The number of prescriptions written for opioids, a class of strong painkillers, has risen dramatically in the past few years. It has fueled a nationwide addiction crisis and spike in overdose deaths.
Because health plans control prescription prices and access for most Americans, they’re on the front lines of this drug war — but no single approach will solve the problem.
“The medical community has developed a ‘no pain’ culture, and that’s a really big hurdle to overcome,” says Dr. Douglas Nemecek, chief medical officer for behavioral health at insurer Cigna. He notes that doctors tend to prescribe very strong painkiller doses right after an injury, illness or surgery, rather than lower doses that might work just as well.
To confront both opioid addiction prevention and treatment, health insurance companies are using their influence to change the behavior of doctors, pharmacists and consumers.
The opioid problem at a glance
|Brand names: Vicodin, Percocet, OxyContin, Percodan, Demerol|
|Prescriptions for opioids have nearly quadrupled since 1999 despite a lack of evidence about their long-term effectiveness and the serious risk of addiction. Source: Centers for Disease Control and Prevention.|
|Heroin is an opioid. The misuse of prescription painkillers doesn’t always lead to addiction, but 79.5% of people who used heroin for the first time had also taken prescription painkillers for nonmedical purposes, according to a 2013 study. Source: U.S. Department of Health and Human Services.|
|About 2 million Americans age 12 or older had a pain reliever use disorder and about 591,000 had heroin use disorder in 2015, the latest year for which data is available. Source: HHS.|
|Each day, 91 Americans die from an opioid overdose related to either heroin or prescription painkillers. Source: CDC.|
What insurers can do about abuse
Medicare and Medicaid plans have processes that detect signs of opioid misuse and discourage abuse. Many insurance companies administer these plans and have expanded their processes to members of private and workplace plans. This includes:
Modifying or rejecting a prescription at the point of sale. Pharmacy “edits” are computer alerts that flag possible problems, including drug misuse and abuse. For example, a quantity edit alerts a pharmacist that more pills than recommended by the Food and Drug Administration were prescribed.
Flagging potential opioid misuse. Some insurers review claims for signs of opioid abuse. An insurer then typically contacts the member, pharmacist and any prescribing doctors involved in a potential abuse case, and they create a plan to lower use. If the patient and doctor can’t reduce the amount or dosage of opioids, the insurer might eventually stop paying for the prescription or send the case to its investigation team.
Changes in “prior authorization.” Doctors use this process to get an insurer’s approval to prescribe medication that will be billed to the plan. Insurers have typically required prior authorization for opioid-withdrawal drugs — creating a delay for addiction treatment — but not for opioid prescriptions. Now some insurers are reversing those restrictions.
Insurers' actions against opioid addiction
|Reviews claims for signs of drug abuse or misuse||Requires prior authorization for opioid prescriptions||Requires prior authorization for addiction treatment|
|Aetna||Yes||Varies by plan||No|
|Kaiser Permanente||Yes||Varies by plan||Varies by plan|
Health insurers’ goals and results
Aetna wants to reduce members’ opioid prescriptions by 50% by 2022, says Dr. Mark Friedlander, the insurer’s chief medical officer for behavioral health.
All of the insurer’s health plans cover medication that helps with opioid withdrawal symptoms because, combined with behavioral treatment, they are “by far the best form of treatment for someone addicted to opioids,” Friedlander says.
Aetna also has a pharmacy lock-in program, which can require plan members who are at risk for opioid addiction and can’t reduce usage to fill prescriptions at only one pharmacy. This can reduce the number of opioid prescriptions a patient fills.
Anthem started its own lock-in program in April 2016, because its internal research shows that many consumers who abuse prescriptions use more than one pharmacy, says Tracy Harrell, the insurer’s director for clinical pharmacy strategies.
Of all the members Anthem flagged for opioid misuse in its monitoring program, 15% are “locked in” to a single pharmacy, and the remaining 85% were able to reduce opioid use without being locked in, according to claims data, Harrell says.
Cigna wants to reduce customers’ prescription opioid use from 2015 levels by 25% before 2019 and was able to make significant progress early on, lowering use by 12% among all plan members between April 2016 and April 2017.
Cigna emphasizes working with doctors to reduce opioid prescriptions and tries to provide them with pain-management treatments other than opioids. The company reports that 158 medical groups in the Cigna network have signed a pledge to reduce opioid prescriptions and treat opioid use disorder as a chronic condition.
Kaiser Permanente employs its own doctors and pharmacists, allowing it to take more direct action against opioid misuse.
For example, Kaiser Permanente in Southern California re-educated doctors on how to safely prescribe opioids and encourages pharmacists to question doctors about high-risk prescriptions, among several other measures. Kaiser Permanente Southern California says it has reduced prescriptions for the highest risk long-acting opioids for non-cancer and non-hospice patients by more than 72% since January 2010.
UnitedHealth Group also reviews member claims for risky behavior, reaches out to doctors who prescribe more opioids than usual and has a pharmacy lock-in program. The company has posted some promising results: In 2015, UnitedHealth says it reduced the number of opioid prescriptions written to its members by 41% and reduced the number of doctors prescribing opioids by 45%.
Expect insurers to continue and even expand their opioid programs. For example, Anthem wants to make sure that all its members who receive medications to treat addiction are also enrolled in counseling, which makes treatment more effective.