1120 North Charles St.

Suite 200

Baltimore, MD 21201

(410) 542-4470

www.discernhealth.com

Panel with the Rural Carrier

Benefit Plan

Improving Care for Rural

Communities At-Risk for Opioid

Abuse and Addiction

October 21, 2019

2

Welcome and Introductions

Cameron Deml, BBA, Director of Insurance Programs

National Rural Letter

Carriers’ Association

(NRLCA)

Terry Flander, DO,

Consultant Medical Director

Rural Carrier Benefit Plan

(RCBP)

Ted Borgstadt, BA, CEO and Co-Founder

TrestleTree, LLC

Donna Dugan, PhD, MS,

Vice President

Discern Health

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Learning Objectives

▪ Discuss challenges facing health plans, providers, and community-

based organizations serving rural residents at-risk for opioid abuse,

addiction, and behavioral health conditions

▪ Identify best practices for improving care coordination, engaging

members and providers, and strengthening community partnerships

to address the opioid epidemic in rural communities, and in turn

improve related quality measure performance

▪ Apply strategies from a national rural population health program to

tailor to local community needs

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About the NRLCA

▪ Represents over 116,000 rural letter carriers’

of the Postal Service.

▪ Plan Sponsor of the Rural Carrier Benefit Plan

▫ Part of Federal Employee Benefits Program

(FEHB) since program inception in 1960

▪ RCBP serves more than 63,000 lives

▪ Closed plan

▫ Only available to active and retired rural

carrier members of the NRLCA

▪ Unique benefits (e.g., 100% cancer coverage)

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RCBP Challenges and

Opportunities

Disparate, rural population

▪ Range of demographic needs

▫ Members 40 years old and 90 years

old on the same benefit chassis

▫ Average member age: 57 years

▪ Serve every zip code in America

▪ Access to care

▫ Typical for an RCBP member to

drive over 15 miles to their primary

care provider (PCP) and over almost

20 to the hospital

Relevant care needs

▪ Care needs relevant to carriers

▫ Back pain

▫ Musculoskeletal (MSK) conditions

▫ Repetitive motion injury

▪ Opioid crisis

▫ Given rural membership, and in

relation to pain and MSK conditions,

appropriate use and overuse of

opioids is of particular concern

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Opioid Crisis

Challenges

▪ Society’s answer to solving opioid crisis over the last three years:

1. Limit quantity

2. Base limitations on morphine equivalency

3. Tougher, more aggressive enforcement of illegal opioids

▪ While necessary, pendulum may have swung too far in the opposite

direction

▫ Before 2015 – Opioids prescribed freely without scrutiny

▫ After 2015 – more stringent, but necessary, restrictions put in place

▪ Pain is subjective

▫ There is no standard prescribing guidance for pain medications

Current strategies don’t address the biggest underlying issue

of the opioid crisis: Pain!

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Real Member Stories

Issue: Quantity Limit

• 94-year old retiree

• Can’t get out of bed without fentanyl

patch

• Hip and back issues

• Plan limits put in place in 2018 would

have prevented him from getting the

pain patch and relief he needed to live

on his own

• Determined regular use did not pose

an undue risk

• Exception made to fill pain medication-

as prescribed by his doctor.

Issue: Access and Social

Determinants

• Early 70s retiree in rural Florida who

didn’t have access to resources for

pain med refill

• Pharmacist would hand-deliver opioid

meds, but left position

• Previous prescriber stopped writing

opioid Rx

• No car

• RCBP assisted with transportation and

worked with area providers

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RCBP Vision

▪ Primary goals of the RCBP:

▫ Complement our members’ health, providers, and well-

being

▫ Eliminate hurdles where possible

▫ Never be a burden to the member

▫ Invest in our members’ long-term health

▫ Provide members with more than just access to a

network of doctors, hospitals and providers, pay claims,

care management, etc.

