American health insurers are wrestling with their own version of a painful truth: Kicking opioids is hard.
Insurers have been too slow to discourage use of opioids, stoking the crisis, according to a sweeping new study of major health insurance plans offered in 2017.
“Even if unwittingly, insurers have contributed to the epidemic,” says the study’s senior author, Caleb Alexander, MD, in an interview. He is the co-director of the Johns Hopkins Center for Drug Safety and Effectiveness.
In response to the study, published on JAMA Network Open today, health insurers say they’re taking steps, but that big changes in policies take time.
“Nobody should experience pain, and nobody should experience the trauma of addiction either,” said Kristine Grow, a spokeswoman for America’s Health Insurance Plans, a trade group representing insurance companies. “There are some pains that can only be treated with an opioid,” she says, “but it’s important to look at alternatives, and that takes time.”
Alexander and fellow researchers focused on how health insurance policies proposed to cover treatment for chronic low-back pain. The study focuses on that condition because it is “one of the most common causes of chronic pain and one of the conditions for which prescription opioids have been commonly overused despite an unfavorable risk-benefit profile,” according to the study.
The study’s premise was that insurance policies play an important role in shaping drug utilization practices.
Researchers analyzed the policies of 15 Medicaid, 15 Medicare Advantage and 20 commercial plans. They also interviewed 43 health care executives.
The study was carried out by researchers at the Johns Hopkins Bloomberg School of Public Health, with funding and assistance from the National Institutes of Health and the Centers for Disease Control and Prevention.
The study found that some strategies employed by insurers to curb unnecessary opioid prescriptions are inadequate, or too rarely used.
One method is so-called “step therapy,” which mandates that, before prescribing opioids, doctors try less risky anti-inflammatory pain medication or other therapy first. Yet half of private insurers’ plans required step therapy for only 4 percent or fewer of opioid prescriptions.
Finding alternative treatments is key to resolving the crisis. But insurers’ 2017 plans “missed important opportunities to steer patients towards safer and more effective treatments than prescription opioids,” the study concluded. It found that “only one plan fully integrated nonpharmacologic therapies.” Alexander declines to name the plan, citing a confidentiality agreement.
Industry spokesperson Grow insists that alternative treatments are on their way. But it will take time, she says, to accumulate scientific evidence that therapies such as “yoga or acupuncture” can function as alternatives to opioids, and insurers won’t cover them until then.
Another practice that can discourage opioid prescriptions is requiring prior authorization. This means the prescriber must ask the insurer for approval before offering the patient opioids. “This was applied to only a minority of covered opioids,” the study found.
Opioids are still enticingly affordable—too affordable, in Alexander’s view. The typical commercial plan, for example, “placed 74 percent of opioid painkillers in Tier 1, the lowest cost category,” according to the study. In general, co-pays are between $10 and $15.
“The relative cost of opioids to non-opioids is going to powerfully shape which products patients and prescribers reach for first,” says Alexander, “and by making opioids so inexpensive relative to their safer and more effective alternatives, insurers have allowed the epidemic to flourish.”
Insurers are not to blame for low prices, contends Grow, the industry spokesperson. Prices have been driven down by generic competition, she says.
A principal problem identified by the study is that insurers are often focused on identifying and curbing prescriptions at so-called pill mills, instead of helping find alternative treatments for patients at places that hand out more moderate amounts of opioids. “There’s too much of an emphasis on weeding out bad apples, instead of transforming the way patients are cared for,” says Alexander.
“There is no conflict between reducing the vast overuse of prescription opioids and improving care for those in pain.” —Caleb Alexander, MD
Hartford, Conn.-based Aetna is sending warning letters to so-called “super-prescribers” and covering more non-opioid drugs, said Ethan Slavin, a spokesman. Aetna last year promised to “reduce inappropriate opioid prescribing” by 50 percent by 2022, as well as to increase the use of non-opioid alternatives.
Weaning America off opioids will require a different approach to treating pain, the study finds. “In many cases, pain has to be managed and lived with, instead of abated,” says Alexander. “The notion that we can strike out all pain” isn’t true, and helped contribute to the opioid crisis, he asserts.
To be sure, not everybody in the medical community believes curbing opioid prescriptions is the right way to tackle the crisis.
“Running the prescriptions back down using a variety of pressures has often been traumatic, including causing patients to lose their lives,” contends Stefan Kertesz, director of preventive medicine at the University of Alabama at Birmingham (UAB). “We should be wary of stampeding backwards.” Reducing opioid use is a noble goal, “but the question is how you get there,” he says. “My inbox is full of patients being forced off their pills.”
Opioid prescriptions have fallen since 2012, but overdose deaths have not, adds Kertesz. “So we’re not getting bang for our buck. We should approach this issue as how do we best protect people, instead of how do we best manage pills.”
In response to Kertesz, Alexander writes in an email: “There is no conflict between reducing the vast overuse of prescription opioids and improving care for those in pain. Improving care for those in pain isn’t threatened by reducing opioid overuse, it demands it. Coverage and reimbursement policies can either be part of the problem, or part of the solution, and for far too long, they have allowed the epidemic to propagate. I agree that this shouldn’t be about managing pills, it should be about managing care for those with chronic, non-cancer pain. That is where the opportunity for insurers lies. And we can do a lot better than we have, starting with aligning coverage and reimbursement policies with the evidence base.”