The goal of Anthem, Inc.’s Pharmacy Home Program (PHP) is to keep members out of it.
The program, which launched April 1, 2016, was created to curtail inappropriate opioid use — and improve drug safety — among a small population of commercially enrolled members. Anthem’s Medicaid plans have been running similar programs for years. At least half of all opioid overdose deaths involve a prescription opioid, according to the Centers for Disease Control and Prevention.
The Blues plan operator uses claims data to flag members who have filled five or more controlled-substance prescription drugs from three or more providers, and who get prescriptions filled at multiple pharmacies — a possible indication of addictive behavior, Anthem says. At-risk members can fill prescriptions at only one retail pharmacy, but can still receive mail delivery and specialty prescription drugs.
Letters are sent to members who are deemed at risk for addiction or abuse issues for opioids or other prescription drugs, and are warned that they could be moved to the PHP. But the actual goal of the program is to work closely with members and providers early on to lessen the potential for the development of a substance use disorder. Members who have a diagnosis or prescription history indicating HIV, sickle cell anemia, multiple sclerosis, cancer or hospice and palliative care are exempt from the program.
Since the PHP’s launch nearly a year ago, only a small percentage of members have been moved into the full program, says Sherry Dubester, M.D., vice president of behavioral health and clinical programs at Anthem. “Our goal is not to push more than is needed, but to change the behavior that our data tells us is leading to the need for a Pharmacy Home Program,” she explains.
Consumer profiles and pharmacy claims data are used to predict when members are most likely to run into problems based on data analytics. That information is shared with providers in hopes of avoiding problems. The care coordination system notifies prescribing providers, in writing, that a member might need to be placed into the program based on risk factors. A member who does not change behavior within 60 days of the letter is asked to select a single pharmacy location to fill all medications for one year. The prescriber also receives a three-month member prescription history and an education piece on the advantages of one pharmacy to review with the member. “We are optimistic about this program and its ability to ensure clinically appropriate use of opioids,” adds Jeff White, staff vice president of clinical pharmacy solutions at Anthem.
In a press release last year, Anthem noted that, even after overdosing on opioids, nine out of 10 people continued to get prescriptions for them, per a 2015 study published in the Annals of Internal Medicine. Some went on to suffer another overdose. Moreover, the vast majority of patients who had overdosed received new prescriptions from the provider who had prescribed opioids before the first overdose.
Dubester says the pharmacy home is the “most intensive” strategy used to coordinate prescribing. “Our data analytics might help us make a doctor aware that a patient is taking a specific combination of medications,” she says. Anthem’s goal is to help providers get the information they need about members to know when to consider non-pharmacologic pain management or other strategies, as opposed to an opioid prescription.
This quarter, Anthem will pilot a resource helpline that patients and families can call if they think a medical crisis might be imminent. “We might get called about a family member who has overdosed and is in the emergency room. We want to move that more upstream and have members or family members call us when things haven’t quite gotten to that point and we might be able to help them and guide them to the appropriate treatment setting,” she explains.