With the number of opioid-related overdose deaths in the U.S. reaching a record high last year, it’s time for our nation to fully embrace evidence-based treatment options that best support our communities, loved ones, friends and families in their recovery efforts.

One growing approach—often considered as the gold standard of treatment—is medication-assisted treatment (MAT). MAT is the use of FDA-approved medications in combination with counseling and behavioral therapies to provide a holistic, person-centered approach to the treatment of substance use disorders (SUDs). The use of this treatment approach has grown to nearly 40 percent in residential facilities and is increasingly leveraged by primary care providers nationwide—but more still must be done for widespread adoption.

The most pervasive stigma surrounding MAT is that it merely enables patients to replace one addiction with another. It’s a belief held not only by some groups of doctors and clinicians, but also family members and peer support groups—those whose support is critical to successful recovery. When a patient’s core support system of family members and peers doubts the legitimacy of an evidence-based form of treatment, the likelihood that the patient will follow through long-term is diminished.

Pair that with a lack of understanding and comfort from the medical community around how to administer MAT, limited numbers of physicians who are certified to prescribe this treatment that actually do prescribe the treatment, as well as the number of residential facilities that offer MAT, and we get low adoption rates as a result of these barriers.

There’s a better way to treat opioid use disorder

Although abstinence-based therapy works for a small percentage of those suffering from OUD, MAT offers a successful way for people to fight their addictions in an outpatient environment, in the community in which they live, and avoid hospitalization or institutionalization. It helps those struggling with OUD and other SUDs address underlying conditions that may have contributed to substance abuse—significantly improving the chances of recovery. In one study, more than half of patients utilizing MAT reported opioid abstinence 18 months after beginning treatment.

Today, while 900,000 U.S. physicians prescribe opioids, fewer than 35,000 physicians are certified to prescribe buprenorphine, one of three medications approved to treat opioid addiction. And even fewer actually prescribe buprenorphine to patients. MAT prescribing is not limited to psychiatrists. In fact, primary care providers provide more access to MAT than any other type of provider.

The impact of limited access to MAT on health outcomes cannot be overlooked. One analysis found only one-third of individuals who experienced a nonfatal opioid overdose received access to MAT. Those who received methadone were linked to a 59 percent decrease in mortality rates after one year, according to the analysis. Additionally, individuals who were treated with buprenorphine were associated with a 38 percent decrease in mortality after a year.

Increasing Access to MAT

The SUPPORT for Patients and Communities Act, signed in October 2018, expands the ability to prescribe MAT by increasing clinician eligibility for certification. This provision is a solid and necessary step toward broadening access to treatment; however to make a true impact on the opioid epidemic, we must break the stigma surrounding MAT.

When it comes to recovery, the potential for relapse is high, especially in the early stages when resolve is fragile. It is important to note that for individuals with co-occurring mental health conditions, chronic pain or other addictions, MAT should be supplemented by treatment for those conditions, such as cognitive behavioral therapy. Building in care management support to assist in navigating the treatment process may reduce the possibility of relapse and/or readmission to a substance abuse inpatient or residential rehabilitation program. It also helps provide individuals with the tools needed to live addiction-free.

By taking the time to dispel the myths about non-traditional addiction treatment like MAT, we create an environment that more fully supports a return to complete health—physical, mental and emotional. Fighting the stigmas around MAT is an important step toward enabling those suffering from OUD to recover from their addiction and live healthy, vibrant lives.

For healthcare providers, prior authorization (PA) via fax or telephone is the second most costly medical administrative function. On average, medical staff spend two business days per week on PA. Automating PA while maintaining clinical excellence is essential for better care delivery. With a focus on leveraging digital solutions and fostering data-enabled decisions, Magellan Healthcare is building more provider-friendly approaches to improve care.

Recently Magellan announced a collaboration with Stanson Health, Premier, Inc.’s clinical decision support (CDS) technology division, to deploy DecisionPoint, an industry-leading automated PA solution. Powered by Premier’s CDS technology, DecisionPoint is available at the point of care and supports true automation within the electronic health record (EHR) and the physician workflow, making the PA process easier and more efficient for providers, patients and health plans.

