Opioids and Mental Health

Our Efforts to Combat the Opioid Epidemic

Cigna was the first in our industry to address the opioid epidemic and we are continuing to set the standard as a combined company – applying our extensive, integrated experience across medical, behavioral, and pharmacy benefits.

Having achieved our goal to reduce customer opioid use by 25%, we’ve expanded our ambition and set a new goal to reduce overdoses among our customers by 25% by 2021.

A Multi-Stakeholder Collaboration

In 2016, we committed to reducing opioid use among our customers by 25% in three years. We chose a 25% reduction target because this would return customers’ usage of opioids to pre-epidemic levels.1 We met our target ahead of schedule by partnering with over one million prescribing physicians as well as dentists, pharmacists, advocacy groups, employers, and regulators to change overprescribing patterns and reduce prescribed opioids to customers. Our engagement with these key stakeholders early on helped us to identify near- and long-term approaches that increased safeguards in the opioid prescribing process, enhanced support and counseling, and made it easier for patients and customers to access treatments for substance use disorders. As a result of our continued work in this area, we have reduced opioid use among our customers by over 50% in three years. Additionally, in 2019 we prevented over 1.9 million days’ worth of opioid pills from being dispensed. This occurred as a result of a 57% reduction in average day supply per claim for first-time opioid users and an additional full-day reduction in the average day supply of the second claim. We also worked to prevent opioid abuse affecting the pediatric patient population that we serve, with the goal of seeing those patients dispensed no more than three days worth of medication. With our enhancements, we have achieved a 99.2% success rate in this regard.

Where Do We Go From Here

While the number of opioid prescriptions is decreasing, the number of Americans overdosing, and dying due to overdose, is increasing. As a result, we intensified our commitment to curtail this epidemic, and, in 2018, set a new goal to reduce overdoses among our customers in targeted communities by 25% by 2021.

To meet this goal, our initial focus has been on targeted U.S. communities where a sizable number of Cigna customers reside and where there are higher incidences of overdose. These communities include Connecticut, Maryland, New Jersey, Virginia, Chicago, New York City, Philadelphia, and Washington, D.C. We are using a multifaceted approach to achieve our new target, including identifying and managing opioid use; providing chronic pain support for those who are suffering; intervening through connective care coordination; and collaborating with stakeholders who can help us drive positive change.

Interventions and Advocacy to Prevent Opioid Use and Abuse

Identifying At Risk Customers and Providing Interventions

Cigna uses a variety of methods to identify customers who may be at risk for substance use disorders, such as behavioral assessments during chronic health and other coaching sessions; predictive analytics driven by our medical, behavioral, and pharmacy data; and hospital or treatment facility admittance, which triggers a notification that we quickly act on to ensure effective ongoing treatment after discharge. Our pharmacy benefit manager (PBM) plays a key role in the company’s management of opioid use by monitoring and measuring consumption; stepping in with first-time-user education and controls; reviewing for appropriate use; reducing patients’ quantity on hand through utilization management; deploying our behavioral health experts to quickly support our customers in need; and collaborating with network providers to oversee medication treatment, taper use, offer alternatives, and counsel patients.

Providing chronic pain support to patients is another tool that we are using to reduce opioid prescribing and overdoses. One in five people in the U.S. are living with chronic pain. By reviewing data across benefits, we are identifying customers who may be struggling with daily pain and letting them know about support programs, including our integrated pain case management and our comprehensive pain management programs. Cigna’s integrated pain case management program is comprised of trained case managers who counsel customers on pain management options other than opioids, such as physical therapy, pain management, and behavioral health. Our comprehensive pain management program equips primary care providers (PCPs) with evidence-based resources and tools to manage the complex needs of customers with back pain. PCPs leverage guidelines for when to refer customers to pain providers, physical therapy, and behavioral health care in the community, including selecting preferred pain management specialists. We are also reducing overdoses through five intervention models:

  • Substance Use Coaching Program – A team of case managers who specialize in substance use disorders follow and support patients through their recovery journey. The program encourages behavioral changes and necessary first steps, such as outpatient treatment at a designated substance use treatment provider. It also includes care coordination with PCPs.
  • PBM Oversight Intervention – When pharmacy or other interventions identify a customer who may be struggling with opioid use disorder, we bring in our behavioral team as well as care coordination assistance to listen and provide education.
  • Predictive Overdose Model – Using integrated pharmacy, medical, and behavioral health data, we identify customers at highest risk of overdose in the next 30 days. Representatives from our behavioral health team then actively reach out to these customers with connections to counseling and other local support.
  • Medication-Assisted Treatment (MAT) – Prescribed by a medical or behavioral provider, MAT can include a combination of therapy and medications to help those identified with opioid use disorder. We have increased our network by more than 66% since 2017 and waived prior authorizations for Cigna Pharmacy customers.
  • Virtual Access – Created specifically for patients who are living in low access areas or who may not be willing or able to seek in-person care or professional counseling, such as during a natural disaster or the COVID-19 pandemic. This intervention is particularly effective because it meets patients where they are. We’re working to provide models of care that consist of complete substance use treatment programs that are almost entirely virtual.

