Substance Use Disorder in the Exchange Population

With essentially one year of Health Exchange experience, this edition focuses on the high rate of substance use disorder among the Exchange population, the pent up demand for effective SUD treatment, and the utilization profile we are seeing.

The rate of substance use disorder in the Exchange population is higher than in Medicaid, Medicare or Commercial lines of business. These Exchange members tend to be more costly, more complex, and offer more of an opportunity for cost-savings.

Affordable Care Act and the Expanding Population in Medicaid and Individual Exchanges

This edition covers the Affordable Care Act and the expanding population in Medicaid and Individual exchanges. Several sources indicate these members will be more costly and have higher rates of substance abuse than current Commercial, Medicare or Medicaid populations.

For perspective, in a Commercial plan we typically see about 1.9% of members diagnosed with substance abuse and they drive $160 million in paid claims per million members (primarily medical claims). As we reported earlier, about 14% of members signing up for exchanges or Medicaid expansion are expected to have substance abuse issues.

Exchanges & Affordable Care Act: Cost Impact of Newly Insured Members with Substance Use Disorder

This edition of the Catasys newsletter examines how costs may change under the Affordable Care Act (ACA) driven by the newly-insured members enrolling on the exchanges and elsewhere. Compared to a Commercial population, the uninsured population has a significantly higher rate of Substance Use Disorder (SUD). Next year, as these newly insured members seek treatment, costs are expected to increase dramatically.

However, this is only the tip of the iceberg. Despite having an SUD diagnosis, most of these members have zero claims for SUD treatment. The bulk of their costs are on the medical side, with the majority of costs driven by members with $25,500 in mainly medical costs per member per year. The shock on the medical (versus behavioral) side may be unforeseen based upon current utilization practices.

CMS 2013 Requirements Regarding Opioid Abuse and Case Management

We are hearing that some health plans are having a challenge finding extra resources to comply with CMS’s 2013 requirements around Case Management and Drug Utilization Reviews (DURs). In a small to mid-size health plan, potentially several hundred members (~0.7% of your Part D membership) would be new Case Management members subject to Case Management intervention with active provider coordination.

Sponsors are, and have been, responsible for establishing reasonable and appropriate drug utilization management programs that assist in preventing overutilization of prescribed medications.

Medicare Advantage Utilization: Bending the Trend on IP and ED Visits

With the graying of America health care utilization and costs will continue to increase. Managed care appears to be bending this trend among several Medicare Advantage (MA) populations, however for every one million covered MA members over $400 million in paid claims annually (medical +behavioral +Rx) is driven by members with a substance abuse diagnosis.

With extra time in retirement, drinking can become more frequent and migrate to start earlier in the day. Excessive alcohol or illicit drug use exacerbates other comorbid conditions, often resulting in avoidable emergency department and inpatient utilization.

Can Cost Effective, Intensive Care Coaching Keep Chronic Cases Out of the Hospital?

As we continue to drive efficiencies in health care delivery, can care coaching really impact health and medical utilization, especially among chronic and costly members? This edition of the Catasys newsletter explores some of the factors for cost effective interventions by Care Coaches and Case Managers.

Care coaching, like many other items in life, may be high-quality or not-so-much. Subject matter expertise, intensive engagement with the member and long-term member skill building all contribute to higher quality and better outcomes. It is no surprise that low health care literacy among the general population creates opportunities for improved compliance, proactive care and better medication adherence. High quality care coaching can help develop the knowledge, skills and confidence of targeted members to address these issues, change behavior and reduce unnecessary and high cost utilization.

Can Health Plans Have A Competitive Advantage When Selling To ASO CFOs?

As Health Plans compete to win large Administrative Services Only (ASO) employers, can they create a competitive advantage with the CFO? This edition of the Catasys newsletter explores the influence of CFOs in selecting health benefits and what CFOs are looking for when making their decisions.

While CFOs place significant emphasis on medical costs (which are objectively measured) they are increasingly incorporating other productivity measures, but struggle with objective and accurate evaluation metrics. Nonetheless, it can be demonstrated that healthier employees are relatively more productive, and an employee who is not absent is more productive than an absent employee. Health plans with wellness or other programs that have shown the ability to improve health, reduce medical costs and keep people at work have the ability to differentiate and capture the favor of the CFO, providing a competitive advantage in winning new business.

High Cost of Opioid Abuse

This edition of the Catasys newsletter outlines the impact of opioid abuse and the relatively low level of intervention with these individuals. Among health plans, opioid abuse is often highly visible due to the strong efforts by pharmacy departments to highlight this high-cost area. For perspective, opioid abuse usually comprises 10-20 percent of the substance abuse savings opportunity in a commercial population. As noted in the articles below, today’s opioid problem seems to be growing.

High Prevalence of Substance Abuse Among Baby Boomers and Older Populations

This edition of the Catasys newsletter outlines the high prevalence of substance abuse among older populations, and while treatment can deliver an attractive ROI, up to 85-90% of these patients are avoiding or not receiving treatment for substance abuse. This is consistent with claims we have analyzed for health plans across the country which show 75% to 95% of members diagnosed with substance abuse do not receive substance abuse treatment.

8 Drivers Impacting Cost Savings

This edition of the Catasys newsletter outlines 8 drivers impacting cost savings from your substance dependent population. Surprisingly, national averages show $160 million in claims are incurred by substance dependent members in a 1 million member health plan. The majority of these costs are medical, driven by the consequences of substance abuse (and are mitigated if the substance abuse is successfully addressed).