By David Raths
Pittsburgh-based insurer Highmark Inc. has broadened its approach to addressing substance use disorders in the wake of the COVID-19 pandemic. Among its response efforts is a partnership with axialHealthcare to offer care navigation and peer support services for members in recovery.
Highmark Inc. and affiliates operate health insurance plans in Pennsylvania, Delaware and West Virginia that serve 5 million members. It also owns Allegheny Health Network, a nonprofit, 13-hospital academic medical system with facilities in Western Pennsylvania and one hospital in Western New York.
In a recent interview, Caesar DeLeo, M.D., vice president and executive medical director of strategic initiatives for Highmark, described the deepening challenge the organization is working to address.
“Prior to COVID we were already in an opioid epidemic. We had a few years when we were doing well in terms of hoping we could change the rate of overdose in this country,” he said. “In 2018, we saw a drop nationally by 4.1 percent. But then in 2019 it went back up. Once you put a pandemic on top of that, it completely upset things.”
The pandemic has brought barriers to the delivery of care, isolation and job losses. “You have people under a tremendous amount of stress, and families in new situations that they have not been accustomed to – young adults living at home with parents,” DeLeo said. “You have a lot of people who may have controlled their substance use disorder a little bit, but the strains have pushed them back over.”
Highmark made a concerted push to expanding access to telemedicine and tele-addiction programs. “As soon of the pandemic hit, we were convening stakeholders and worked closely with the Allegheny Health Network to make sure we could get tele-addiction services up and running,” DeLeo explained. “At the beginning of the year we were doing less than 1 percent tele-behavioral health and tele-addiction visits. A lot of education and operational pieces got put in place and by May, the Allegheny Health Network was doing over 90 percent tele-behavioral and tele-addiction services, which was really remarkable.” There was an increase in volume in addiction medicine of 15 percent during that time, he added.
He said they peaked at around 76 percent, and are currently at about 65 percent of visits being tele-addiction system-wide. “In the future we think we are going to find a sweet spot where it will be a hybrid model,” DeLeo added. People will start off being seen in person to gain trust and to do an assessment, and then could be seen through a combination of telehealth and in person. “We also promoted tele-addiction services from vendors, including one called Bright Heart Health that is in most states in the U.S. now. We launched in West Virginia in January with them because it is the state with the highest number of overdoses in the U.S. in terms of rate. Once the pandemic hit, we expanded to Pennsylvania and Delaware with them.”
Beyond expanding telemedicine offerings, Highmark has convened inpatient and outpatient providers and held regular calls with them and harm reduction organizations. “We created forums to share best practices among themselves around what to do when staff is in quarantine or how to separate patients who may be in quarantine, how to come up with testing protocols and keep new patients separated until they clear COVID testing,” DeLeo said.
“One of the things we saw an opportunity to do was provide individuals better transitions out of the inpatient setting, and we understood the value of peer support counselors or specialists across behavioral health but in particular we were interested in addiction medicine,” he explained. “We partnered with axialHealthcare on their peer support specialist program. What is unique about axial as opposed to a lot of stand-alone peer support programs, is that they begin their coverage while the patient is still in the facility and work with the facility to develop the relationship prior to the discharge,” he added. “That gives them a head start and creates stickiness and trust, which is important.”
As the patient enters back into the community, axialHealthcare can help them with managing their own medication and treatment, being able to be connected by phone or in person or digitally with their caregivers, knowing what their personal health record is, and knowledge of the red flags or triggers that predispose them to relapsing into prior habits, DeLeo said. “It is important to have a peer support specialist who can help guide that individual when things are blowing up. If there are problems with a social determinant of food or housing, they are there to help identify and use resources we are sharing with axial through Aunt Bertha, a directory of community-based organizations.”
Dirk Wales, M.D., axialHealthcare’s chief medical officer, noted that the company started about five years ago with an offering to help provide evidence-based medicine guidelines within physician practices around opioid prescribing. The company developed applications and educational tools and to educate providers. About a year and a half ago, the company added a Recovery solution, designed to help people who have chemical dependency get through the fragmented healthcare system successfully and achieve sustained remission.
Nashville-based axialHealthcare works in partnership with payer organizations on its Recovery solution, classified as a care coordination service. “We use a dyad of a peer specialist — a person who has gone through addiction and come out the other side and has sustained sobriety and has been trained on how to guide people — as well as a licensed clinician on our side to help guide people through the fragmented system,” Wales said.
He said they work as a convener or integrator of services. “A person may be seeing clinicians such as a medication-assisted treatment provider or primary care or mental health,” Wales said. “Our team helps them make sure they understand the need for those appointments, helps get them those appointments, and makes sure their care plan is delineated and that they are taking medications on a regular basis.”
Wales echoed DeLeo’s comments about the impact of the pandemic on the opioid crisis. “One of the key things we have seen with the pandemic is a significant rise in the number of people who are using or relapsing,” he said. “COVID has pushed people to become isolated, and in recovery that is not the option we want. We want people connected and getting the support they need. The emotional stress of the pandemic, and fear and uncertainty created a stressor on these individuals. We have seen a significant uptick in overdoses. For instance, in Cumberland County, Pennsylvania, the overdoses have spiked to almost 30 people dying this year, on track to beat the high-water mark from 2017.”
Andy Thomas, axialHealthcare’s vice president of national provider relations, said the company identifies providers that have a high volume of health plan partners’ members going through treatment. “In Pennsylvania, we are starting with brick-and-mortar residential and inpatient treatment providers,” he said. “We have hired staff in the market to support patients as they are transitioning back to the community.”
Thomas said he can speak from experience about the importance of peer support. “I am in long-term recovery myself and have had a significant history of opioid addiction. I went through treatment in 2010, and fell into long-term support by chance. I was introduced to someone by a counselor and ended up meeting this individual for coffee, and they took me under their wing and connected me into the local recovery community.” He said the company’s goal is to activate that type of community for people at scale. “We are hiring local staff — people who are in recovery and have been through treatment. They can help people activate their care program and connect them to outpatient programming.”
Highmark’s DeLeo stressed that this is an evidence-based practice. “It is no longer a question whether this is effective. There is literature that shows it decreases hospitalizations, decreases length of stay and decreases costs, and increases various different variables in quality of life.”