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1120 North Charles St.
Suite 200
Baltimore, MD 21201
(410) 542-4470
www.discernhealth.com
Panel with the Rural Carrier
Benefit Plan
Improving Care for Rural
Communities At-Risk for Opioid
Abuse and Addiction
October 21, 2019
2
Welcome and Introductions
Cameron Deml, BBA, Director of Insurance Programs
National Rural Letter
Carriers’ Association
(NRLCA)
Terry Flander, DO,
Consultant Medical Director
Rural Carrier Benefit Plan
(RCBP)
Ted Borgstadt, BA, CEO and Co-Founder
TrestleTree, LLC
Donna Dugan, PhD, MS,
Vice President
Discern Health
3
Learning Objectives
▪ Discuss challenges facing health plans, providers, and community-
based organizations serving rural residents at-risk for opioid abuse,
addiction, and behavioral health conditions
▪ Identify best practices for improving care coordination, engaging
members and providers, and strengthening community partnerships
to address the opioid epidemic in rural communities, and in turn
improve related quality measure performance
▪ Apply strategies from a national rural population health program to
tailor to local community needs
4
About the NRLCA
▪ Represents over 116,000 rural letter carriers’
of the Postal Service.
▪ Plan Sponsor of the Rural Carrier Benefit Plan
▫ Part of Federal Employee Benefits Program
(FEHB) since program inception in 1960
▪ RCBP serves more than 63,000 lives
▪ Closed plan
▫ Only available to active and retired rural
carrier members of the NRLCA
▪ Unique benefits (e.g., 100% cancer coverage)
5
RCBP Challenges and
Opportunities
Disparate, rural population
▪ Range of demographic needs
▫ Members 40 years old and 90 years
old on the same benefit chassis
▫ Average member age: 57 years
▪ Serve every zip code in America
▪ Access to care
▫ Typical for an RCBP member to
drive over 15 miles to their primary
care provider (PCP) and over almost
20 to the hospital
Relevant care needs
▪ Care needs relevant to carriers
▫ Back pain
▫ Musculoskeletal (MSK) conditions
▫ Repetitive motion injury
▪ Opioid crisis
▫ Given rural membership, and in
relation to pain and MSK conditions,
appropriate use and overuse of
opioids is of particular concern
6
Opioid Crisis
Challenges
▪ Society’s answer to solving opioid crisis over the last three years:
1. Limit quantity
2. Base limitations on morphine equivalency
3. Tougher, more aggressive enforcement of illegal opioids
▪ While necessary, pendulum may have swung too far in the opposite
direction
▫ Before 2015 – Opioids prescribed freely without scrutiny
▫ After 2015 – more stringent, but necessary, restrictions put in place
▪ Pain is subjective
▫ There is no standard prescribing guidance for pain medications
Current strategies don’t address the biggest underlying issue
of the opioid crisis: Pain!
7
Real Member Stories
Issue: Quantity Limit
• 94-year old retiree
• Can’t get out of bed without fentanyl
patch
• Hip and back issues
• Plan limits put in place in 2018 would
have prevented him from getting the
pain patch and relief he needed to live
on his own
• Determined regular use did not pose
an undue risk
• Exception made to fill pain medication-
as prescribed by his doctor.
Issue: Access and Social
Determinants
• Early 70s retiree in rural Florida who
didn’t have access to resources for
pain med refill
• Pharmacist would hand-deliver opioid
meds, but left position
• Previous prescriber stopped writing
opioid Rx
• No car
• RCBP assisted with transportation and
worked with area providers
8
RCBP Vision
▪ Primary goals of the RCBP:
▫ Complement our members’ health, providers, and well-
being
▫ Eliminate hurdles where possible
▫ Never be a burden to the member
▫ Invest in our members’ long-term health
▫ Provide members with more than just access to a
network of doctors, hospitals and providers, pay claims,
care management, etc.
