MaineCare & Opioid Treatment Where we are… How we got here… Where we are going… Kevin S. Flanigan, MD Medical Director Office of MaineCare Services
Changes throughout the Year In the beginning of 2012, there were no restrictions on MaineCare coverage of opioid prescribing. The initial law passed in April 2012, created a 45-day lifetime limit on opioid medication coverage. The 45-day limit was replaced with the a new Pain Management Policy (PMP), effective 01/01/2013.
Opioid Use on the Rise: 1991 to 2009 • Prescriptions for opioid analgesics nearly tripled. • 56% of painkiller prescriptions were given to patients who had filled another prescription for pain, from the same or different providers, within the past month. (Source: National Institute on Drug Abuse)
Why Opioids are Widely Used for Pain Management Opioids: • Are inexpensive. • Control pain which leads to faster recovery. • Improve patient quality of life when properly used. • Are used to control pain and pain control is used as a measure of quality, driving increased use of opioids to control pain.
The Path to Increased Opioid Prescribing • Opioids improve positive pain management outcomes when used by cancer and post-surgery patients. • With positive outcomes for this use, opioid prescriptions were expanded to other types of pain management. • There is a lack of professional consensus concerning patient outcomes in using opioids in the treatment of pain.
Opioid Coverage and MaineCare • There are a limited number of covered treatment options for MaineCare members with pain. • Other pain treatment options are more expensive than opioids. • Pain control is accepted as a leading quality indicator for positive patient outcomes.
From Drug Management (45-day limit) to Pain Management Developing strategies based on type of pain: • Acute (new onset). • Chronic (long term or poor response to other treatment). • Diagnoses known not to typically respond to opioid treatment.
Pain Management: Acute Pain • Acute pain is expected to last less than 8 weeks. • Opioids are allowed for 15 days per 12 month period. • 14 additional days of opioid treatment may be covered with Prior Authorization (PA). • A face-to-face visit is required for each prescription within 96 hours of being written. • Up to three (14 day) refills may be allowed after the first 15 days. • Surgeons may request a one-time PA for 60 days of opioid coverage.
Pain Management: Chronic Pain • Chronic Pain is expected to last longer than 8 weeks. • The patient must try one or more interventions from treatment plan. • The patient must fail to have adequate response to interventions. • There will be a daily limit on opioid dose.
Chronic Pain Treatment Options • Osteopathic Manipulative Treatment (OMT) • Chiropractic Services- 12 per year maintenance program. • Physical Therapy- 6 visits per year. • Cognitive Behavioral Therapy. • Acceptance Commitment Therapy.
Chronic Pain Treatment PlanExceptions Each patient is required to complete at least one chronic pain treatment option. Exceptions to completing the chronic treatment plan are: • The patient has completed at least 50% of plan with no progress or worsening symptoms. • The patient is not a candidate for treatment options due to cognitive loss or other health related issues.
Opioid Dosing Limits Minimum • 30mg or less of Morphine Sulfate equivalent- exempt from PA process Maximum • <300mg of Morphine Sulfate equivalent- maximum allowed dose
Chronic Pain: Diagnoses No Longer Covered Discontinuing MaineCare coverage for selected diagnoses: • Headaches • Chronic back and neck pain • Fibromyalgia
Second Opinion Program: PA is Required for Chronic Use The following patients will need a second opinion before opioid prescriptions are authorized: • Patients with illness known to have poor response to opioids such as headaches, neck & back pain, and Fibromyalgia. • Physicians providing a second opinion must be from a different site.
PA is Not Required for Selected Situations • End-of-life care • Pain caused by cancer • Nursing Home patients • Inpatient care • HIV/AIDS
Working with Opioid Prescribers is a Fundamental Goal of MaineCare’s PMP • Evaluate effective use of opioids by looking at the patient behavior patterns. • Inform physicians about their own treatment patterns in comparison to peers. • Outreach to individual providers concerning opioid prescribing patterns. • Follow-up to encourage providers to bring prescribing patterns in line with peers.
PMP: Outreach Steps • First letter- “just to let you know.” • Second letter- educational opportunities available. • Third letter- request letter of explanation or letter explaining corrective plan within 14 days. • Fourth letter with accompanying phone call- if no action forthcoming, referral to Board of Licensure vs. change of Provider Agreement.
Concluding Remarks: Working Together Leadership at DHHS & OMS has welcomed input from the medical community and from patient advocates when creating a PMP for MaineCare coverage. This collaborative approach has lead to a policy that is reflective of quality care, yet allows appropriate use of opioid medications where indicated.
For More Information For more information about MaineCare’s PMP, contact MaineCare’s Medical Director, Kevin Flanigan, MD at: Kevin.Flanigan@maine.gov (207) 287-1827