Lauren Moran, MPP and Rachel Yard

June 19, 2018

The opioid epidemic is a national public health crisis, with more than 115 Americans dying daily from opioid-related overdoses. As the country’s largest health insurer, Medicaid is uniquely positioned to lead innovative strategies targeted at reversing this horrific trend. Wendy Long, MD, TennCare Director and Deputy Commissioner, and Cynthia Beane, MSW, LCSW, Commissioner of the West Virginia Bureau for Medical Services, are pioneering ways to combat their own states’ epidemics through cross-sector collaboration and relationship building, while carefully navigating the political complexities and challenges.

CHCS recently spoke with Dr. Long and Ms. Beane, both recent fellows of CHCS’ Medicaid Leadership Institute, who shared how they are creating synergies across state agencies to confront the opioid epidemic.

Q: Both of your states have implemented a range of strategies to address the opioid epidemic. Can you briefly describe the focus of your work?

A – W. Long: We have a three-pronged approach to address opioid use: primary prevention, secondary prevention, and treatment. Our primary prevention focuses on limiting dosage and duration of opioid prescriptions among new users. We also severely restrict the circumstances under which TennCare will pay for chronic opioid therapy for a member just starting opioid treatment — typically only individuals on hospice or who have cancer-related pain. Our secondary approach seeks to reduce neonatal abstinence syndrome (NAS). This initiative encourages women of child-bearing age taking opiates to take advantage of voluntary long-acting reversible contraception (LARC), which is covered by TennCare. Our third focus is on treatment. Currently, we have 48,000 individuals in TennCare taking opioids habitually. We need to have an adequate treatment network available and target individuals at highest risk for overdoses and facilitate treatment.

A – C. Beane: We’re currently rolling out our 1115 waiver promoting substance use disorder (SUD) services, with a focus on increasing the availability of medication assisted treatment (MAT). We’ve started covering methadone, and also signing up new providers (PCPs and APRNs) to prescribe Suboxone. Starting in July, we’ll begin covering residential treatment and peer recovery services to supplement our other treatment programs. Our Naloxone initiative includes reaching out to members with previous overdoses using data collected in a 2016 study — the study has helped us identify where additional interventions are needed. Lastly, we now cover a neonatal abstinence center that helps babies going through withdrawal and engages parents to reduce future NAS births.

Q: How are your efforts beginning to make a difference?

A – C. Beane: We haven’t seen the needle move down, in fact, it continues to go up when you look at statistics for overdose deaths, NAS births, and the number of individuals diagnosed with SUD. We have seen some improvement in counties where we’ve rolled out treatment programs, particularly in reduction of overdose deaths. We hope to see a bigger difference as treatment becomes more accessible state-wide.

A – W. Long: TennCare is seeing a decline in the number of opioid prescriptions it is covering, but we’re not yet seeing a reduction in the number of NAS births and overdoses. At the same time, we’re seeing an increase in the number of individuals diagnosed with SUD. We’re not sure if that’s a feature of our additional focus and outreach on the issue — which could be a positive thing if we’re identifying more individuals who need treatment.

Q: Medicaid’s efforts around opioids are always part of a larger strategy that involve others agencies. What have you learned about how to work effectively with these partners?

A – W. Long: It’s important to understand what motivates a particular partner and play to those interests. A recent example is our work with the Tennessee Initiative for Perinatal Quality Collaborative. They’re incredibly interested in NAS. As such, we’ve let them dig into our LARC program, which they’ve now really made their own. It was an impeccable fit and a great utilization of resources for Medicaid.

TennCare’s role in the epidemic has reminded the legislature and key stakeholders that we’re a health agency — not just an insurance program. We hope this will catalyze other agencies to think of Medicaid more often when faced with challenging health problems, such as infant mortality, adolescent pregnancies, etc. We have a role relative to all of these issues and we have a lot of resources to leverage.

