A recent claims review by Aetna revealed that each month, between 300 and 400 of its members are treated for opioid overdoses in emergency rooms.
"The data was alarming," Daniel Knecht, MD, Aetna's vice president of clinical strategy and policy, told Becker's Hospital Review. More than 142,557 Americans presented to the ER with opioid overdoses from 2016 through September 2017, according to the CDC. Dr. Knecht, chief of staff to Aetna's CMO Harold L. Paz, MD, placed the Aetna-specific data on Dr. Paz's desk. "We need to do something here," he said.
The two clinical leaders designed the Guardian Angels program, a case-management pilot connecting opioid overdose members with a specially trained nurse. Among early successes of the program, which rolled out in March 2018, is a 22-year-old woman from Colorado who had two overdoses on fentanyl-laced heroin. After intervention, she began attending group therapy five times a week, Aetna CEO Mark Bertolini wrote in U.S. News & World Report. In concert with Aetna's other opioid-related initiatives, Dr. Knecht believes Aetna is pushing past the "myopic" goal of only reducing the number of opioids prescribed.
Here, Dr. Knecht details how Aetna is confronting an epidemic gripping hundreds of its members.
Question: Can you dive deeper into the Guardian Angel program?
Dr. Daniel Knecht: We use claims data to identify our members who end up in the emergency room due to an opioid overdose. A nurse does a telephonic outreach. We rely on claims data, so it's usually a two- to four-week lag. At first we were concerned it might be too late. But that's not the case. I think what happens is these members suffer a brush with death and they need some time to reflect. Then they're more open to support.
A nurse calls members up to seven times, which is assertive. Generally, industry standard is calling three times and giving up. Our nurse will leave messages in a HIPAA compliant way, and can connect with up to 40 percent of these folks. The nurse provides those members resources on treatment options in their community, naloxone, caregiver support and behavioral health case-management connections.
Q: What has member reception been like?
DK: Surprisingly, most members are appreciative of the outreach. This is such a sensitive subject. They're in dire straits and need support. They can't navigate the confusing healthcare system. But the nurse has worked in addiction centers, dual diagnosis space, Medicaid, and knows how to interact with these members.
Q: The Guardian Angels program is hot off the press. What results do you anticipate?
DK: We set an aspirational goal of reducing our overdose recurrence rate by 50 percent. It's too early to see if we've made an impact. But we have a number of anecdotes where we managed to connect these members with providers in the neighborhood, or where people have actually gone out and picked up Narcan and naloxone. We have conversations with caregivers, because they too are impacted by the epidemic. We provide them education on Narcan and information on Narcotics Anonymous and opioid use disorder. The key point is to connect these people with treatment options like medication and therapy.
Another objective is to fight stigma. We hear time and time again that members think they're trading one addiction for another, which is completely false. They think medication-assisted therapy like methadone and buprenorphine are the same as heroin and prescription painkillers. No — it's a treatment option.
Q: Are these treatment options covered under members' health insurance plans?
DK: Absolutely. The Guardian Angel plan is being funded out of Aetna's office of the CMO. It's a pilot, but we're trying to help all of our members. We provide information on in-network providers and medication, and waive copays for naloxone for fully insured members. We want to connect the dots for them.
Q: Can you talk about your partnership with Pacira on Exparel, a nonopioid pain reliever that can be used for wisdom tooth extractions?
DK: We have an ongoing collaboration with Pacira, which is the manufacturer of Exparel. As we continue to deepen our collaboration, we've identified oral surgeons who prescribe too many opioids for wisdom tooth extractions.
Now we have DocFind, an online directory of Aetna-participating providers, and we put a flag next to oral surgeons and other surgeons. When you click the flag, it gives information on nonopioid pain options like NSAIDs and Tylenol, but also Exparel.
Patients don't want opioids. If there is a product like Exparel that provides local analgesia for up to three days after the surgery that does not have an abuse potential, we're promoting that. The purpose of updating DocFind is to empower our members to understand opioids are not the only treatment option for post-op pain.
Q: What is health insurers' role in the opioid epidemic?
DK: Most of the other insurers just look at the reduction of opioids prescribed, which is good, but myopic in my opinion. What makes Aetna unique is we look as holistically as possible.
We set a five-year goal of increasing the percent of our members with access to medication-assisted therapy by 50 percent. That's where the Guardian Angel program comes into play. It has been scientifically proven that people with opioid use disorder who get treated by some form of MAT are roughly 50 percent less likely to die than those who do not get treated with MAT. [Dr. Knecht referenced an Annals of Internal Medicine study.] This is a life-saving intervention like no other; it's incredible. As an insurer, Aetna is in the process of becoming a health company. But we need to do everything possible to get our members with opioid use disorder to treatment.
Q: How is Aetna addressing opioid overdose on the provider side?
DK: We teamed up with the Yale School of Medicine in New Haven, Conn., the National Institute on Drug Abuse and the American College of Emergency Physicians to make a set of brief educational videos for ER physicians. The videos go over how to treat patients with opioid use disorder in the ER. We have over 600,000 physicians in our network. We can't rely on other entities to provide this information.
Q: How do you see Aetna's impending merger with CVS Health affecting its opioid overdose strategy? I'm thinking about getting MAT to opioid use disorder patients as quickly as possible.
DK: At a very high level, the aspiration of this transaction is to have more front doors to healthcare, to make healthcare more accessible to people. I imagine a world where we could be supporting anyone with a health issue as they walk through the doors at CVS. I think there's potential. Healthcare as a system is broken. We need to think of innovative ways of fixing it and trying new things.
Q: What kind of innovative interventions are you thinking of?
DK: The silver lining of this national health tragedy is it's pushing health entities to work together in nontraditional ways. Working with Pacira in such an innovative way, I feel, is unprecedented. We're working with academics like the Yale team in a very unique way. It's pushing the whole health ecosystem to work in a more innovative way. I just wish we could do that without the circumstances of such a health crisis.