Advocacy

To fight opioid overdoses we are also teaming up with stakeholders with a mutual interest in driving positive change. We have engaged prescribers since the start of the epidemic and are continuing to expand this relationship. We offer providers data, tools, and support to help them deliver effective care. High-risk alerts go out annually to 145,000+ prescribers whose patients have a hazardous pattern of opioid prescription use and providers are notified when their patients reach a high daily narcotic potency level to help with intervention and pain management options. We also partner with Centers of Excellence (COE), which are Cigna-contracted behavioral facilities that have earned top rankings for patient outcomes and cost efficiency based on our methodology. Additionally, we are working closely with communities to fight opioid overdoses. For example, we have donated more than $300,000 to Shatterproof™, a nonprofit organization committed to giving those living with addiction, and their families, resources and information to overcome addiction.

Cigna is also advocating for policy solutions at state and federal levels that advance prevention and optimal treatment. We are partnering with policymakers to modernize the sharing of addiction treatment records, which will allow providers to treat substance use disorders in a coordinated way, like other chronic diseases. We are also working with policymakers to provide health plans access to state prescription drug monitoring programs (PDMPs). PDMPs collect, monitor, and analyze electronically transmitted prescribing and dispensing data submitted by pharmacies and practitioners. Access to PDMPs would greatly enhance the ability of regulators, providers, pharmacies, and insurers/health plans to monitor and manage opioid utilization. Additionally, we are working with policymakers to expand Medicare coverage for alternative pain treatments. Coverage of alternative pain treatments and therapies could reduce demand for opioids to address chronic pain. We are also pushing to expand coverage for the full range of substance use disorder treatment levels. Lastly, we are collaborating with researchers in the hopes of uncovering new insights and evidence-based treatments.

Opioids Initiative: Comprised of physicians, dentists, patient awareness programs, and support organizations in local communities, this collaborative effort identified immediate and longer-term approaches that increased safeguards in the opioid prescribing process, enhanced support and counseling, and made it easier to access treatments for substance use disorders.

Removing Stigmas and Creating Necessary Dialogue on Mental Health

Cigna was an early leader in viewing physical health and mental health holistically. We have strengthened our commitment to behavioral health through our transformative model of health care, which elevates whole person health and puts the patient at the center.

We remain dedicated to removing the negative stigma of mental health through a variety of initiatives. Cigna’s Go. Know. Take Control.® campaign is a strategic initiative intended to remove mental health stigmas, encourage annual check-ups, and galvanize open and honest conversations between patients and health care providers about behavioral and physical health matters. To help bring this initiative to life, Cigna developed a grassroots Health Improvement Tour (HIT) that visits communities around the country to deliver free health screenings. In 2019, HIT held more than 140 events in 71 cities, providing over 10,000 free health screenings.

The mind and body are inextricably linked – both suffer and drive costs when patients are not receiving the support and resources that they need. As such, we are committed to finding novel ways to encourage customers experiencing stress, anxiety, depression, loneliness, or substance use disorders to connect with their health care providers. As a result of these mind-body initiatives, Cigna has seen an 18% increase in annual check-ups among customers since the launch of the campaign.

In 2019, we launched our new initiative SeeStressDifferently, which builds on our Go. Know. Take Control.® campaign and the results of the 360 well-being survey, Well and Beyond, that we have commissioned over the past five years. The need for this initiative is underscored by the results of the 2019 survey, in which 64% of respondents around the world blamed an “always on” work culture as a direct cause of their stress.2 Stress at work is also costing businesses worldwide – over $187 billion.3 The reality is that stress leads us to neglect our personal health and make seemingly insignificant decisions that over time have serious long-term implications. According to the American Institute of Stress, people who are highly stressed are less likely to eat healthy and exercise, and get half as much sleep. In fact, stress drives more than 75% of primary care doctor visits.4 Now more than ever, it is critical for both individuals and businesses to think about health holistically rather than viewing it as separate pieces. Our approach to support workplace health and well-being, called Health Accelerated: Life Connected, is a way for us to help clients and their employees by addressing their whole health needs. Our goal in partnering with employers is to optimize their workforce health and well-being. Leveraging the Health Accelerated: Life Connected approach, we can help drive better health, greater resiliency, and increased productivity by looking at the following five dimensions of well-being:

  • Physical Health: Putting Fitness and Nutrition at the Forefront
  • Emotional Health: Coping with Stress
  • Environmental Health: Improving Creativity
  • Financial Health: Preparation and Peace of Mind
  • Social Health: Staying Connected and Engaged

Talking About Loneliness and its Root Causes

Loneliness is a rising public health problem in the U.S.5 Research shows that chronic loneliness leads to poorer health outcomes.6 It has been correlated with increased risks for diabetes,7 heart disease,8 depression,9 suicide, substance use disorders, and even dementia. It is as deadly as smoking 15 cigarettes a day.10 As such, improving people’s sense of connection to others will improve their overall health and functioning. In 2018, Cigna released results from a groundbreaking national survey exploring the impact and the potential underlining root causes of loneliness in the U.S. The survey of more than 20,000 U.S. adults age 18 and over, conducted in partnership with market research firm Ipsos, revealed that most American adults are considered lonely, and that the youngest generation of adults is the loneliest of all.