DecisionPoint is built with Magellan Healthcare’s Advanced Imaging Management program clinical guidelines and Premier’s award-winning technology platform. Magellan maintains one of the industry’s most comprehensive evidence-based sets of clinical guidelines. Our clinicians develop our criteria through an extensive process of innovation and refinement. We base these guidelines on the analysis of public, peer-reviewed articles; health plan medical policies; the Centers for Medicare & Medicaid Services (CMS) policies; specialty physician reviews, professional society guideline statements; and other rigorous reviews of scientific documents. We continually monitor peer-reviewed literature, professional society guideline statements, and CMS-covered criteria to update our guidelines regularly, no less than annually. Initially, DecisionPoint will include our suite of the 20 highest-volume advanced imaging studies that make up 85% of all requests.

Working directly in the EHR, DecisionPoint guides provider decisions in real time in response to key workflow events, such as ordering an advanced imaging study. Integrating within the EHR improves efficiency while ensuring safety and quality and reducing undesirable variation in care.

Rules-based programming leverages EHR data, locating all relevant patient clinical information and citing appropriate Magellan clinical guidelines. Requests that satisfy the clinical guidelines are automatically approved and posted in the EHR, and approval IDs are automatically loaded to the record. With a confirmed authorization determination, the member leaves the appointment with a clear plan of action.

Hawai‘i Pacific Health (HPH), one of the largest healthcare providers in Hawai‘i, is leading the way in automating prior authorization by piloting DecisionPoint to help ensure their patients receive real-time, evidence-based decisions at the point of care whenever possible. Administered through HPH’s Accountable Care Organization (ACO) with over 800 physician members, the pilot leverages Magellan’s clinical guidelines and our full panel of clinical experts. We expect DecisionPoint to be available to additional providers in the fourth quarter of 2019 and include additional specialties and tests in the future.

The healthcare industry is in the midst of a significant paradigm shift as it transitions from a fee-for service model to value-based care. As a technology-augmented service backed by the support of providers, DecisionPoint is designed to minimize the industry’s challenges by fully integrating with EHRs at the point of care to enable faster PA and help deliver on the triple aim—improved quality, reduced cost and improved patient/provider experience.

To learn more about DecisionPoint, click here to go to our website, or email ProviderSolutions@MagellanHealth.com.

Prior authorization (PA) goes by many names—preauthorization, preapproval, advance notification, precertification and preadmission, to name a few. All these terms refer to the utilization management (UM) process used by many U.S. health insurance companies to ensure patients receive the right services, equipment and prescriptions at the right time and place. PA requires healthcare providers to request and obtain approval before rendering certain services, equipment or prescriptions in order to receive insurance reimbursement for those services. Not everything requires PA. Typically, authorization is needed for more complex services such as hospital admissions, diagnostic tests, medical equipment and complex prescription medications.

The PA process is intended to act as a safety and cost-saving measure. It can lower costs to the patient, prevent unnecessary or invasive procedures, and reduce the use of unnecessary tests that may expose patients to potentially harmful radiation and/or undue stress. For example, up to half of advanced imaging procedures ordered fail to provide information that improves patients’ welfare.[i] In addition, despite studies demonstrating overuse, rates of advanced imaging procedures continue to rise—increasing costs and exposing consumers to excessive radiation.  Despite its benefits, the prior authorization process needs an upgrade.

According to the 2018 CAQH Index , manual prior authorizations (via fax or telephone) are the second most-costly medical administrative transaction, costing providers $6.61 per submission. Providers estimate their staff members spend up to 30 minutes completing one manual prior authorization. While manual prior authorization is a much-debated topic due to the time and cost it requires, many parties support standardizing and simplifying the process.

Technology can significantly  decrease the need for expensive manual processes.  According to the 2018 CAQH Index, the medical industry could save $417 million annually by transitioning to electronic prior authorizations, which includes $278 million in annual savings for providers and $139 million for health plans.

