Up for grabs: Payers share responsibility for opioid epidemic

The prescription opioid epidemic ravaging the country claims almost a hundred lives daily with an annual economic cost upward of $500 billion.1 This epidemic is so widespread that current estimates are that almost 2 million Americans are dependent on or abuse prescription opioids.2

As would be expected, there is no lack of finger-pointing at who is to blame. But curiously, there hasn’t been much focus on who should take responsibility for adequately addressing it.

The usual suspects are the pharmaceutical companies that promote highly addictive opioid painkillers through aggressive marketing programs, providers who prescribe the drugs — and the distribution channel of pharmacies that make them available 24/7.

When it comes to payers, however, their role has not been the subject of much attention. They now, however, find themselves under much closer scrutiny for their role in allegedly getting and keeping patients addicted to opioid painkillers while not doing enough to help fix a problem they are accused of helping create and perpetuate.

Fueling the epidemic

Various studies, most recently one by the Johns Hopkins University Bloomberg School of Public Health, strongly suggest that payers have not done enough to combat the opioid epidemic. The study, for example, concluded that major insurer coverage policies for drugs to treat lower back pain — one of the more common types of chronic, non-cancer pain for which prescription opioids have been overused — “missed important opportunities” to steer patients toward safer and more effective treatments than prescription opioids.3

While there are a variety of payer policies and actions blamed for the ongoing increase in prescription opioid use (and abuse), they fall into three basic areas:

1. Prescription opioids are too price accessible

In an open market, there is usually a direct relationship between price and demand. This is perhaps nowhere more evident than with prescription opioid painkillers. The logic is simple and unavoidable: If opioid-based medicines cost less than safer alternatives — including non-narcotic medicines — then prescribers and consumers will opt for the addictive opioids rather than less-addictive medicines.

This economic reality has been consistently borne out by researchers. In the Johns Hopkins study, for example, it was shown that both public and commercial insurance plans tend to make covered opioids available relatively cheaply to patients. How cheaply? The median commercial plan, for example, places 74% of opioid painkillers in Tier 1, the lowest cost category, and the median commercial copay for Tier 1 opioids was just $10 for a month’s supply.

In stark contrast, studies show that only one-third of the more than 40 million people covered by Medicare have access to an available painkiller skin patch that contains a much less risky opioid as its key active ingredient. Other plans simply do not cover non-addictive alternatives to opioids or have copays that are higher than those for opioids. Many plans also require pre-authorization for the safer, alternative painkillers.4

According to Elijah Cummings, ranking member of the House Committee on Oversight and Government Reform, the insurance industry has, in effect, created incentives that may steer patients to the very drugs fueling the opioid crisis.5

The price preference for opioids also tends to make tamper-resistant and abuse-deterrent formulations more expensive than their alternatives.

2. Prescribers are rewarded for patients being on opioids

The inclusion of pain questions on Medicare’s patient satisfaction surveys may have contributed to the opioid epidemic. The belief is that these surveys pressure doctors to prescribe unnecessary opioids in hopes of getting a better score on patient surveys. The results of patient surveys are used to determine a hospital’s reimbursement rate.

It is easy to spot the conflict here. Tying money to great reviews can easily lead to undue pressure on doctors to prescribe opioids to make a patient happy to get a good score. And, perhaps the biggest area affected by patient satisfaction surveys has been the emergency room. Several studies suggest that ER doctors have drastically changed their practice to avoid negative patient satisfaction reviews. They may sometimes prescribe painkillers, even when not entirely necessary, to get paid by Uncle Sam.6

Two surveys of more than 800 emergency physicians by Emergency Physicians Monthly and the South Carolina Medical Association reported that more than 50% of ER docs routinely ordered tests and procedures, prescribed medications and even admitted patients to the hospital unnecessarily.7 Why? Because patient satisfaction affects their bottom line.

Compounding the problem are savvy patients aware of how the system now works. One physician wrote that drug seekers “are well aware of the patient satisfaction scores and how they can use these threats and complaints to obtain narcotics.”8

3. Lax application of utility management protocols

Another factor identified by the Johns Hopkins study is that many insurers failed to apply evidence-based “utilization management” rules to discourage opioid overuse and encourage safer and more effective alternatives.9 What’s more, many of the utilization management rules in place were applied as often to non-opioids as opioids.

