

• Evaluate risk of harm or misuse

During Treatment

• Start low and slow and evaluate effectiveness before increasing

• Assess, tailor and taper

• Treat overdose and addiction

Immediate Access to Provider

Capitated Provider

Stat LineSober Living

Inpt. Detox

Counseling

PHP

IOP

MAT

Prescriber MAT

Certification

Inpt Rehab

Peer Support

Community Resource

for on-going

HPN Promoting the Southwest Medical initiative to provider an in house multi

disciplinary pain clinic

Recovery &

Resiliency

PCP SUD

Training

Behavioral Health

Southwest Medical

Source: www.cdc.gov/drugoverdose/prescribing/guideline.html cdc.gov > A-Z topics > opioids > information for providers > resources

http://www.cdc.gov/drugoverdose/prescribing/guideline.html

42

Questions

Laurine Tibaldi, M.D., Chief Medical Officer

Health Plan of Nevada

702-797-2131

Timothy Justice, M.D., Medical Director

Behavioral Healthcare Options

702-364-1484

Anthem Blue Cross Blue Shield Healthcare Solutions

Opioid Accountability Initiatives

2018

COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY

Presented by: Lisa Thompson, M.D.Associate Medical Director

Introduction

4

4


• Anthem is working to transform health care with trusted and caring solutions

• Anthem serves more than 40 million people within its health plans and is one of the nation’s leading health benefits companies

• Our Nevada health plan, Anthem Blue Cross and Blue Shield, has been serving the state for nearly 50 years

• Through our affiliated health plan, Anthem Blue Cross and Blue Shield Healthcare Solutions of Nevada (formerly Amerigroup) and our care delivery system CareMore Health, we serve over 234 thousand members in our government-sponsored health benefits programs including Medicaid and Medicare

• Overall we provide a superior breadth of healthcare solutions that deliver a better, more personalized experience for our patients

SHORT-ACTING OPIOID ANALGESICS

Limited to a 7 days’ supply per fill and 14 days’ supply per 30 days before requiring a prior authorization.

LONG-ACTING OPIOID ANALGESICS

Require prior authorization. Individuals currently using a long-acting opioid analgesic will not require prior authorization.

Reduce the amount of opioids dispensed by 35% by the end of 2019

Anthem Pharmacy Programs and Strategies

Goal:

45

RETROSPECTIVE MONITORING: Provider Engagement

• Members attempt to fill > 10 claims in 90 days• Concurrent claims• Opioid fill after claim for Suboxone• 3 opioids, 3 prescribers, 3 pharmacies, 3 months• Claims > 120mg of MME

PRESCRIPTION OPIOID MANAGEMENT

EARLY IDENTIFICATION AND TREATMENT

• Limiting initial prescriptions for short-acting opioids

• Requiring prior authorization for all long-acting opioids

• Covering MAT for members• Cover naloxone• Drug list strategy

Prefer non-opioids over opioids• Pharmacy Home program

• Improving MAT access through PCP recruitment

• Controlled Substance Utilization Monitoring (CSUM) Program

Impact of Anthem Pharmacy Program Strategies on Nevada Medicaid Opioid Utilization

Since 10/1/16, Anthem has seen 27% reduction in opioid utilization measured as RX/1000 and a slight reduction in Units/RX in our Nevada Medicaid Plan

52.0

54.0

56.0

58.0

60.0

62.0

64.0

66.0

68.0

70.0

0.0

100.0

200.0

300.0

400.0

500.0

600.0

700.0

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

2016 2017

RX per K

Units per RXShort Acting Opioid 7 Day Edit 10/1/16

Hydrocodone added to Short Acting Opioid 7 Day Edit 7/1/17

Since 10/1/16, Anthem has seen a 28% increase in medication assisted treatment measured as RX/1000 and a slight reduction in Units/RX in our Nevada Medicaid Plan

Increase in MAT for our Nevada Medicaid Plan

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

2016 2017

RX per K

Units per RX

We have seen a 3 fold increase in naloxone prescriptions

Metric 1: prescriptions/1000Metric 2: paid/prescription

Neonatal Abstinence Syndrome: Prevalence of NAS Related to Opioids

• In 2017, 96 members were identified by our case management team with multiple claims related to neonatal abstinence syndrome or “NAS”

