BCBS takes steps to respond to opioid abuse

This article is from Aug 2017, and according to this .. their timetable for and contributing factors to opiate epidemic. Once again Congress gets a pass on their passing of the Decade of Pain Law that became law in 1999-2000. That was a significant cause of the creation of “the fifth vital sign” and the joint commission adopted that as a major standard that hospital had to address pt’s pain and most had discharge surveys that included a question if their pain was well treated. When the law expired the political party in control of Congress had flipped and it was not renewed.  The “fifth vital sign” DISAPPEARED and no longer  any concern of the Joint Commission.  Opiate Rxs peaked in 2011-2012 and have dropped every year since and now about 60% down from their peak, but the number opioid poisoning – most all from illegal “street fentanyl” has increased SEVEN TIMES in the last 10 yrs. It seems, that most all bureaucrats still believes that the “jury is still out on the matter of prescribing opiates to treat pain doesn’t cause addicts ” Since “we” don’t track suicides from untreated pain and/or premature deaths from under/untreated pain very well… “we” really don’t seem to care how many people are dying while bureaucrats are trying to satisfy their opiophobia.

BCBS takes steps to respond to opioid abuse





Jody Gembarski, pharmacy manager at Blue Cross Blue Shield of Michigan

Jody Gembarski, pharmacy manager at Blue Cross Blue Shield of MichiganNearly one in five Blue Cross Blue Shield of Michigan members had a prescription for an opioid filled in 2015. The dispensing rate nationally was higher, at 21.4 percent. Between 2010 and 2016, the 36 Blue Cross Blue Shield plans across the U.S. recorded a 493-percent spike in enrollees diagnosed with a disorder associated with opioid use. Those statistics from the Chicago-based Blue Cross Blue Shield Association reflect the opioid epidemic in America that in 2016 resulted in more than 33,000 overdose deaths. MiBiz spoke with Jody Gembarski, a pharmacy manager at Blue Cross Blue Shield of Michigan who oversees its controlled substance work group, to discuss the association’s analysis and the role the state’s largest health insurer has in responding to the epidemic.

What do you make of the Blue Cross Blue Shield Association data on opioid use?

There clearly is a problem with opioids for our members and across the nation. Michigan definitely has a problem. You can see the statistics. We have a high dispensing rate of opioids and high opioid use disorder. It’s definitely a problem and we are very invested in attacking that and seeing what we can do to improve the situation for everyone involved.

What can Blue Cross Blue Shield of Michigan do?

We try to look at it on multiple different avenues. There’s no one solution that fixes this. We look at it from the providers, our physicians and health care providers that are involved with this. We have educational webinars (and) an opioid toolkit for them to use. We encourage them to check the Michigan Automated Prescribing System that will let them see if the member and their patient has gone to a physician a week before or a month before (for an opioid prescription).

What about from the member perspective?

We have a new pilot program that focuses on overdoses and trying to get those members connected to treatment or help. My controlled substance work group, what we do is we monitor claims and if somebody has a concerning behavior, we try to connect them with appropriate resources, whether behavioral health, case management, a pain management referral, or even treatment of a substance abuse disorder that they have.Do you have a way of identifying doctors who perhaps are outside of the norm and have a higher prescribing rate for opioids?

We have a corporate and financial investigations unit. They do look at prescribers who are outliers and compare them to their peers and they investigate those prescribers. There is a whole process to evaluate physicians prescribing opioids, and we have a process to remove them from our network. A lot of times we are ahead of the state and federal government because we have our own data. We actually receive reports from the Centers for Medicare and Medicaid Services — it’s a prescriber outlier report — and we take action on that as well.

Is Blue Cross getting more aggressive in identifying outliers prescribing opioids?

We’ve definitely increased our focus there as we’re seeing how much the opioid epidemic is impacting everything. We are looking much more closely at those that are outliers and identifying what’s going on (and) why. It’s definitely a high priority for us.

Why should this be an issue for employers?

The impact of the opioid epidemic is significant. It’s raising health care costs overall with the prescribing of opioids, and then once somebody is addicted, it is very costly for the health care system. The cost for the health care system is definitely going to impact employers and everyone else involved.

What should an employer do?

Ask what type of programs are in place from the health care provider that they have. We have a list of initiatives and programs and things that we do to help identify fraud, waste and abuse. We have initiatives in providing treatment of our members. As an employer, it is worth investigating and asking the question of what’s being done from the health provider perspective? What are you doing to help improve the situation or decrease prescribing?

Is there any consensus out there on what led to the epidemic?

