UTAH HEALTH INSURANCE ASSOCATION ANNUAL EDUCATIONAL CONFERENCE JANUARY 12 2017 Reversing the Opioid Epidemic by Decreasing High Risk Opioid Prescribing Habits Representative Ray Ward MDPhD The Opioid Epidemic ID: 762135
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UTAH HEALTH INSURANCE ASSOCATION ANNUAL EDUCATIONAL CONFERENCE JANUARY 12, 2017
Reversing the Opioid Epidemic by Decreasing High Risk Opioid Prescribing Habits. Representative Ray Ward M.D-Ph.D.
The Opioid Epidemic How We Got Here Where we are now with respect to national and state policyWhat do we need to do to reverse the Epidemic. –Decrease High Risk Prescribing Practices.
In the mid-late 1990s, the medical establishment came to believe that opiates were safe and effective for long term non-cancer pain. This was based on small short term studies. No long term randomized studies were ever done to show safety or effectiveness. Government quality measures mandating pain reporting played a roleNew pharmaceutical products, marketed as being “safer” and “less addicting” such as oxycontin also played a role
By the late 1990s, at least 20 states passed new laws, regulations, or policies moving from near prohibition of opioids to use without dosing guidance WA law: “ No disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opioids prescribed. ” Laws were based on weak science and good experience with cancer pain: Thus, no ceiling on dose and axiom to use more opioid if tolerance develops You will not be able to effectively alter epidemic if you don’t understand how the epidemic began .
Worst man-made epidemic in modern medical history Over 200,000 deaths in the US Many more hundreds of thousands of overdose admissions Millions addicted and/or dependent Degenhardt et al Lancet Psychiatry 2015; 2: 314-22; POINT prospective cohort: DSM-5 opioid use disorder: 29.4% Spillover effect to heroin and to SSDI Slide 7
Case and Deaton, 2015 Recent data from this year show increasing mortality in middle aged whites
Mortality by Cause
By 2009 We realized that we had a problem So we decided to have the Department of Health write a guideline. So The Utah Department of Health together with other involved Medical Organizations Drafted a guideline for Opiate prescribing.And after the creation of that guideline -- Here is the effect on levels of opiate prescribing in Utah….
Total opioids prescribed in Utah 2002-2015
Take home message…. Simply writing a guideline is not an effective way to change prescribing behavior, and has not reduced the level of addiction or overdosedeaths.
What is different now from 2009? We have a much greater scientific understanding of how much damage has been done. We have national consensus that it is a problemAnd we have (as of March 2016) CDC guidelines with concrete recommendations of safer prescribing recommendations.
*100% of patients on opioids chronically develop dependence 60% of patients on opioids for 3 months will still be on opioids 5 years later 47% of patients on opioids for 30 days in the first year of use will be on opioids 3 years later Even low risk individuals, a single exposure to opiates prior to high school graduation increases their chance of future dependence by 33%. Martin BC et al. J Gen Intern Med 2011; 26: 1450-57; Express Scripts study: URL: http://lab.express-scripts.com/publications/~/media/d48ef3ee579848e7bf3f14af536d7548.ashx , Accessed 3/4/2015 Mieche et al, Pediatrics,Nov 2015: Prescription opioids in adolescence and future opioid misuse Opioids are the most addicting substance that We have yet discovered. .
Risk of high dose Narcotics 4 studies
Early opioids and disability in WA WC. Spine 2008; 33: 199-204 Population-based, prospective cohort N=1843 workers with acute low back injury and at least 4 days lost time Baseline interview within 18 days(median) 14% on disability at one year
Early opioids and disability in WA WC. Spine 2008; 33: 199-204 Population-based, prospective cohort N=1843 workers with acute low back injury and at least 4 days lost time Baseline interview within 18 days(median) 14% on disability at one year Receipt of opioids for > 7 days, at least 2 Rxs , or > 150 mg MED doubled risk of 1 year disability, after adjustment for pain, function, injury severity
With this compact , the undersigned commit to build on Their efforts to fight opioid addiction by --Taking steps to reduce inappropriate opioid prescribing,Which may include: * Partnering with health care providers to develop orUpdate evidence-based opioid prescribing guidelines, whichMay be informed by the CDC’s guideline, and consider Prescription limits with exceptions for certain patients and Circumstances.
Preventing opioid Addiction Is better than Treating opioid Addiction
HB 50 – Opioid Prescribing RegulationsMakes a new condition for prescribing narcotics. It applies toBoth prescribers and pharmacists. It says, A first narcotic prescriptionCan be for no more than 7 days. That is, if a person has not alreadyFilled a narcotic prescription in the last 90 days, the first narcotic Prescription they fill can’t be more than a 7 day supply.