• At least 13 members were identified as meeting the criteria for pregnant women with known substance use disorder and received outreach from our case management team

• Unfortunately we have many moms who are using illicit drugs or unreported narcotics

• Often these moms get limited, late or no prenatal care at all


Neonatal Abstinence Syndrome: Prevention Efforts


2 Unique Programs

• A specialized case management program that focuses on pregnant women with substance use issues

• OB case managers monitor prescription claims

• When the OB case managers identify members receiving buprenorphine prescriptions, they reach out to them,motivate them to actively engage in their care and connect them to resources

• A coordinated program through collaboration with Wellcare and Renown’s Pregnancy Center in Reno

• Pregnant moms who are using illicit drugs or who are struggling with substance use disorder are assigned to an addiction specialist at Wellcare and an Obstetrician at Renown to get the support they need throughout pregnancy, delivery and post-partum

Anthem Blue Cross Blue Shield Healthcare Solutions NevadaInnovative SUD Initiatives

Program Description Outcomes

“Lock-in” List • Pharmacy “lock-in” team• Identifies members who meet criteria

for potential misuse/abuse (i.e. > 5 controlled substances, > 3 opiates in past 45 days, >2 pharmacies, >3 providers)

• Approximately 656 members on current list

• Members are “locked-in” to a specific pharmacy and their prescription utilization is closely monitored

Partial Hospitalization Program (PHP)/Intensive Outpatient Program (IOP)

• Our case management team is actively engaging with members while they are in the inpatient facilities

• Case managers get “buy-in” from the members to participate in partial hospitalization or intensive outpatient programs

• Case managers facilitate discharge planning and help work around the usual delay to post-acute treatment

• Member buy-in and engagement achieved prior to discharge from inpatient facility

• Removal of barriers and delays to continuity of care

• Improved coordination of care including transportation and connection to community resources

Nevada Anthem Blue Cross Blue Shield Healthcare Solutions Innovative SUD Initiatives


Wellcare IntensiveOutpatient Program

(IOP)

• Program provides support and addresses barriers to recovery such as providing transportation to appointments

• Wellcare is permitted to dispense suboxone and vivitrol

• As a result of the WellcareIOP, there are several success stories of memberswho completed the program and who are now employed, maintaining their therapy, remaining compliant with medical care and even living independently in some cases

Tracking Controlled Substance Utilization in the Substance Use Disorder (SUD) Population

• The program tracks the prescribing of Benzodiazepines and Opiates in the SUD population in order to reduce rapid readmissions to inpatient facilities

• Providers are educated while members are in an inpatient facility and, when appropriate, providers are asked to taper or discontinue these meds.

• Additional inpatient days are authorized to reduce risk of severe withdrawal.

• The same education and requests are also reinforced in joint operating meetings between the facilities and our utilization management team

• Active for about 1 year• The number of members

discharged on a controlled substance has reduced

• Providers have expressed appreciation for the additional inpatient days to provide safe detox.

Nevada Anthem Blue Cross Blue Shield Healthcare Solutions Innovative SUD Initiatives


High Outreach to Promote Engagement (H.O.P.E.)

• An integrated behavioral health andphysical health case management program targeting high utilizers of emergency room and inpatient services

• Provides care coordination and promotes engagement in treatment

• Field-based and telephonic support

• Local Certified Peer Support Specialist willmeet members in the field

• Program launched May, 2018

Nevada Recovery Coach

• A case manager who specializes in substance use disorder management connects with members while they are still in the hospital and begins intervention before they are discharged

• The case manager continues on-going follow-up telephonically after discharge

• Motivational interviewing techniques are utilized and members are connected to community resources

• Improved continuity of care for recent detox patients

CONTACT INFORMATION

Lisa Thompson, MDAssociate Medical DirectorAnthem Blue Cross and Blue Shield Healthcare [email protected]

Jeannine MurrayPharmacy Account Director, MedicaidAnthem, [email protected]

Tracey WoodsSenior Director, Government RelationsAnthem Blue Cross and Blue Shield Healthcare [email protected]

Confidential and Proprietary InformationConfidential and Proprietary Information 55

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SilverSummit HealthplanTransforming the Health of the

Community, One Person at a Time

Tom Beranek – Director, Pharmacy

July 17, 2018


Introduction

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circle can

go here.