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TrestleTree Overview

▪ RCBP and TrestleTree partnered together

since 2015

▪ Expertise in behavior change for less

motivated or non-adherent members, with

a focus on whole-person care

▪ 18 year book of business outcomes

▫ Diabetes: 67%

▫ High Blood Pressure: 78%

▫ High Cholesterol: 79%

▫ Weight loss: 57%

▫ Tobacco Cessation: 53% (ITT)

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Comprehensive Pain

Management Program

▪ Pain/musculoskeletal related costs

▫ Top 1 or 2 spend categories for RCBP

▪ Pain is fiercely unique to each person

▪ TrestleTree’s approach to behavior

change a strong fit for pain and MSK

with RCBP population:

“Building a relationship of Trust

and Earning the right to influence”

TrestleTree Model

Match & Move

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MSK-Cascade Analysis

RCBP Musculoskeletal Cascade % of % of Avg Cost/

Total Lives Total Cost Member

Total Population 100% 100% 7,303$

TrestleTree Coachable Conditions 80% 89% 8,168$

Musculoskeletal (MSK) Diagnosis 74% 84% 8,274$

MSK and Coachable Conditions 64% 77% 8,789$

MSK and 3+ Coachable Conditions 35% 57% 10,488$

MSK and Related Surgeries 17% 44% 19,572$

Opioid users 6% 20% 25,010$

Opioid users and MSK 5% 18% 25,832$

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Opioid Risk Prediction

▪ Tool predicts opioid addiction, substance use disorder, and

overdose with 90%+ precision

▪ C-index of .90 - .93

▪ Provides individual risk score using 320 variables found in medical

and prescription claims data

▪ Developed by Brad Martin, PharmD, Ph.D., UAMS School of

Pharmacy

▪ 4 million opioid users over a ten year period in analytical data set

▪ All IP and exclusive rights acquired by TrestleTree in 2018

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Opioid Risk Prevention

▪ Behavior change intervention for at-risk individuals prescribed an

opioid

▪ Unique approach to behavior change enables a more contextual

understanding of patient predisposition for opioid abuse, such as

family, culture, finances, social factors, etc.,

▪ TrestleTree’s expertise is helping people change tough health

behaviors who struggle with change

▪ Whole-person approach to health behavior change allows influence

on health co-morbidities and fosters referrals/access to all available

resources

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Application

▪ Dedicated and assigned Health Coaches

▪ Pre-surgery / post-surgery opioid and pain management

▪ Daily opioid Rx outreach

▪ Whole-person approach

▪ Multi-tiered ongoing communication

▪ Member and family outreach

▪ Provider outreach

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Real Member Stories

Issue: Fear of Opioids

• 43 year old female

• Required surgery scheduled in two

weeks

• Pre-surgery conversation with a

TrestleTree Coach, disclosed prior

opioid addiction

• Fearful of taking any opioids

• Threatened to cancel surgery

• Coach walked alongside post-surgery

• Successful in managing pain with

oversight from physician and help from

her Coach

Issue: Chronic Pain

• 63 year old female

• Chronic back pain for 30 years

• “Tried & failed, tried & failed” to control

pain

• “You are the only one listening to me

and has taken the time to learn my

situation”

• Trust built, hope instilled, positive

results

• Pain diary revealed

• Confident to control pain and be able

to go about her daily activities

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Best Practices—Notes

from the Field

▪ Dr. Terry Flander:

▫ Board certified in family medicine

▫ Clinical practice as a family physician for 15

years

▫ Physician Executive positions in payer and

provider organizations

▫ Involved with Federal Employees Health

Benefits (FEHB) plans for the past 9 years

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Best Practices—Notes

from the Field

▪ Participation in National Quality Forum (NQF) Measures

Application Partnership (MAP) Rural Health Work Group

▫ Make recommendations on relevant rural health quality

measures

▫ Address misalignment of provider incentives

▪ Importance of support for physician directives

▫ Align quality guidelines

▫ Educate prescribers about best practices for treating

chronic pain

▫ Help providers break old habits for pain pill prescribing

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Best Practices—Notes

from the Field

Member EngagementWhole Person Pain

Management Approach

Achieve High QCR ScoresAvenue to Provider

Engagement

TrestleTree-RCBP Partnersip

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About Discern Health

Multi-stakeholder Client Services and Expertise

Develop accountability models for health through innovative measurement and payment systems

Implementation Support

Partner directly with health care providers and others to transform care management and delivery

Guide health care organizations as they position themselves for success in accountable care environments

