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Insurers tackling opioid crisis with support for addicts

Michael “Seme” Semertgakis, of Everett, is recovering from a heroin addiction with the help of his insurer, CeltiCare.Wendy Maeda/Globe Staff/Globe Staff

Michael "Seme" Semertgakis just celebrated a birthday. He made it to 42.

He was not always certain he would get here, after spending much of the past 18 years in the grip of heroin addiction, coming close to death more than once. But he just completed two months of sobriety, with the help of family, friends, health care workers, recovery support groups, and new medication.

There's one other party that Seme credits: his health insurance company.

The company, CeltiCare Health Plan, is one of many insurers taking new and unusual steps to combat the state's growing opioid crisis, an epidemic that has claimed nearly 700 lives in Massachusetts in the first six months of the year, wreaked havoc on thousands of others, and pushed up health care costs.


The growing costs — in the billions of dollars nationally — have spurred insurers to tackle the opioid problem through a variety of new measures, including imposing restrictions on prescriptions for painkillers like Vicodin and OxyContin, because addiction often starts with such drugs, lifting restrictions for addiction treatment, and deploying case managers and coaches to guide patients through treatment.

Blue Cross Blue Shield of Massachusetts, which first put limits on opioid prescriptions three years ago, is now contacting its members who are in detox programs to help coordinate their care and prevent relapses. Boston Medical Center HealthNet Plan, a subsidiary of Boston Medical Center, has assigned staff to call and visit members with addiction to help them find and stick with treatments.

Neighborhood Health Plan, the insurance arm of Partners HealthCare, where nearly 9 percent of members were diagnosed with substance abuse in the last year, recently partnered with Massachusetts General Hospital to hire a recovery coach to help members stay sober.

"If we're able to learn that attaching someone to a recovery coach early reduces recidivism, it would easily be worth the investment," said Dr. Paul Mendis, chief medical officer of Neighborhood, which covers people on Medicaid as well as those with commercial health plans.


CeltiCare, a small Waltham insurer owned by Centene Corp., a for-profit health care company based in St. Louis, has gone beyond what most other insurance companies are doing, developing one of the most comprehensive plans in the state for preventing and treating addiction.

The insurer, which predominantly manages care for low-income people on Medicaid — some of them homeless, and many dealing with chronic diseases — has acted out of necessity. Its costs related to addiction are significant; nearly a quarter of all hospital admissions the insurer covers are related to substance abuse.

CeltiCare, with about 50,000 members, is on track to spend more than 10 percent of its $24 million prescription drug budget this year on suboxone, a drug used to fight addiction. That's more than it will spend on any other drug.

This month, CeltiCare began limiting prescriptions of opioid painkillers to 15 days at a time. Doctors who want to prescribe more than a two weeks' supply must fill out extra paperwork.

For those fighting addiction, the insurer has lifted prior-authorization requirements for all treatments, from detox to outpatient care to medication, meaning that patients don't need the insurer's approval before accessing services.

This fall, CeltiCare took the unusual step of offering training to its members who take opioids — legally and illegally — and their families to use the drug naloxone, known by the brand name Narcan, which can revive people on the brink of death from a heroin overdose.


Not all the changes are welcome. Doctors generally oppose restrictions on how they treat patients, and CeltiCare executives said they expect some blowback from their new requirements on prescriptions.

Dr. Dennis M. Dimitri, president of the Massachusetts Medical Society, said the organization already encourages physicians to prescribe the lowest dose for the shortest effective time. Restrictive rules, he said, "create some significant burdens sometimes for physicians" and for patients who need the drugs.

But Jay Gonzalez, the chief executive of CeltiCare and formerly budget chief under Deval Patrick when he was governor, said insurers must try new strategies to address the epidemic. "We and the rest of the health care community have an obligation to do what we can to bend the cost curve on it," he said.

So CeltiCare and other insurers, especially those who manage care for people on Medicaid, employ health care workers who reach out to members living with addiction and offer services that may help.

Seme, one of those recovering addicts, got a few messages from a case manager earlier this year.

"You're not alone," the man told him. Eventually, Seme called back.

Through his case manager, Seme found his way to a therapist and got access to Vivitrol, a drug injected monthly to fight addiction. Last week, Seme got his second shot.

Seme, who lives in Everett, has an addiction story that is both unique and sadly familiar.


He said he first tried heroin while traveling with his rock band, and it quickly became a habit. He used it to numb the pain of a broken marriage and the punishing symptoms of his bipolar disorder. For nearly two decades, it consumed him. He lost his work as a carpenter, he said, and the job after that.

He was in and out of detox and psychiatric hospitals, he said. He got clean, sometimes for months at a time, then fell into heroin use again. Two months ago, friends, including a Revere police officer, Mark DeSimone, confronted him and helped Seme get off drugs again.

Every day since has been a struggle. But this time, Seme said, he wants to stay sober.

"I'm grateful and blessed that I'm still here," he said. "It's me doing the work, but without asking for that help that I'm getting from CeltiCare and my therapist and my support network, I wouldn't be able to do this on my own."

Priyanka Dayal McCluskey can be reached at priyanka.mccluskey
. Follow her on Twitter @priyanka_dayal.