While many health plans offer web portals to process prior authorizations, this approach requires providers to use different online systems for each health plan. Instead, digital solutions should include automation within the electronic health record (EHR) and the physician’s workflow. Automation is essential to reducing inefficiencies for providers and health plans and enabling authorizations at the point of care while maintaining clinical integrity.

The goal is to make the right decision for each patient—quickly and easily so patients get the care they truly need. Automating prior authorizations will benefit everyone involved.

[i]Beachy, D. (2014, September 8). Defensive medicine driving up wasteful imaging. Retrieved from https://www.healthimaging.com/topics/healthcare-economics-policy/defensive-medicine-driving-wasteful-imaging.

As we observe National Minority Mental Health Awareness Month, we sat down with Dr. Rakel Beall-Wilkins, a former Magellan Healthcare medical director.

 Magellan Health Insights: Dr. Beall-Wilkins, thank you for speaking with us today. Of course, everyone’s mental health is critical, but why is it important to pay particular attention to the mental health of Black, Indigenous and People of Color (BIPOC)?

Dr. Rakel Beall-Wilkins: We know that mental health conditions can be successfully treated. However, BIPOC are significantly less likely to receive treatment for mental health conditions, including substance use. And it’s reaching crisis levels, especially among our young people. For example, suicide is now the third leading cause of death among African American males who are 15-24 years old.

Magellan Health Insights: What are the barriers to BIPOC receiving high quality mental health treatment?

Dr. Rakel Beall-Wilkins: BIPOC are less likely to seek treatment, both for their physical and mental health. However, when they do reach out for assistance, they are less likely to receive consistent, high-quality treatment.

There are many contributing factors to these barriers. The high costs of care can be a deterrent. Most BIPOC in the U.S. (with the exception of Asians) have higher than average rates of poverty. BIPOC are more likely to lack insurance coverage, and may only seek emergency care, which costs more and is less effective than sustained treatment. Medications or diagnostic procedures may be viewed as too expensive. Or reliable transportation for follow-up care may not be available.

There are also what are called the social determinants of health (SDoH). These include factors such as consistent transportation, the availability of healthy food, safe and affordable housing, access to education, public safety and working conditions. BIPOC are more frequently negatively impacted by the SDoH. For example, these members are more likely to be homeless or move frequently, which interferes with maintaining consistent treatment. They may lack adequate nutrition and are at greater risk for having associated medical conditions like hypertension or diabetes.

Further, the stigma around mental health conditions, while improving, is still a deterrent to seeking treatment—for everyone. Some cultures may see it as taboo to request help or be seen as someone who needs help.

When BIPOC patients do seek treatment, there may be no one available who speaks their language. In some clinical settings I’ve been in, it could take a week to arrange for an interpreter or a therapist who was proficient in the patient’s language. They may not have a primary care physician (PCP) to help with screening for mental health conditions or provide follow-up care. In addition, the community clinics where BIPOC are more likely to receive care may be understaffed, overcrowded and have long wait times. Understaffing may lead to inadequate screening or even misdiagnosis. And, frankly, the clinic also may not be in a place where the member feels safe traveling so, they may hesitate to go in the first place or return for continued treatment.

Magellan Health Insights: How can everyone, including healthcare professionals, best support minority mental health?

Dr. Rakel Beall-Wilkins: Everyone can help eliminate stigma. Be open to talking and hearing about mental health conditions, and make it clear that you know that having a mental health condition is nothing to be ashamed of. When someone you care about is going through a difficult time, encourage them to get help, and learn ways you can support someone who coping with a mental health challenge.

As healthcare providers, we personally can help by:

• Ensuring we are taking into account each person’s wishes when referring them to other providers: We should ask every patient whether they prefer to see someone of a specific race, ethnicity, gender or sexual orientation.
• Educating ourselves to be more culturally competent and making cultural training a priority for our staff.
• Expanding our workforces with staff from various backgrounds, sexual orientations, cultures and with varied linguistic skills particularly for the unique cultures that are most prevalent in the community.
• Screening for psychiatric conditions during routine visits. Many patients will report physical symptoms instead of talking about the underlying mental health concerns. PCPs and others see many cases of mild or moderate depression during routine care, and screening every patient can help prevent costly emergency visits and admissions. Self-screening tools can also help.