HB 50 – Opioid Prescribing RegulationsRequires that a prescriber check the controlled substance database prior to prescribing narcotics if:It is the first time they have met the patient, andDon ’t have other access to their prescription history, andAre writing a prescription for more than 3 days.
HB 90 – Insurance Opioid Regulation* Requires that Health Insurance Plans in UtahEnact policies regarding certain topics relatedTo coverage of opioids.* Requires that those policies are reported to The legislature. * DOES NOT specify what those policies have to be.
(2) A Health Insurer that provides prescription drug coverage shall enact a prescribing Policy to minimize the risk of opioid addiction and overdose from: co-prescription of opioids with benzodiazapines and other sedating substancesPrescription of very high dose (over 90 MME per day) opioids in the primary care setting; and The inadvertent transition of short-term opioids fro an acute injury into long-term opioid dependance.
A Health Insurer that provides prescription drug coverage shall enact policies to facilitate:Non-narcotic treatment alternatives for patients who have chronic pain.Medication assisted treatment for patients who have opioid use disorder.
Washington State Department of Health Unintentional Prescription Opioid Overdose Deaths Washington 1995-2014 Source: Washington State Department of Health, Death Certificates
UTAH HEALTH INSURANCE ASSOCATION ANNUAL EDUCATIONAL CONFERENCE JANUARY 12, 2017
Pricing Health Insurance Pre and Post PPACA
Things you’d rather do than hear how health insurance is priced
“Utahns ’ health-insurance premiums to soar” “Utah insurers request big rate hikes”“‘A lot of people are in despair’: Utah’s individual insurance options now costlier and fewer”Salt Lake Tribune“Rates for health insurance plans on the individual marketplace are likely to rise by an average of 30 percent next year”Deseret News Read all about it…
1) Pricing health insurance is easy if nothing changes, but gets complicated when things change. 2) Something always changes 3) Pricing health insurance under the Affordable Care Act means lots of changesTakeaways-
Plan only covers primary care doctors visits Plan covers 100,000 people (bellybuttons) 40% had a visit in the last year (no one had more than one)Visits cost $40Total cost of benefits last year is 1.6M Simple Ratemaking Example
It costs money to run an insurance company Medical Loss Ratio 80% for small employer / individual85% for large employer$16 becomes $20 if you assume an 80% loss ratio Administrative Expenses
Cost of a visit – increased by 5% Length of PCP visit changed – Averaging 35 Minutes instead of 27 minutes – New CPT code, more expensive per visitNew law – all children get 3 PCP visits per yearBenefit Changes – 20% coinsurance on first PCP visitWhat could have changed?
Utilization adjustment – Some people won’t visit doctor if they have to pay 20% Network changes – contracted with new PCP group that accepted lower fee schedule Demographics – Signed new group “Multiparous matriarchs with a genetic propensity for triplets of American Fork”What could have changed?
Demographic Changes http://www.healthcostinstitute.org/files/Age-Curve-Study_0.pdf
Lather, Rinse, Repeat
Rx Rebate / contract negotiation Formulary modifications Out of network penetrationMoving from PPO to EPOChanges in deductibles / out of pocket maxTrend leveragingExpansion into new geographic areasOther stuff to consider
SeasonalityMultiple Plan Choices Antiselection Changes in competitionReinsurance contractsUnderwritingSmall group Guaranteed Issue – but can rate upIndividual you can rate up or deny coverage Other stuff to consider
“Any fool can make something complicated. It takes a genius to make it simple.” ―Woody Guthrie In comes PPACA
Single Risk Pools Everyone is priced together Rates only vary byAgeSmoking StatusGeographic locationSemi-Uniform benefitsEssential Health BenefitsMetal level plansOne renewal date – individual market Some things are simpler
Prior to ACA Old Profitability Profitability Premium Actual claims cost Administrative costs = - - Source – SOA webinar: Can this marriage be saved? Risk adjustment and the ACA
Post ACA New Profitability Profitability Premium Actual claims cost Administrative costs = - - ± ± Reinsurance payments Risk adjustment transferPotential MLR Refunds+±± --Source – SOA webinar: Can this marriage be saved? Risk adjustment and the ACAPrivate reinsurance premiums / recoveriesCSR prepayments vs actuals Exchange participation fees Risk corridors
No underwriting – must accept everyone, can’t rate anyone up No pre-existing conditions exclusion 90 day grace periods – still on the hook for claims first 30 daysBenefit changesEssential Health BenefitsMental Health Parity and Addiction Equity Act (MHPAEA)3:1 ratio from highest to lowest rates3R’s – Reinsurance, Risk Adj, Risk CorridorsUnified Rate Review Template PPACA Changes
Uninsured – Will they enroll? What is their risk profile? Transitional plans – You can keep your plan Risk Adjustment – risk profile of uninsured / switchersPent up demandRisk Corridors – 112th Congress giveth, 113th Congress taketh awaySpecial Enrollment Periods handed out like candy at a 4th of July parade Keep opening Open EnrollmentUnknowns
How could anyone possibly get the premiums wrong?