There are a number of factors and we all ask, ‘What’s the root cause?’ Some of the national meetings that I sit on, there is discussions about how in the ’90s there was this push about the ‘fifth vital sign’ and pain management. That was kind of the focus and people shouldn’t be in pain if they’re having pain. Maybe that fueled a little. Everyone you talk to might have a different idea about that, but that is something that is on the table. There was this focus on pain management. It wasn’t being assessed appropriately and it wasn’t given enough attention. That could be the reason that partly led to this, but that’s not the reason. I don’t think there’s one reason. There are multiple things that led to this and it’s kind of hard to point to something.

5 Responses

  1. First and foremost, you really can’t “average out” opioid users. They are not all opioid abusers. It depends on the population, the need for pain control.
    BCBS you are responding to numbers, not a case by case response which is the way it should be.
    While I know “averaging out” patients who take opioids is expensive, it is the only way to get a true picture. Unfortunately the way you take percentages is not a true picture. You absolutely punish people in true need.
    Most of my spine is fixated either with rods and screws or laminectomy. It is extremely painful and ultram doesn’t help.

    So staying off my feet causes a multitude of other health disorders. What do I do? I have a horrid confrontation problem meaning I avoid doctors at all costs. Unless my blood pressure goes up to 257/156. Then it is an ambulance to the hospital because of stress, pain and headache.

    But PROP has done their job.


  3. Insurance companies shouldn’t be policing the practice of medicine. Who are they to drop a physician for prescribing medication. Chronic pain patients are being forced to suffer INHUMANELY, CRUELLY AND UNETHICALLY. It’s a doctor’s duty to ease suffering but no doubt with insurance companies and the DEA and buracrates dictating, do you blame doctors for being afraid. The doctor patient relationship within the chronic pain community is fractured. Doctors don’t trust their patients and patients are left fearful to say anything about their pain. Drug testing, random pill counts that leave patients on a short leash. Can’t go anywhere because you’re expected to be at your doctors office within 30;minutes for a pill count,basically because we don’t trust you. Under surveillance just because of the bad luck of a drawl that you have a painful condition at no fault of your own. And still left to suffer in serve pain maybe due to tolerance. My nurse practitioners and physician assistants don’t care. Absolutely no change in medication for my pain. Short acting opioids for severe intractable pain is like a plane that keeps nose diving. Because the dose doesn’t maintain the painThat in itself is repeated torture . The rigid inflexible opioid prescribing since the 2016 CDC guidelines and it continues after the new CDC guidelines. Insurance companies don’t want the costs of chronic pain patients. BSBC mentions FRAUD but they themselves have committed FRAUD in order to prosecute pain management doctors who are only doing their jobs to the best of their knowledge 3in good faith. Doctors didn’t cause the “opioid epidemic ” we have an illicit fentanyl epidemic . Pain should be the 5th vital sign still in my opinion . Pain is subjective . I shouldn’t have to think about suicide to ease my pain. I can tell you that before the 2016 CDC guidelines, suicide ideation because of my pain wasn’t nearly as what it is today. And unless you yourself are suffering, you’re clueless. It’s torture. Plain and simple. And it’s unnecessary. Our government continues to allow our citizens and youths to die from illicit fentanyl poisoning because of prohibition. It’s immoral in their mindset. Addiction is a disease. I know if I weren’t suffering from severe intractable pain, I wouldn’t be taking an opioid because I wouldn’t need it . It wasn’t bad enough to end up having severe pain from surgery . Pain can be managed. But not in today’s bureaucracy. But what are my choices for forced pain and suffering? There’s no many choices . How many people have to die? How many doctors have to practice medicine in fear,be targeted or end up behind bars? The corruption runs deep in this anti opioid prohibition, forced suffering propaganda

    • Very well said. I have a huge issue with BCBS limiting the # of doses I can have for X number of days. It’s messed up and I have to pay out of pocket, and THAT looks suspicious!

      I am so sorry you are suffering. I am very fortunate that I do get proper treatment, pill counts, pee tests, etc, and still have a life. I’ve experienced not being treated and it is hell. My heart goes out to you.

  4. It’s disturbing that they have taken the tack that “identifying outliers” is going to do anything but drive physicians out of the practice of prescribing. Probably eventually any controlled med, in all honesty. We do not have cookiecutter bodies, therefore it’s impossible (and impractical) for doctors to maintain a cookiecutter standard,. It cannot be done without sacrificing care. Although everyone and their dog seems to want to believe they’ve found the magic bullet answer, I have yet to see a single one that has any real rationale behind it, except to make it appear that they’re “doing something!”. The anti-opioid sentiment will likely be the death of far more patients than they will ever know. Not because they can’t figure it out, but because they don’t want to acknowledge it. That’s perhaps one of the most despicable components to all of this. It isn’t like it’s a big secret that we suffer when pain goes untreated or under treated. They just don’t want to know about it so they can avoid that nagging feeling of guilt that is common to the human conscience, when people know they’re doing something that is morally bankrupt. For those that haven’t successfully stamped out any semblance of conscience they were born with, anyway. They can’t all be socio/psychopaths…can they?

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