Beyond what we can personally do to educate and equip ourselves and our staff, I believe that the best solutions come from an integrated, collaborative approach. Everyone can help eliminate the disparities. If we work with leaders in the community, for example in churches and schools, we can raise awareness of mental health conditions, destigmatize treatment seeking, help address the social determinants, and improve the lives of everyone in our communities.

Two patients, both 73-year-old males with newly diagnosed congestive heart failure, are seen by the same provider and prescribed the same therapeutic regimen. Despite the similarities, the 2 patients experienced drastically different therapeutic outcomes. These divergent outcomes were not attributable to the clinical care they received but instead to non-clinical factors surrounding each patient’s circumstances. These non-clinical factors are also referred to as social determinants of health (SDOH). According to the Centers for Disease Control and Prevention (CDC) website, SDOH are conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes. Some key SDOH that may influence clinical outcomes include housing insecurity, food insecurity, lack of transportation, and lack of family or other social support.

It is widely known that social and economic factors have significant impacts on health outcomes of both individuals and communities. At a population level, it has been estimated that clinical care accounts for only 20% of a community’s health outcomes while the remaining 80% is related to a combination of health behaviors (e.g., diet and exercise), the physical environment (e.g., housing security), and socioeconomic factors (e.g., education and social support). Despite this insight, addressing SDOH has traditionally been the purview of government and charitable organizations rather than healthcare providers. However, with the shift toward value-based reimbursement and increased accountability for the costs and health status of patients, there is an incentive for health plans and providers to further consider the social and economic barriers that contribute to poor health outcomes. Models are being developed that link healthcare systems, providers, and community resources in an integrated fashion to address SDOH. These models are evolving from systems that rely on acute episodes of care to a coordinated system focused on prevention and care management.

As the largest payer for healthcare in the United States, Medicare has also recently begun to make accommodations in order to address SDOH in the privately administered Medicare Advantage (MA) program. MA is a capitated system placing health plans that administer MA benefits at risk for the cost of caring for each beneficiary. MA plans are permitted to offer supplemental benefits beyond traditional Medicare offerings as long as those benefits are “primarily health-related.” Historically, the most common supplemental benefits offered by MA plans have been services not traditionally covered by medical insurance such as vision exams, hearing tests, and preventative dental services.

The Centers for Medicare & Medicaid Services (CMS) have recently begun to implement regulatory changes allowing MA plans more flexibility with regard to these supplemental benefits. First, the definition of “primarily health-related” has been expanded. Examples of this expanded interpretation include providing in-home support for activities of daily living (ADLs) or installation of grab bars in the bathroom in order to prevent injuries and reduce avoidable emergency room utilization. In addition, supplemental benefits that may reduce exacerbations of existing illnesses, such as installing air conditioning units or providing carpet shampooing for patients with asthma, may be considered. Beginning in 2020, MA plans may offer chronically ill patients additional benefits that directly impact SDOH, such as expanded meal delivery options to address food insecurity and transportation for non-medical needs like grocery shopping. In announcing the expanded options for MA plans, CMS Administrator Seema Verma said the changes “give plans the ability to be innovative” and the changes permit “benefits and services that address SDOH for people with chronic disease.”

The shifts occurring in healthcare delivery, including the expansion of accountable care organizations (ACOs), the rise of capitated reimbursements, and penalties associated with hospital readmissions, incentivize healthcare systems to become increasingly focused on holistic care for beneficiaries. By addressing individual and population SDOH, healthcare systems, providers, and community support can be integrated to improve health outcomes and reduce unnecessary healthcare utilization.

