Tufts Health Plan and the Opioid Epidemic

We’re tackling a complex problem with compassion, with the goal of delivering the very best care and support to our members and their families

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Between July 2016 and September 2017 opioid overdoses increased 30% 

The numbers tell the story for themselves: of the 64,000 drug-overdose deaths in the US in 2016, three quarters were caused by opioids, according to the Centers for Disease Control.  And recent reports from the CDC show opioid overdoses increased 30 percent between July 2016 and September 2017.

The opioid epidemic is not new and it’s not going away.  It is a complex problem that tragically affects too many people. As a company, Tufts Health Plan has made it a priority to support our members, our employees, and the communities we serve who are struggling with opioid use.

It’s about going above and beyond providing good coverage for treatment

This is about more than what’s covered and what’s not. To truly help our members, we’ve organized multiple teams in the company to study, analyze, and create effective care solutions for our members who are struggling with opioid addiction.

We’ve identified the most skilled behavioral health and substance use disorder experts who deeply understand the complexities of addiction and effective treatment, and placed them in roles that best position them to help members and providers coordinate effective treatment.

Our goal: help members access the right care, at the right time, in the best place

Our clinical programs are developed to help members access the services they need, and ensure those services are integrated with their medical treatment. We want to ensure social supports are mobilized to help members achieve their goals. Our goal is to give members the tools to build strategies for recognizing when they may need additional supports.

The data is critical to identifying members who might be using or struggling with addiction, so we can proactively reach out to those members and their providers to coordinate the right care approach.

We created a role dedicated to helping addicted members

As the opioid epidemic has compounded, more and more members are calling us to understand treatment options and coverage.

To address this, we created the role of Substance Use Disorder Family Navigator, a position dedicated to helping members and their families understand addiction, treatment options, and benefits and coverage, and find solutions that fit their situation.

But what’s most important about this role, is a deeply nuanced understanding of substance use disorder

What we know now that we didn’t fully appreciate in years past is that Substance Use Disorder is neurobiological, not a moral or character failing of an individual. The nature of substance use disorder is that is has relapse and remitting characteristics and we need to approach it from a disease management philosophy, not a one-size-fits-all plan. Just because a person realizes they have a problem doesn’t mean they can apply the solution. It may take 1 or 2 or 3 more tries. Relapse behavior is not an indication of treatment failure or failure of commitment — it is the nature of the disease.

The navigator role complements the work of our Care Management Program, an outreach program designed to offer individualized support to members with various complex conditions, including substance use disorder. The navigator works collaboratively with our Medical Care Managers and members who may be using opioids, so members can be referred to the right services at the right moment.

Members have to be willing to engage with the navigators and care managers, it may not be the right time now, but we will be there in the future..

To speak to our Substance Use Disorder Family Navigator, members or their family members should call 800.208.9565

We emphasize the importance of local care 

The data speaks for itself: patients who are surrounded by their own physicians, behavioral care practitioners, and personal support systems have a better chance at successfully recovering from substance use disorder.

As a result, we’ve contracted with a broad network of substance use disorder facilities, programs, and practitioners, including:

  • An ambulatory network, which has added more than 100 additional licensed alcohol and drug counselors over the past year
  • Providers who specialize in and adhere to evidence-based practices in the care of substance use disorder patients

Says Sousa, “We really look at the organic community that the member is living in and what other resources and supports are there so they can have access to care and support 24 hours a day.”

Critical coverage: a broad range of treatment options

We recently decided to cover the life-saving drugs Narcan and Naloxone injection at a $0 cost-share for all members. And last year we eliminated the member cost-share for methadone clinics for all commercial plans.

In addition, we’ve made sure our insurance products cover a broad range of treatment options, including coverage for:

  • Inpatient detoxification and acute residential treatment
  • Partial hospital programs and intensive outpatient programs
  • Outpatient therapy and medication management
  • Medication-assisted treatment, including methadone maintenance and prescription of Suboxone
  • Pharmacy coverage for medications used to treat addiction, and for medications that can reverse an opioid overdose at no cost to members

Substance Use Disorder is a complex care challenge for everyone

For our members and their families, accessing and navigating treatment, and finding supportive services, while trying to maintain work or family is challenging. Substance Use Disorder also comes with guilt, shame, denial, and remorse, making treatment complicated and sensitive.

Opioid use is at an all-time high and its impact can be seen across all the demographics and communities we serve 

Treatment requires an approach that integrates expertise in substance use disorder, social work, and medical treatment. As an insurer, we at Tufts Health Plan are responsible for acting as a guiding resource and intermediary for our members, their providers, and health care facilities.

Our goal remains to be a trusted partner for our members, and to help them access the right care, in the right place as they need it. Learn more about the behavioral health services we offer.