Strategic Advising

Policy Leadership Quality measure development

and endorsement

Alternative incentive and payment

models

Patient-centered care

transformation

Data modeling and analytics

Guidelines and pathways that

define quality care delivery

Research and program evaluation

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Discern’s Role:

Strategic Advising for RCBP

▪ Serve as a healthcare quality strategic advisor to

RCBP

▪ Provide support for RCBP’s performance measure

and quality tasks that best align with RCBP’s goals

and resources

▪ Identify opportunities for RCBP to maximize use of its

available data to improve performance on quality

measures

▪ Facilitate and support knowledge-sharing and

collaboration among RCBP vendors to improve care

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Impacts of Quality Measurement

HEDIS® and other quality metrics provide a scorecard for how well a health plan is

doing. Plans, providers, and vendors can use that data to help focus QI initiatives.

Employers and patients can use the scores to inform their healthcare decision-

making.

Patient impacts estimated from improved national measure rates:1

▪ 670,000 additional patients with controlled blood pressure

▪ 510,000 fewer patients with poor diabetes control

▪ 2,000 fewer deaths following hospitalization for a heart attack

▪ 70,000 fewer unplanned readmissions

▪ 840,000 fewer pressure ulcers among nursing home resident

▪ Nearly 9 million more hospitalized patients with a highly favorable experience with

their hospital

1 CMS. 2018 National Impact Assessment of the CMS Quality Measures Report. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/QualityMeasures/Downloads/2018-Impact-Assessment-Report.pdf.

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FEHB, OPM, Plan Performance

Assessment (PPA) Measures

2020 OPM PPA Clinical Quality, Customer Service, Resource Use (QCR) Measures (Scored)

Clinical

Quality

Breast Cancer Screening

Cervical Cancer Screening

Colorectal Cancer Screening

Flu Vaccinations for Adults Ages 18-64

Timeliness of Prenatal Care

Well Child Visits in the First 15 Months of Life

Avoidance of Antibiotics in Adults with Acute Bronchitis

Asthma Medication Ratio

Statin Therapy for Patients with Cardiovascular Disease (Adherence)

Controlling High Blood Pressure

Comprehensive Diabetes Care-A1c Control <8%

Follow-up after Discharge from ED for 1) Alcohol or Drug AND 2) Mental Illness

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PPA Measures (cont.)

2020 OPM PPA QCR Measures (Scored)

Customer

Service

Getting Needed Care

Getting Care Quickly

Claims Processing

Overall Health Plan Rating

Coordination of Care

Overall Personal Doctor Rating

Resource

Use

Use of Imaging Studies for Low Back Pain

Emergency Department Utilization

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PPA Measures (cont.)

2020 Farm Team Measures (Reported but not Scored)*

Customer Service

Plan All-Cause Readmissions

Acute Hospitalization Utilization

Use of Opioids from Multiple Providers

Risk of Continued Opioid Use

Antidepressant Medication Management

Childhood Immunization Status

*2020 Farm Team measure list to be confirmed by OPM

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Relevant PPA Measures

Use of Opioids from Multiple Providers

For members 18 years and older, the rate per

1,000 receiving prescription opioids for ≥15

days during the measurement year who

receive opioids from multiple providers (4 or

more pharmacies; 4 or more prescribers).

Use of Imaging Studies for Low Back Pain

Assesses adults 18–50 with a primary

diagnosis of low back pain who did not have

an imaging study (plain X-ray, MRI or CT

scan) within 28 days of the diagnosis (a

higher score indicates better performance).

Risk of Continued Opioid Use

Assesses members 18 years of age and older

who have a new episode of opioid use that

puts them at risk for continued opioid use (15

days of opioid Rx in 30 day period; 31 days of

opioid Rx in 62 day period)

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Rural Health-Relevant Quality

Improvement Tactics

Assessing provider availability/access

Harnessing data from Health Information Exchanges

(HIEs)

Leveraging telehealth opportunities

Utilizing incentives to motivate positive change

Examining opportunities for closing gaps in care

through health plan vendor partners, member and

provider outreach!

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Panel Discussion Q&A

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THANK YOU!

For more information, contact:

Donna Dugan

ddugan@discernhealth.com