A – C. Beane: By working with our partners, we’ve been able to uncover the most effective use of our resources while looking for ways to blend funds to maximize the Medicaid dollar. The opioid epidemic is now beyond SUD treatment alone as it has had a rippling effect, causing additional issues that we need to address. For example, we’ve seen a 43 percent increase in children being taken out of the home and put into foster care — a direct correlation of the epidemic. We’re working with the Bureau of Children and Families to find ways to strengthen in-home supports and treatments with hopes to decrease this number. Another example is the Hepatitis A outbreak we’re currently facing, which we’re combating alongside the Bureau for Public Health by making sure vaccines are readily available.

Q: As states have made changes in prescribing guidelines and access to prescription opioids, people talk about how the epidemic evolves with new drugs of choice. Do you see this happening and, if so, how does this change how your programs respond?

A – W. Long: We do worry immensely that as we crack down on opioid prescriptions, people will turn to heroin and other street drugs. We continue to track overdose deaths and what substances were used as best we can to monitor what’s happening on the streets. Our main strategy to avoid this evolution is to roll out restrictions very carefully and with a focus on new users.

A – C. Beane: As we’ve identified and shut down pill mills, we have seen the evolution of prescription opioids to street drugs, such as heroin and fentanyl. But regardless of the drug, it’s all the same disease — addiction. Our response is to continue to push MAT.

Q: What have you learned about responding to opioid misuse that can be applied to future challenges? What impact has your relationship with each other and your other Medicaid Leadership Institute Fellows had?

A – C. Beane: We’ve learned that a comprehensive approach is the most effective for issues that extend beyond the Medicaid population. The relationships I’ve formed through the Medicaid Leadership Institute have been invaluable. This is West Virginia’s first 1115 waiver. Being able to connect and learn from others that have gone through the process has been tremendously helpful.

A – W. Long: I have to echo Cindy’s response — a multi-agency approach has been key. The opioid initiative has presented many opportunities to partner with agencies and use their expertise to bear down on the issue.

The Medicaid Leadership Institute has allowed me to get to know five other directors really well. Each Medicaid program is so different — no two operate alike, yet there is virtually no issue another state hasn’t grappled with and learned from already.

Q: What advice would you offer to the next generation of Medicaid leaders from this experience?

A – W. Long: It’s important to build cross-agency relationships before there’s an emergency, otherwise, you’re faced with the additional challenge of trying to get to know everyone at the same time you’re dealing with a crisis. Also, you can use big challenges and initiatives like this to develop your staff. Set the course and then get out of the way! This is the best way to institutionalize an initiative and build it into the culture of your organization so that it sticks beyond your own tenure.

A – C. Beane: You can’t operate in a silo — it takes a lot of collaboration to make your program as effective as it can be. Also, listen to other states. There’s no reason to reinvent the wheel when tackling widespread issues like the opioid epidemic. We all understand how challenging it can be to run these programs. We’re open to helping each other as much as we can.

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I appreciate the work the Medicaid Directors do within the constraints of their budgets and resources, and applaud them for their work in collaborating with other state agencies. However, as a relatively recent transplant to Tennessee from a state where Medicaid coverage is available for single adults, I can’t help but wonder how much more the response to the opioid crisis would be if Tennessee expanded Medicaid as most states did, including West Virginia, which saw a 56% decrease in its uninsured rate. If more people had more access to primary care, their SUD could be diagnosed and treated much… Read more »

Rebecca Stricklin

We hear about collaboration with different agencies but I don’t see the law enforcement agencies mentioned. Can a comprehensive, in house, drug rehab program be an alternative to actual jail time for first and 2nd non-violent offenders? We should take a few lessons from the Salvation Army’s Drug Treatment Program or collaborate with them. Their program is fairly successful. This epidemic has reached every corner of our population. It’s going to take input from most of those corners to be effective. There also has to be a Legislative component. Mandatory treatment for overdoses drunk driving deaths have been reduced since… Read more »

Mark Larson, VP for Policy, CHCS

All helpful points illustrating the need for a comprehensive multi-sector approach. We applaud states like Tennessee and West Virginia that are thinking broadly and evolving cross-agency approaches to address this national epidemic. To your point about the importance of collaboration with law enforcement specifically, we are aware that both states have engaged in efforts in this area.