Cigna’s 2020 Loneliness Index showed that America’s loneliness epidemic is getting worse, with three in five adults (61%) reporting they are lonely, a seven percentage-point increase from 2018. These results come against the backdrop of a rising mental health crisis in America, with more than 46 million people living with a mental illness.11 In response, Cigna is taking action to help communities across the country proactively reduce the risks of mental illness and improve mental well-being overall.

lonliness-chart

Cigna Takes Action

To combat the rise of loneliness and improve mental health at home, in the workplace, and in our schools, Cigna is taking several steps to alleviate this multifaceted issue. These include:

  • Redefining and broadening the services available to address and deliver support for mental health needs.
  • Expanding access to our comprehensive network of more than 170,000 behavioral health care providers who are dedicated to helping customers improve their well-being and navigate issues such as loneliness, stress, depression, anxiety, and addiction. Cigna is also creating preferred provider networks to target areas of the country where the behavioral provider industry faces a significant supply and demand issue.
  • Making it easier and quicker for customers to connect with mental health specialists virtually through our own broad network of 18,000 virtual providers, and schedule appointments online through an expanded partnership with MDLIVE. Virtual care helps customers overcome stigmas as well as scheduling and accessibility barriers, while giving people peace of mind, privacy, and convenience.
  • Creating a path forward for future generations, Cigna is partnering with clients and school districts in select areas to provide a School Support Line for junior high or high school (grades 7–12) students, staff, and parents for the upcoming 2020–2021 school year. The dedicated phone line will be provided at no charge and will be staffed by Cigna advocates who are trained in how to interact with students, parents, and staff.
  • The Cigna Foundation is committing $3 million over three years to support mental health well-being in schools, as part of our broader $25 million dollar initiative, Healthier Kids for Our Future.

Case Study: Cigna Partners with the Department of Veterans Affairs to Help Prevent Opioid Misuse

In 2019, Cigna and the U.S. Department of Veterans Affairs launched a public-private partnership to improve the safety and quality of care for veterans with chronic pain, who are at risk for opioid misuse.
Read More

1To track our progress against this goal, we have been measuring the total volume of opioids being prescribed based on morphine milligram equivalent doses, taking into account the number of pills, the dosing of those pills, and the relative strengths of the different opioid medications.

2“Cigna 360° Global Well-Being Survey,” Cigna, 2019, https://wellbeing.cigna.com/. Based on Cigna 360 Global Well-being survey of 13,200 people across 23 markets: Australia, Benelux, Canada, China, France, Germany, Hong Kong, India, Indonesia, Korea, New Zealand, Nigeria, Saudi Arabia, Singapore, South Africa, Spain, Taiwan, Thailand, Turkey, UAE, UK, and USA.

3The cost of work-related stress to society: A systematic review,” Hassard et al.,The Journal of Occupational Health Psychology Volume 23. Published January 2018,https://psycnet.apa.org/PsycARTICLES/journal/ocp/23/1.

4Stress: America’s #1 Health Problem, American Institute of Stress, January 4, 2017, https://www.stress.org/americas-1-health-problem.

5Loneliness in the Workplace Can Be a High Cost For Employers, American Psychiatric Association (APA) Center for Workplace Mental Health, 2018; http://workplacementalhealth.org/News-Events/Blog/January-2018/Loneliness-in-the-Workplace-Can-Be-a-High-Cost.

6Loneliness and social isolation as risk factors for mortality: a meta-analytic review.

7Socially Isolated Individuals are More Prone to Have Newly Diagnosed and Prevalent Type 2 Diabetes Mellitus - the Maastricht Study, BMC Public Health, 2017; https://bmcpublichealth.biomedcentral.com/articles/%2010.1186/s12889-017-4948-6.

8Loneliness and Social Isolation as Risk Factors for Coronary Heart Disease and Stroke: Systematic Review and Meta-Analysis of Longitudinal Observational Studies, BMJ Journals Heart, 2016; http://heart.bmj.com/content/102/13/1009.info.

9Unraveling the Role of Loneliness in Depression: The Relationship Between Daily Life Experience and Behavior, Interpersonal and Biological Processes, 2017; https://www.tandfonline.com/doi/full/10.1080/00332747.2016.1256143.

10Testimony before the US Senate Aging Committee, Julianne Holt-Lunstad, Ph.D., 2017; https://www.aging.senate.gov/imo/media/doc/SCA_Holt_04_27_17.pdf.

11National Institute of Mental Health (2019, February). Mental Illness. Retrieved from https://www.nimh.nih.gov/health/statistics /mental-illness.shtml