While utilization management takes various forms depending on the clinical setting and payer policies, the most common are quantity limits, step therapy and prior authorization. Here are ways in which not correctly applying these rules exacerbates the opioid crisis:

• Quantity limits. While the U.S. Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain is for a short-term supply, many insurance policies allow for 30-day supplies. The danger is that duration of early prescriptions is associated with a patient converting to chronic use.
• Step therapy. This is a strategy that makes riskier opioids the “last resort” for pain management after other, non-narcotic medications have failed to provide pain relief. By permitting opioids to be a “first step,” the risk of addiction and/or chronic use increases. Unfortunately, fewer than 10% of government and commercial plans require step therapy for opioids.
• Prior authorization. The idea is that requiring a provider to get in touch with the insurer before prescribing an opioid will help reduce the number of prescriptions or encourage quantity control or step therapy. The reality is that only a minority of plans require this.

The way forward

Providers have a stake in working with payers — commercial and public — as well as with distribution channels to continue to develop integrated solutions to the opioid crisis. Aside from the human toll on their communities, they also are not immune to the economic costs. Studies have clearly shown that the epidemic is increasing hospitalizations and that it hits emergency rooms especially hard.
Some estimates put the average cost of treating an overdose patient in the intensive care unit at almost $100,000. If a majority — or even a minority — of these patients are underinsured or uninsured, the resulting uncompensated care costs can easily cripple a provider that is already operating on a razor-thin margin.
Three things that providers can do now to contribute to a solution are to support initiatives being undertaken by such groups as America’s Health Insurance Plans (AHIP) that seek to combat opioid abuse. They also can develop, implement and maximize the value of programs designed to identify potential opioid abusers and limit the prescribing of opioid painkillers. Finally, they can negotiate contracts with payers that require prompt authorization and reimbursement for non-opioid alternatives where indicated.

Key takeaways

Although pharmaceutical companies are often targeted for their role in the opioid epidemic, studies suggest that payer policies and actions also result in the ongoing increase of prescription opioid use.
These policies and actions fall under three general ideas that result in consumers choosing addictive opioids rather than safer and more effective treatments:

1. Prescription opioids cost less than alternative painkillers
2. Providers benefit from prescribing addictive opioids, which is perpetuated by cost-driven initiatives such as patient satisfaction surveys
3. Lack of “utilization management” rules to limit opioid overuse including quantity limits, step therapy and prior authorization

Providers should support initiatives that combat opioid abuse, implement and maximize programs to identify potential abusers and limit the number of painkiller prescriptions and finally, reconfigure contracts with payers requiring timely authorization and reimbursement for non-opioid alternatives.
 

Notes:

1. The Council of Economic Advisers. “The underestimated cost of the opioid crisis.” November 2017. Available from: bit.ly/2BaCND7.
2. Centers for Disease Control and Prevention. “Prescription opioid data.” Accessed Sept. 17, 2018. Available from: bit.ly/2ideSIk.
3. Johns Hopkins University Bloomberg School of Public Health. “Health insurance plans may be fueling opioid epidemic.” June 22, 2018. Available from: bit.ly/2tkxcYA.
4. Thomas K and Ornstein C. “Amid opioid crisis, insurers restrict pricey, less addictive painkillers.” ProPublica and The New York Times. Sept. 17, 2017. Available from: bit.ly/2yh3jbQ.
5. Ornstein C. “Pressure mounts on insurance companies to consider their role in opioid epidemic.” ProPublica. Oct. 19, 2017. Available from: bit.ly/2xapMqL.
6. Heath S. “Opioid use associated with higher patient satisfaction scores.” Patient Engagement HIT. Jan. 10, 2018. Available from: bit.ly/2DgMUvp.
7. Pho K. “Be wary of doctor-rating sites.” USA Today. Sept. 14, 2014. Available from: usat.ly/2xrSV1N.
8. Zgierska A, Rabago D, Miller MM. “Impact of patient satisfaction ratings on physicians and clinical care.” Patient Preference and Adherence. 2014;8:437-446. doi:10.2147/PPA.S59077.
9. Johns Hopkins.