9
TrestleTree Overview
▪ RCBP and TrestleTree partnered together
since 2015
▪ Expertise in behavior change for less
motivated or non-adherent members, with
a focus on whole-person care
▪ 18 year book of business outcomes
▫ Diabetes: 67%
▫ High Blood Pressure: 78%
▫ High Cholesterol: 79%
▫ Weight loss: 57%
▫ Tobacco Cessation: 53% (ITT)
10
Comprehensive Pain
Management Program
▪ Pain/musculoskeletal related costs
▫ Top 1 or 2 spend categories for RCBP
▪ Pain is fiercely unique to each person
▪ TrestleTree’s approach to behavior
change a strong fit for pain and MSK
with RCBP population:
“Building a relationship of Trust
and Earning the right to influence”
TrestleTree Model
Match & Move
11
MSK-Cascade Analysis
RCBP Musculoskeletal Cascade % of % of Avg Cost/
Total Lives Total Cost Member
Total Population 100% 100% 7,303$
TrestleTree Coachable Conditions 80% 89% 8,168$
Musculoskeletal (MSK) Diagnosis 74% 84% 8,274$
MSK and Coachable Conditions 64% 77% 8,789$
MSK and 3+ Coachable Conditions 35% 57% 10,488$
MSK and Related Surgeries 17% 44% 19,572$
Opioid users 6% 20% 25,010$
Opioid users and MSK 5% 18% 25,832$
12
Opioid Risk Prediction
▪ Tool predicts opioid addiction, substance use disorder, and
overdose with 90%+ precision
▪ C-index of .90 - .93
▪ Provides individual risk score using 320 variables found in medical
and prescription claims data
▪ Developed by Brad Martin, PharmD, Ph.D., UAMS School of
Pharmacy
▪ 4 million opioid users over a ten year period in analytical data set
▪ All IP and exclusive rights acquired by TrestleTree in 2018
13
Opioid Risk Prevention
▪ Behavior change intervention for at-risk individuals prescribed an
opioid
▪ Unique approach to behavior change enables a more contextual
understanding of patient predisposition for opioid abuse, such as
family, culture, finances, social factors, etc.,
▪ TrestleTree’s expertise is helping people change tough health
behaviors who struggle with change
▪ Whole-person approach to health behavior change allows influence
on health co-morbidities and fosters referrals/access to all available
resources
14
Application
▪ Dedicated and assigned Health Coaches
▪ Pre-surgery / post-surgery opioid and pain management
▪ Daily opioid Rx outreach
▪ Whole-person approach
▪ Multi-tiered ongoing communication
▪ Member and family outreach
▪ Provider outreach
15
Real Member Stories
Issue: Fear of Opioids
• 43 year old female
• Required surgery scheduled in two
weeks
• Pre-surgery conversation with a
TrestleTree Coach, disclosed prior
opioid addiction
• Fearful of taking any opioids
• Threatened to cancel surgery
• Coach walked alongside post-surgery
• Successful in managing pain with
oversight from physician and help from
her Coach
Issue: Chronic Pain
• 63 year old female
• Chronic back pain for 30 years
• “Tried & failed, tried & failed” to control
pain
• “You are the only one listening to me
and has taken the time to learn my
situation”
• Trust built, hope instilled, positive
results
• Pain diary revealed
• Confident to control pain and be able
to go about her daily activities
16
Best Practices—Notes
from the Field
▪ Dr. Terry Flander:
▫ Board certified in family medicine
▫ Clinical practice as a family physician for 15
years
▫ Physician Executive positions in payer and
provider organizations
▫ Involved with Federal Employees Health
Benefits (FEHB) plans for the past 9 years
17
Best Practices—Notes
from the Field
▪ Participation in National Quality Forum (NQF) Measures
Application Partnership (MAP) Rural Health Work Group
▫ Make recommendations on relevant rural health quality
measures
▫ Address misalignment of provider incentives
▪ Importance of support for physician directives
▫ Align quality guidelines
▫ Educate prescribers about best practices for treating
chronic pain
▫ Help providers break old habits for pain pill prescribing
18
Best Practices—Notes
from the Field
Member EngagementWhole Person Pain
Management Approach
Achieve High QCR ScoresAvenue to Provider
Engagement
TrestleTree-RCBP Partnersip
19
About Discern Health
Multi-stakeholder Client Services and Expertise
Develop accountability models for health through innovative measurement and payment systems
Implementation Support
Partner directly with health care providers and others to transform care management and delivery
Guide health care organizations as they position themselves for success in accountable care environments
Strategic Advising
Policy Leadership Quality measure development
and endorsement
Alternative incentive and payment
models
Patient-centered care
transformation
Data modeling and analytics
Guidelines and pathways that
define quality care delivery
Research and program evaluation
20
Discern’s Role:
Strategic Advising for RCBP
▪ Serve as a healthcare quality strategic advisor to
RCBP
▪ Provide support for RCBP’s performance measure
and quality tasks that best align with RCBP’s goals
and resources
▪ Identify opportunities for RCBP to maximize use of its
available data to improve performance on quality
measures
▪ Facilitate and support knowledge-sharing and
collaboration among RCBP vendors to improve care
21
Impacts of Quality Measurement
HEDIS® and other quality metrics provide a scorecard for how well a health plan is
doing. Plans, providers, and vendors can use that data to help focus QI initiatives.