SilverSummit Healthplan is a wholly-owned subsidiary of Centene Corporation,

a Fortune 500 company.

• The company is committed to improving the health of the community it serves one individual

at a time. We’re here to treat the whole person by breaking down barriers to accessing care,

walking members through their benefits and connecting them to the resources they need.

• Established July 1, 2017

• Serving Nevada Medicaid and Nevada Check Up members • Clark – 48,179

• Washoe – 6,821

• Offices in Las Vegas and Reno • Over 120 employees


Pain ManagementOpioid Prescribing Trends

2,749

23,448

34,900

43,942

50,945

55,065

2.84%

4.45%

2.59%

2.44%

-

10,000

20,000

30,000

40,000

50,000

60,000

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

4.50%

5.00%

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

MC

O P

op

ula

tio

n

Rat

es

SSHP Population 2017-2018

Note: SilverSummit Healthplan launched effective 7/1/2017. Rate is the percentage of members with Opioid Prescriptions.


Pain ManagementPolicies Related to Prescribing

• Methadone (Dolophine) CP.PPA.20

• Opioid Analgesics CP.PPA.12

• Oxycodone SR (Oxycontin) CP.PPA.04

• Point of Sale edits are in place for retail fills


Pain ManagementCoverage for Non-pharmacological Treatment of Pain

• Chiropractic It is the policy of Centene Corporation that chiropractic services are medically necessary when

meeting the most current policy criteria

• Physical Therapy and/or prescribed Home Exercise Program Step therapy requirement prior to approval for injections for pain management

• Cognitive Behavioral Therapy Covered benefit

• Interdisciplinary Rehab Covered benefit



Prescribing Trends

2,749

23,448

34,900

43,942

50,945

55,065

0.07%

0.37%

0.30%

0.27%

0.24%

-

10,000

20,000

30,000

40,000

50,000

60,000

0.00%

0.05%

0.10%

0.15%

0.20%

0.25%

0.30%

0.35%

0.40%


MC

O P

op

ula

tio

n

Rat

es


Note: SilverSummit Healthplan launched effective 7/1/2017. Rate is the percentage of members with MAT.



Policies

It is the goal of SilverSummit Healthplan to maximize opportunities for clients

to receive effective and successful treatment for Substance Use Disorders.

Medication Assisted Therapy Products:

• Disulfiram(Antabuse®) No authorization required or limitations.

• Oral Naltrexone (ReVia®) No authorization required or limitations.

• IM Naltrexone (Vivitrol®) PA required CP.PHAR.96

• Buprenorphine(Subutex®) PA Required CP.PMN.82

• Buprenorphine/naloxone (Suboxone® ) PA Required CP.PMN.81


Co-Prescribing NaloxonePrescribing Trends

2,749

23,448

40,235

55,065

0.07%

0.05%

0.04%

0.05%

-

10,000

20,000

30,000

40,000

50,000

60,000

0.00%

0.01%

0.02%

0.03%

0.04%

0.05%

0.06%

0.07%

0.08%


MC

O P

op

ula

tio

n

Rat

es


Note: SilverSummit Healthplan launched effective 7/1/2017. Rate is the percentage of members with co-prescribed Naloxone.


Co-Prescribing NaloxonePolicies and Education

Policy/Criteria CP.PMN.47

It is the policy of health plans affiliated with Centene Corporation® that opiate

use while concurrently on buprenorphine/naloxone or buprenorphine is

medically necessary for members meeting the following criteria:

1. Opiate prescriber must complete the Opiate with Concurrent

Buprenorphine/Naloxone or Buprenorphine Prior Authorization request Form

2. Opiate prescribing provider must notify the buprenorphine/naloxone or

buprenorphine prescriber and seek approval of the use of the prescribed

opiate therapy.