While there may be some debate as to who deserves credit for originally developing insulin in the 1920s, there is no doubt that its serendipitous discovery had a life-saving impact. In an attempt to provide affordable treatment to the public, the researchers opted to sell the patent for insulin to the University of Toronto for $1. The researchers later collaborated with a pharmaceutical company to develop insulin due to limited ability of the university to develop it on its own. Once made primarily from animal sources in limited selection, several insulin options are now available, and each product differs slightly in manufacturing and design to better mimic the lacking endogenous insulin in patients with diabetes. Today, insulin is marketed primarily by three manufacturers, and counterintuitive to its length of time on the market as a primary treatment, insulin costs continue to increase. One assessment reported that annual spending per person with type 1 diabetes nearly doubled between 2012 and 2016, and the reported cost of one specific brand of insulin increased by 668% from 2001 to 2015. There are several purported reasons for the high costs of insulin, even resulting in lawsuits and a push for legislative involvement.

The high cost of insulin is a hurdle for many patients and the entire healthcare system, especially considering a reported 1.2 million Americans have type 1 diabetes and a portion of the nearly 30 million Americans with type 2 diabetes are insulin-dependent. So, what happens when a medication necessary for life continues to increase in price? Patients may resort to acquiring insulin from less expensive resources outside of the United States (US). In addition, some patients will continue to use insulin vials beyond their stable use (i.e., beyond 28 days once opened) or share insulin pens. Patients may ration their insulin for their own use or sell the remaining insulin to others, as the temptation for potential income may be too enticing for those with limited financial means. One study reported that the rise in costs has resulted in nearly 25% of patients not taking insulin as directed. Lack of blood glucose control resulting from these measures could be life-threatening.

Taking insulin access to another level, one project aims to develop a protocol for insulin production that would circumvent intellectual property concerns, enabling manufacturers to produce more affordable insulin. Theoretically, an open protocol for manufacturing of insulin could result in community biolab production or somewhat “home-brewed” insulin, but there would still be several costly regulatory hurdles for each product. Even if crowdfunding could support these “biohacked” insulin barriers, would the resulting product be the best treatment for all patients? Would it still result in a high-cost product?

Historically, the US Food and Drug Administration (FDA) has regulated insulins as small molecule drugs; thus, the few generics available are actually branded competitors and considered “follow-on” insulins. The FDA has announced insulins will be transitioned from the small molecule pathway to the biologics pathway effective in March 2020 as part of their Biosimilars Action Plan. According to acting FDA Commissioner, Dr. Ned Sharpless, after this transition, the FDA will be able to license biosimilar and interchangeable insulin products that may be substituted at the pharmacy, potentially leading to increased access and lower costs for patients.

While the idea for “generic” (cheaper) insulin is becoming more of a reality, what will patients do in the meantime for a disease state in which the treatment is not optional? Will interchangeable biosimilar insulin finally be the solution for reversing the constant upward trajectory of insulin prices?

Care is core to every service we deliver and everything we do at Magellan Health. Through our work, we are listening, learning and using our collective insight to make a difference in the lives of those we serve.

Wyoming’s High Fidelity Wraparound program is just one of many examples where Magellan team members, who have lived through similar experiences, are returning the favor and providing the care and concern they consider themselves fortunate to have also personally received.

High Fidelity Wraparound is a voluntary planning and care coordination process for children and young adults (ages 4-20) with complex behavioral health conditions. High Fidelity Wraparound’s community-based solutions and planning process bring people together from different areas of a family’s life to form a team. The team, led by a Family Care Coordinator, creates steps to help youth stay in their homes, schools and communities.

Through collaboration with the Wyoming Department of Health, Division of Healthcare Financing (Medicaid), Magellan serves as the Care Management Entity for the High Fidelity Wraparound program, setting the rules and providing training for everyone involved in the process.

One of Magellan’s certified Family Care Coordinators, a person responsible for managing a High Fidelity Wraparound team, recalls the story of a recent family she worked with. “In December, the family’s generator went out and without power they had to leave their home. As a result, the family had to move which was highly disruptive and caused a lot of tension within the family as their culture is centered on independence. In addition, it was upsetting to a young member of the family as the unfamiliar environment became very troubling.”

Living away from home negatively impacted progress the youth was making before having to move. Relationships were being affected and everything for this youth became more difficult. The family requested help to get back to their property through Magellan of Wyoming. Their Family Care Coordinator said, “When we found out our flex funds were approved to help get them home, [mom] cried and I did as well. This family finally felt hope, and there could now be a clear plan to help them move back home.”