Employers and patients can use the scores to inform their healthcare decision-
making.
Patient impacts estimated from improved national measure rates:1
▪ 670,000 additional patients with controlled blood pressure
▪ 510,000 fewer patients with poor diabetes control
▪ 2,000 fewer deaths following hospitalization for a heart attack
▪ 70,000 fewer unplanned readmissions
▪ 840,000 fewer pressure ulcers among nursing home resident
▪ Nearly 9 million more hospitalized patients with a highly favorable experience with
their hospital
1 CMS. 2018 National Impact Assessment of the CMS Quality Measures Report. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/QualityMeasures/Downloads/2018-Impact-Assessment-Report.pdf.
22
FEHB, OPM, Plan Performance
Assessment (PPA) Measures
2020 OPM PPA Clinical Quality, Customer Service, Resource Use (QCR) Measures (Scored)
Clinical
Quality
Breast Cancer Screening
Cervical Cancer Screening
Colorectal Cancer Screening
Flu Vaccinations for Adults Ages 18-64
Timeliness of Prenatal Care
Well Child Visits in the First 15 Months of Life
Avoidance of Antibiotics in Adults with Acute Bronchitis
Asthma Medication Ratio
Statin Therapy for Patients with Cardiovascular Disease (Adherence)
Controlling High Blood Pressure
Comprehensive Diabetes Care-A1c Control <8%
Follow-up after Discharge from ED for 1) Alcohol or Drug AND 2) Mental Illness
23
PPA Measures (cont.)
2020 OPM PPA QCR Measures (Scored)
Customer
Service
Getting Needed Care
Getting Care Quickly
Claims Processing
Overall Health Plan Rating
Coordination of Care
Overall Personal Doctor Rating
Resource
Use
Use of Imaging Studies for Low Back Pain
Emergency Department Utilization
24
PPA Measures (cont.)
2020 Farm Team Measures (Reported but not Scored)*
Customer Service
Plan All-Cause Readmissions
Acute Hospitalization Utilization
Use of Opioids from Multiple Providers
Risk of Continued Opioid Use
Antidepressant Medication Management
Childhood Immunization Status
*2020 Farm Team measure list to be confirmed by OPM
25
Relevant PPA Measures
Use of Opioids from Multiple Providers
For members 18 years and older, the rate per
1,000 receiving prescription opioids for ≥15
days during the measurement year who
receive opioids from multiple providers (4 or
more pharmacies; 4 or more prescribers).
Use of Imaging Studies for Low Back Pain
Assesses adults 18–50 with a primary
diagnosis of low back pain who did not have
an imaging study (plain X-ray, MRI or CT
scan) within 28 days of the diagnosis (a
higher score indicates better performance).
Risk of Continued Opioid Use
Assesses members 18 years of age and older
who have a new episode of opioid use that
puts them at risk for continued opioid use (15
days of opioid Rx in 30 day period; 31 days of
opioid Rx in 62 day period)
26
Rural Health-Relevant Quality
Improvement Tactics
Assessing provider availability/access
Harnessing data from Health Information Exchanges
(HIEs)
Leveraging telehealth opportunities
Utilizing incentives to motivate positive change
Examining opportunities for closing gaps in care
through health plan vendor partners, member and
provider outreach!
2727
Panel Discussion Q&A