3. Opiate therapy prescribed is 7 days or less.


Neonatal Abstinence SyndromePrevalence of NAS Related to Opioids

NAS Newborns Rate per 100 Births

NAS Newborns Rate per 100 Births

YrMONTH SSHP Membership TOTAL BIRTHS NAS Babies Total Health Newborns NAS Newborn Rate Per 100

2017-07 2,749 2 1 1 50.0

2017-08 8,629 10 1 9 10.0

2017-09 16,778 30 5 25 16.7

2017-10 23,448 38 0 38 0.0

2017-1129,243 57

3 54 5.3

2017-12 34,900 80 6 74 7.5

2018-01 40,235 99 9 90 9.1

2018-02 43,942 106 9 97 8.5

2018-03 46,684 112 5 107 4.5

2018-04 50,945 145 7 138 4.8

2018-05 54,126 142 6 136 4.2

2018-06 55,065 149 3 146 2.0


Neonatal Abstinence SyndromePrevention Efforts

Care Management Team completes relevant screenings and assessments to

identify needs, barriers and motivation to change

Team develops a member-centric Care Plan that coordinates care among all the

involved providers, including OB, PCP, psychiatrist, addictionologist and other

specialists

Education and support provided to the member regarding services and community

resources to address the identified needs and gaps in care

Care managers focus on member’s motivation to change based on individual

needs

Complex cases discussed and reviewed by the multidisciplinary team, which

includes the medical director, medical and behavioral health care managers,

pharmacy coordinators, and outpatient providers


Innovations in Nevada

Corporate OpiEnd - Prescription Opioid Reduction through Policy

Program Summary

Clinical Programs is leading an initiative to systematically address opioid misuse and

abuse; from addressing prescriber behavior, inappropriate member utilization, to

preventing opioid addiction. Phase 1 of the program includes implementation of an

updated narcotic analgesics policy and notifying providers of the policy change in

order to reduce opioid prescriptions to opioid naive members. The goal of the

program is to reduce the amount of opioids that naive members can receive, thus

reducing the incidence rates of opioid abuse.


Innovations in Nevada

Overcoming the SUD Epidemic

Integrated Care Management (ICM)• Team comprised of both medical and behavioral health staff

• Predictive modeling identifying high risk members

• Single point of contact for both members and providers

• Ensure the member is connected with a PCP

• Establish and maintain an integrated care plan accessible to

the member to improve quality of care

.



Contact Information

Tom Beranek, Director Pharmacy (775)834-9211

[email protected]

Nicole Figles, VP Medical Management (775)834-9242

[email protected]

Tanya Phares, Chief Medical Director (775)834-1502

[email protected]




Foundation for Recovery – Dona Dmitrovic

DEFINITION OF RECOVERY COMMUNITY ORGANIZATION

An independent, non-profit organization led and governed by representatives of local

communities of recovery. Organizations are formed around recovery focused policy advocacy,

recovery focused community education and outreach and/or provide peer based recovery

support services. The sole purpose is to mobilize resources within and outside of the recovery

community to increase long term recovery.

CORE VALUES OF THE RCO

• Recovery vision: The RCO, leaders and members have a singular goal: enhancing the quality and quantify of support available to people seeking or in recovery.

• Authenticity of voice: The RCO represents one or more communities of recovery.

• Independence: Most credible and effective as a stand along entity

CORE STRATEGIES

• Build a strong, grassroots organization that develops leaders, offers opportunities for recovering people and provides a forum for community service.

• Advocating for meaningful representation and voice for people in recovery and families that affect their lives.

• Assessing needs related to adequacy and quality of local treatment and recovery support services.

• Educating public, policymakers and service providers about multiple pathways to recovery.• Develop human and fiscal resources.• Advocate for policy changes at the local, state and federal levels to promote recovery and

remove barriers to recovery.• Celebrate recovery from addiction through public efforts and living testimony.

• Supporting research to illuminate effective strategies and process of long term recovery.

PEER BASED RECOVERY SUPPORT SERVICES

• Peer-based recovery support services that are distinct from professionally-directed clinical services offered by treatment organizations or other helping institutions.

• Peer support is defined as “offering and receiving help, based on shared understanding, respect and mutual empowerment between people in similar situations.”

• Peer recovery support services are a wide range of activities that include: one-to-one coaching, housing, transportation, vocational training, employment services, telephone support, support groups, system navigation, recovery resource dissemination, life skills training and recovery focused social activities.

• There is a conscious effort to achieve cultural diversity, emphasize leadership development within the community and focus on the individual’s recovery other than their problem.