Tammy Cooley, senior operations director at Magellan Healthcare of Wyoming, said, “We are honored to provide a means for a family to get back to their home, and keep their youth with them. Sometimes, we see families in situations where youth cannot remain at home. When we can fill a need and keep a youth safely at home because it’s the right thing to do, we will do that. The work we do, at the very core, is about the success of youth and families being able to meet their needs in positive ways.”

The single most important thing you can do to help your children is to show that you love them no matter what. Knowing that you are close by and available gives your children a sense of security. Although your children’s world is expanding, you remain their primary influence.
Always remember that you are a role model.

Your children learn by watching you. So be sure that your actions and behaviors teach them how to:
• Show love and affection.
• Control anger.
• Work with other people rather than against them.
• Stay calm.
• Look forward to tomorrow.
• Express feelings.
• Be brave.
• Laugh.

Safety and security
To build inner strength, children need to feel loved and safe. They need a family that is close, that spends regular time together, and that offers a safe haven as they grow.
• Make sure that your child feels safe. Your child is more likely to feel safe and secure if you are dependable, consistent, respectful, and responsive. These qualities are especially important for parents of preschool children, because these children are gaining a basic sense of trust in themselves and in the important people in their lives.
• Encourage safe exploration. Children need to explore. Children who explore learn new skills and how to solve problems. They learn that actions have consequences, and that causes have effects. Offer a variety of things to play with, read, create, and build. It might be hard, but try not to limit your child because of safety fears. Instead, do what you can to keep the child safe as he or she explores the world.

Social support
• Help your child build social skills. Teach your child by showing your acceptance of others and not gossiping or saying mean things about other people.
• Provide peer contact. Playing with other children even 1 day a week gives children opportunities to learn and practice important social, emotional, and language skills. Children learn to share, cooperate, and negotiate as they interact with their peers. Around age 9, many children successfully form close friendships. Forming these relationships helps children learn sensitivity to the feelings of others.

Confidence and independence
• Encourage independence. Children learn a sense of independence by practicing skills and doing things for themselves, such as getting dressed or brushing their teeth. Children who are not allowed to perform tasks on their own get the message that they are not capable.
• Help your child build self-esteem. Parents have the greatest influence on a child’s belief about himself or herself. Letting children know that they belong, are doing well, and are contributing can help them build healthy self-esteem.
• Reduce stress. Teach your child how to manage stress. Controlling stress increases resilience.
 Stress Management: Helping Your Child With Stress
• Deal with fears. Understand that your child may become extremely interested in scary subjects or images as a way to overcome them. Help your child as much as you can by answering questions and providing reassurance as needed.
• Recognize and develop special talents. To build healthy self-esteem, all children need to feel that they can do at least one thing very well. Pay attention to what your children like to do. Help them develop those skills, or find out where they can learn more.
• Build thinking skills. One way to help your child build thinking and reasoning skills is to get involved in your child’s school. Volunteer if possible, work on having good relationships with teachers and other staff members, and show your interest in what your child is learning.

Caring about other people
Empathy is an important part of building inner strength. It means that a child can recognize and appreciate how others are feeling. It means that a child cares when others feel bad and that the child wants to help them. You can help your child learn empathy by demonstrating it in your own life and talking with your child about it.

• Volunteering. Do volunteer work. If you can, take your child with you.
• Sharing. Teach your child the importance of sharing.
• Helping. Let your child help you with household chores, and show how happy it makes you to have help.

Helping others can help children learn that they have the power to make others feel better.

Self-control and teaching your child what’s right
• Set limits. Setting limits for your children shows them that you love and care about them. Make sure that your rules are reasonable and that your children understand them. And follow through on any consequences you have established for failing to follow rules.
• Use good discipline techniques. Discipline is the teaching of polite and appropriate behavior. Effective parenting techniques encourage your child’s sense of responsibility, nurture self-esteem, and strengthen your parent–child relationship.
• Teach self-control. Children learn by example. Teach appropriate behavior. Avoid physical punishment for behavior that is not appropriate.
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