Five Questions With: Dr. John Fallon

DR. JOHN FALLON led an 18-month effort to create a new policy for prescribing pain medication, with the goal of curbing abuse of the drugs by patients. / COURTESY BLUE CROSS BLUE SHIELD OF MASSACHUSETTS
DR. JOHN FALLON led an 18-month effort to create a new policy for prescribing pain medication, with the goal of curbing abuse of the drugs by patients. / COURTESY BLUE CROSS BLUE SHIELD OF MASSACHUSETTS

Starting July 1, Blue Cross Blue Shield of Massachusetts, the state’s largest health insurer, is launching a policy to curb abuse of prescription painkillers by limiting the amount of pain medication most patients can receive without prior approval from the insurer. Under the program, patients will be allowed to fill a 15-day prescription and one additional 15-day supply of opioid drugs such as Percocet and Vicodin before the insurer steps in and halts prescription refills.

Dr. John Fallon, Blue Cross’s chief physician executive and senior vice president, led the 18-month effort to develop the new policy. Providence Business News asked Fallon to describe the how’s and why’s of the program, which Fallon believes can serve as a national model.

PBN: What prompted you to develop a plan to stem the oversupply of prescription pain killers in the marketplace by limiting the quantity of pills available up front?

FALLON: Prescription opioid misuse, abuse and diversion are serious public health issues. The Centers for Disease Control and Prevention has called prescription drug abuse an epidemic and the fastest growing drug problem in the United States.

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As Massachusetts’ largest commercial health insurer, we believe health plans can play a role in helping address these problems that have consumed too many individuals, families and communities. We must always ensure that our members who need treatment for pain get it, but we can also work to minimize the risks of using opioid medications.

In our research, we found that most people only use a 7-day supply of pain medication to treat their symptoms. However, we found that more than 30,000 of our members received prescriptions for short-acting painkillers lasting longer than 30 days. Experts believe that taking a narcotic for more than 30 days increases your chance of dependency.

PBN: In developing the new rules, with whom did you consult and work? How long did it take to arrive at a final plan?

FALLON: We worked with a panel of outside experts over an 18-month period to come up with this plan. We had specialists in pain management, primary care and addiction work with us to come up with the evidence-based prescribing practices that are promoted as part of this policy.

Our plan was developed by practicing physicians and pharmacists for physicians and prescribing clinicians. It’s been a long process, but the end result is a policy that balances the needs of patients first – particularly the treatment needs of vulnerable patients – and the need for greater safety and quality in narcotic prescribing.

We have made special accommodations for people on chronic medications, and for those who have cancer or who are at the end of life so that their care is not impacted by this change.

PBN: Has there been push back from doctors? From other insurers?

FALLON: For the most part, we have received very positive feedback on our plans. We’ve also briefed a number of state officials, and they have been similarly supportive.

We are aware that some of the elements of this program will require more effort on the part of doctors and other health care providers, and we were very sensitive to that in designing a program that was not unduly burdensome for doctors.

However, we think that a small amount of front-end effort will pay real dividends in the long run. Opioid addiction creates a lot of work for all practicing clinicians, both because of the addiction itself and the negative effects it has on the overall health of the patient. If we can help prevent that addiction in the first place, benefits will accrue to doctors and society as a whole.

PBN: Do you see your plan as a potential national model to address the epidemic in abuse of prescription painkillers?

FALLON: We believe that health plans should play a role in addressing this serious public health problem, and we do believe that our plan could be a model for other health plans to follow.

We know that there is no silver bullet to solving this issue – if there was it would have been solved a long time ago. However, we do believe that health plans can play a constructive role in the overall community response to prescription misuse, abuse and diversion.

PBN: What kind of cooperation have you received from pharmacies? Do you believe there is a need to have a higher co-pay for opioids?

FALLON: We’ve had very good cooperation from the pharmacies that we have worked with, and their contributions have been helpful to our planning.

At the outset of this process, we made a very clear decision to not do anything that might result in a barrier to care for our members who need treatment for pain. Our focus is on safety, quality and evidence-based narcotics prescribing for our members. We believe that approach is better for our members, better for doctors and ultimately will be better for our society as a whole.

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