• Peer recovery support services are strengths-based, build on recovery-oriented systems and offer hope.

• Support is adaptable across the continuum of care and distinguished from:

Professional Treatment• Professional treatment providers are accredited and licensed• Staff/counselors are credentialed, licensed and/or certified• Need to define roles


Mutual Aid Groups• Beliefs and practices of recovery fellowship• Sponsors or other indigenous community support not to be replaced• Differences

Operate in relative isolation from professionals Particular fellowship philosophy “Limited to desire to stop drinking / using” Focused on 12 step tools Not reimbursed Not accountable by formal organizational code of ethics

• Facing Addiction in America, the Surgeon General’s Report on Alcohol, Drugs and Health (2016), dedicates an entire chapter to Recovery, “The Many Paths to Wellness” outlining the transformation of our health and social service system into a recovery oriented system of care addressing addiction through a chronic care management model.

• The President’s Commission on Combating Drug Addiction and the Opioid Crisis (November 2017), recommends the Department of Health and Human Services include guidelines and reimbursement policies for recovery support services including peer to peer programs, job and life skills training, supportive and recovery housing.

• Legislative bills focused on funding services for substance use disorder particularly opioid addiction.

REPORTS FOCUSED ON PRSS

PEER SUPPORT SERVICES – STATE OF NEVADA

• Training / Education• Certification - PRSS / IC & RC• Medicaid billable• Partnerships with organizations

Center for Behavioral Health (STR Grantee)Nevada Behavioral Health (MH Drop In Center)

PEER SUPPORT SERVICES – STATE OF NEVADA

• Challenges, Issues or Barriers to Implementation

• Next Steps

• Priorities for Next Quarter

Questions?

Thank you!

Dona M. Dmitrovic, Executive DirectorFoundation for Recovery

[email protected]


Track 3DATA COLLECTION AND INTELLIGENCE SHARING

Track 3 Progress Update – Kyra Morgan, State Biostatistician, DHHS

Presentation of Emerging Data Capabilities and

Recent Data Trends

Opioid Data Collection and SurveillanceProjects in Place• Overdose Reporting – AB 474

• Prescription Drug Monitoring Program – Impact Analysis of AB 474• http://dpbh.nv.gov/Resources/opioids/DHHS-data/DHHS-Opioid-Data/

• OD MAPS• DHHS signed a data sharing agreement in order to gain access in early July.

• Opioid Dashboard• https://opioid.snhd.org

• Nevada Opioid Surveillance Report• http://dpbh.nv.gov/Resources/opioids/DHHS-data/DHHS-Opioid-Data/

http://dpbh.nv.gov/Resources/opioids/DHHS-data/DHHS-Opioid-Data/

https://opioid.snhd.org/

http://dpbh.nv.gov/Resources/opioids/DHHS-data/DHHS-Opioid-Data/

Information and TrendsOverdoses in Nevada – Reporting under AB 474

• 534 reports from 43 facilities received (2/1/18 – 5/31/18)• 85% with diagnoses listed

• 73% with ICD 10 code of T40, T41.1, T42, T43 (388)

• Compared to 2/1/17 – 5/31/17 statewide ED billing dataset• 1,551 records with T40, T41.1, T42, T43

• Completeness varies widely by facility• Anywhere from 136% to 0% of what was reported in 2017

Data as of 7/3/2018

Information and TrendsPrescription Drug Monitoring Program (pre/post AB 474)

103,174 95,358

106,360

95,534 102,804 101,153

93,687 101,154

91,888 92,848 87,081

82,389

62,656

53,152 56,331 53,162 54,340

104,592 98,465

110,494

99,477 106,583 104,914

97,733 102,062

91,964 92,666 90,443 88,760 91,526 84,617

91,939 87,124 89,984

-

20,000

40,000

60,000

80,000

100,000

120,000

Opioid Prescriptions With <30 Days Supply

Opioid Prescriptions With >=30 Days Supply


Top 10 Diagnoses on Opioid Prescriptions by Days Supply, 2018 (Jan - May)

