At-risk opioid users in a managed care insured population: Identification and outreach from a medical and pharmacy claims database

Abstract

Objective: To deploy an algorithm using medical and pharmacy claims data to identify members of a managed care organization at risk for opioid misuse and provide outreach.

Methods: A retrospective review of 2019 enrollment information and prescription and medical claims data identified members aged 18-64 years with medical and pharmacy benefits and at least one paid pharmacy claim for an opioid. The most recent paid prescription claim served as the index date for each patient. Members with cancer or sickle cell disorder, receiving palliative/hospice care, or nursing home residents were excluded. Diagnoses were obtained for 12 months prior to the index date, while medication use was assessed within 6 months prior to the index date. Clinical characteristics were used to stratify members by risk of opioid misuse into risk-based cohorts.

Results: There were 62,986 adult members with medical and pharmacy benefits receiving at least one scheduled (II, III, or IV) opioid during 2019. In this group, the average age was 43.3 years (±13.0), with 56 percent being female. More frequent diagnoses included low back pain (13.2 percent) and anxiety disorder (12.4 percent). About 10.3 percent of the group (n = 6,486 members) were assigned to one or more at-risk cohorts. Out of a total outreach attempt for 804 members, 45 percent had successful engagement. Of those members engaged, 39.8 percent declined any support services offered.

Conclusion: An evidence-based algorithm found 10.3 percent of members at higher risk of opioid misuse. Interventions for targeted members reached fewer than half, and many declined assistance. Health plans need more effective intervention strategies.