Individual Market: How robust were 2015 Rates? 2015 Calendar Year Experience Total Fed Reins Adjusted Total Premiums (net of MLR Rebate): 508,429,840 508,429,840 Incurred Claims 700,794,785 (77,337,869) 623,456,916 Member Months 2,331,358 2,331,358 Premiums PMPM 218.08 218.08 Incurred Claims PMPM 300.60 267.42 Incurred Loss Ratio 137.8% 122.6% Without the federal reinsurance, the market experienced a 138% loss ratio After taking into account reinsurance, the loss ratio only drops to 122% for the market Target loss ratios are in the 80-85% range
Risk Adj - % of Premium 2015 Individual2015 Small Group Carrier% of Premium Aetna of Utah -12%Arches -20% BridgeSpan -14% Molina -21% Natl Foundation Life -41%Regence BCBS of Utah8%SelectHealth11% UHC Life3%Carrier% of PremiumAetna-23% Aetna of Utah -14% Arches 3% Humana Ins Co -5% Natl Health -27% Regence BCBS of Utah -2% SelectHealth 1% UHC Ins 5% UHC of Utah 22% WMI 2% Using 2017 URRT data and data from the 6/30/2016 CCIIO reinsurance and risk adjustment report, adjusting out premium for transitional plans. Negative indicates payment into risk pool, positive is receipt from risk pool.
Company Requested Actually Paid Molina Healthcare of Utah 3,522,866 (34,984) Arches Mutual Insurance Company 58,427,968 1,915,442 BridgeSpan Health Company 9,730,880 321,512 Aetna Health of Utah Inc. 5,069,802 320,065 Humana Medical Plan of Utah, Inc. 10,159,920 1,541,403 UnitedHealthcare of Utah, Inc. (77,147) (83,845)SelectHealth 194,592,118 13,315,524 Total 281,426,406 17,295,117 Risk Corridors (2014-2015)
Utah Individual Rates (age 21 non-smoker, Salt Lake County)
Utah Individual On Exchange Rates (age 21 non-smoker, Salt Lake County) Age 21 Avg Silver Avg Inc 2014 $ 161.24 2015 $ 167.46 3.9% 2016 $ 198.84 18.7%2017 $ 229.97 15.7% Age 21Avg GoldAvg Inc2014 $ 181.81 2015 $ 194.70 7.1% 2016 $ 232.92 19.6% 2017 $ 343.33 47.4%
FFM Individual Rates 2017
State Increase State Increase MS -11% SD 31% PA -1% SC 34% IN0%NE 38%MI0%UT43%AR4% DE 50% FL 7% IA 52% OH 7% VA 54% IL 14% LA 57% NJ 14% MT 67% NH 14% KS 68% GA 14% NC 69% WY 17% AZ 78% WI 21% AL 79% ME 22% TN 79% ND 24% WV 89% TX 25% OK 99% NM 25% AK 100% MO 29% Average Silver Plan Increase from 2014 to 2017 (FFM Exchange)
Utah’s rank in FFM Individual Rates – Minimum Silver by State by Year Utah Age 21, Non-Smoker, Salt Lake County
Utah still has lower rates than most of the country The small group and large group have had relatively normal increases Individual market is about 8% (240K)Between 65-85% have premium subsidyDespite the headlines
UTAH HEALTH INSURANCE ASSOCATION ANNUAL EDUCATIONAL CONFERENCE JANUARY 12, 2017
UTAH HEALTH INSURANCE ASSOCATION OUR PANEL JANUARY 12, 2017
Dr. Raymond Ward, USL Jaak Sundberg, FSA, MAAA / UDI Sunshine Moore, AHIPMichelle McOmberUHIA PANELJANUARY 12, 2017
Materials for this Conference may be found at: UHIA.info Conference2017 MaterialsJANUARY 12, 2017