-

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

M5

4G

89

F11

K0

2M

25

K0

4K

08

M5

1R

52

R1

0

< 30 Days Supply

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

M5

4

M5

1

M4

7

G8

9

M2

5

M5

0

M7

9

M9

6

M4

8

F11

>= 30 but < 90 Days Supply

-

50

100

150

200

250

300

350

400

M5

4

M5

1

M2

5

G8

9

M7

9

M4

7

M1

7

M1

9

M1

5

G4

3

>= 90 Days Supply

• M54: Dorsalgia (back pain) was the most common diagnosis regardless of the days’ supply of the prescription. • F11: Opioid related disorders


-

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,0002

01

7-1

20

17

-2

20

17

-3

20

17

-4

20

17

-5

20

17

-6

20

17

-7

20

17

-8

20

17

-9

20

17

-10

20

17

-11

20

17

-12

20

18

-1

20

18

-2

20

18

-3

20

18

-4

20

18

-5

<50 MMEs Prescriptions

<50 MMEs Patients

>= 50 but <90 MMEsPrescriptions

>= 50 but <90 MMEs Patients

>=90 MMEs Prescriptions

>=90 MMEs Patients


• 1-3 priorities that will be accomplished or in progress in next 2-4 months

1. Continue to monitor and improve overdose reporting under AB 474 (NAC 441A) and the impact of AB 474 on prescribing patterns.

2. Onboarding and monitoring of ODMAPs.

3. Analyses of criminal history repository and the impact of specialty courts (Washoe County pilot analysis).


Kyra Morgan

Chief BiostatisticianDepartment of Health and Human Services, Office of AnalyticsState of Nevada

[email protected]

Track 4Criminal Justice Interventions

Terry Kerns, Substance Abuse/ Law Enforcement Coordinator, Office of the Attorney General

Criminal Justice Information and Data Sharing

• Overview of overdose mapping system• Jurisdictions signed up with ODMAP

• Humboldt County• Carson City• North Las Vegas

• Discussions with other jurisdictions to sign on with ODMAP

• Churchill County• Douglas County• Washoe County

In-State Incinerators

• Mineral County (Hawthorne) – Fully operational

• Nye County (Pahrump) – Installed but waiting on vent to be installed

• Boulder City – Submitted paperwork to EPA, power to the pad has been installed, waiting on cement pad to be poured.

• Elko County – Has permit and began cutting asphalt to start cement work week of 7/9/2018

• Storey County (Lockwood) – Pad is poured, installing gas line, power, and fencing.

Nye County Incinerator

Statewide Partnership on the Opioid Crisis (SPOC)

• Meeting held March 8, 2018

• Two subcommittees• Information sharing of real time data (ODMAP) (May 15,

2018)• Coroner Training (May 14, 2018)


• 1-3 priorities that will be accomplished or in progress in next 2-4 months1. Work with jurisdictions already signed up with overdose

mapping system to implement response plans

2. Bring additional jurisdictions onboard with overdose mapping system and assist with response plans

3. Monitor progress on incinerator installation and use


Terry Kerns

Substance Abuse/ Law Enforcement CoordinatorOffice of the Attorney General [email protected]


Cross-Cutting InitiativesDisposal Efforts and Naloxone Distribution

Prepared for the

Governor’s Opioid State Action Accountability Taskforce

July 17, 2018

Linda Lang, Executive Director

Nevada Statewide Coalition Partnership

April 28, 2018 – 8,012 pounds collected statewide

Disposal Efforts – Take Back Days

Other collections

Coordinated by Coalitions – Clark – 2,601 pounds

Coordinated by Coalitions – North and Rural – 21 locations – 7

counties – 4,740 pounds

Coordinated by DEA – Clark – 3,272 pounds

Disposal Efforts – Deterra and DisposeRx

1,480 Deterra bags distributed to 10 community coalitions

1,710 DisposeRx packets purchased (2,000 on back order)

Safe Disposal trainings – 32 trainings in 12 counties

11 trainings to date

7 counties

Over 225 attendees

Naloxone Distribution

Partnerships with CASAT and SNHD

1. Conduct 12 naloxone distribution events in 7 counties by

the end of August.

2. Collaborate with CADCA (Community Anti-Drug Coalitions

of America) to bring 50,000 Deterra bags to Nevada by

mid September.


Thank you for your time.

Linda Lang, Director

Nevada Statewide Coalition Partnership

[email protected]

775-450-7333