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For many people struggling with opioid use, a key to their success in recovery is having support. Some are getting that support from an unlikely place: their health insurer.
Amanda Jean (or "A.J.") Andrade, 24, has been drug- and alcohol-free since October, the longest amount of time she's been off substances in a decade. She gives a lot of the credit for that to her case manager, Will, who works for her insurance company. He's helped her find the sober house where she moved after inpatient treatment, and he's helping her figure out where she'll go from there.
"Having Will is the best thing in the world for me. If I have the slightest issue with anything to do with my insurance, that included like prescriptions, even when I had a court issue, I know that I can call him," Andrade said.
Her insurer, CeltiCare Health Plan, is one of several health insurance companies taking new steps to deal with the nation's growing opioid epidemic. CeltiCare has about 50,000 members in Massachusetts and mostly manages care for low-income patients on Medicaid.
CeltiCare president and CEO Jay Gonzalez says making sure its members stay on track in recovery is critical.
"This is the biggest potential solution to this problem, I think, because at the end of the day we have to find the members who are or could be in trouble and we need them to be invested in addressing their issues," Gonzalez said.
Gonzalez says for CeltiCare, the costs related to the opioid epidemic are huge: Nearly a quarter of its hospital admissions are related to substance use, and the insurer spends more on Suboxone, a medication to treat addiction, than any other drug. Gonzalez believes that investing in the extra attention for patients like Andrade — after inpatient treatment — will help them stay sober and eventually pay off.
"At the end of the day we think it's going to cost a lot less. If somebody is cured of their addiction, — and this is hard thing for people to break — they're gonna be healthier, they won't be in the emergency room. We have people who show up in the emergency room 50 to 100 times a year. That's very expensive, and it's not good for the member," Gonzalez said.
CeltiCare also limits first prescriptions of opioid painkillers, where opioid use often starts, to 15 days and it plans to reduce that even more starting next month.
CeltiCare is not the only insurer taking action: Massachusetts' largest insurer, Blue Cross Blue Shield, has been limiting first prescriptions for the past three years. Blue Cross Blue Shield Associate Chief Medical Officer Tony Dodek says about 11 percent of its more than 2 million members were treated for a substance use problem in the last year. Federal numbers show that most misused controlled substances originate as legal prescriptions, so he says limiting prescriptions is one way to deal with the problem.
"We decreased the number of doses in circulation when you compare the three-year period after implementation to the prior period — by over 21 million doses. Something that was relatively straight forward and simple," Dodek said.
What's not so easy is finding ways to keep patients out of the hospital. Between 1993 and 2012 the rate of inpatient hospital stays related to opioid use went up 150 percent across the country, according to Association of Community Affiliated Plans, a group of 60 health plans in two dozen states. Neighborhood Health Plan in Boston is one of them. Its chief medical officer, Dr. Paul Mendis, says the insurer has developed algorithms to identify members at risk for substance use and has hired social workers to reach out to them. The company is also piloting a program in which a recovery coach is assigned to those taken to the hospital after an overdose.
"The commonwealth is staggered by the toll in human life. We're averaging about four deaths a day," Mendis said. "But I think it's helpful now that there's so much attention now. So it's easier to get resources, frankly, to help fight it."
Those resources appear to be helping patients like A.J. Andrade. She said she started using drugs as a teenager after both of her parents left home and she was essentially homeless. She temporarily stayed in foster care and with various family members or boyfriends — some of them abusive. Her son was born six years ago, but she lost custody and her drug use spiraled.
Although Andrade feels that many people in her life have let her down, she also believes that it's other people holding her accountable that will now help keep her on track.
"All the people I hurt and let down not reaching for it, not at least even trying to reach for it," she said. "I have in one of my poems: 'Don't let anyone diminish your self confidence, your pride. If you feel something, it means that you tried.' I at least want to try for all the people that tried for me."
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