With the United States in the grip of an opioid epidemic, many insurers limit access to pain medications that carry a lower risk of addiction or dependence, according to an investigation by ProPublica and The New York Times. But insurers often provide comparatively easy access to generic opioid medications. The reason, experts say: Opioid drugs are generally cheap while safer alternatives are often more expensive.
Drugmakers, pharmaceutical distributors, pharmacies, and doctors have come under intense scrutiny in the opioid crisis, but the role of insurers and pharmacy benefit managers (PBMs) has received less attention. ProPublica and The New York Times analyzed Medicare prescription drug plans covering 35.7 million people in the second quarter of 2017.
Only one-third of the people covered, for example, had any access to Butrans, a painkilling skin patch that contains a less-risky opioid, buprenorphine. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval for them. In contrast, almost every plan covered common opioids and very few required any prior approval. The insurers have also erected more hurdles to approving addiction treatments than for the addictive substances themselves, the analysis found.
UnitedHealthcare, the nation’s largest health insurer, places morphine on its lowest-cost drug coverage tier with no prior permission required, while in many cases excluding Butrans. And it places Lyrica, a nonopioid, brand-name drug that treats nerve pain, on its most expensive tier, requiring patients to try other drugs first.
Matthew N. Wiggin, a spokesman for UnitedHealthcare, said that the company was trying to reduce long-term use of opioids. “All opioids are addictive, which is why we work with care providers and members to promote nonopioid treatment options for people suffering from chronic pain,” he said.
Dr. Thomas R. Frieden, who led the Centers for Disease Control and Prevention under President Obama, said that insurance companies, with few exceptions, had “not done what they need to do to address” the opioid epidemic. Right now, he noted, it is easier for most patients to get opioids than treatment for addiction.
Leo Beletsky, an associate professor of law and health sciences at Northeastern University, went further, calling the insurance system “one of the major causes of the crisis” because doctors are given incentives to use less expensive treatments that provide fast relief.
The Department of Health and Human Services is studying whether insurance companies make opioids more accessible than other pain treatments. An early analysis suggests that they are placing fewer restrictions on opioids than on less addictive, nonopioid medications and nondrug treatments like physical therapy, said Christopher M. Jones, a senior policy official at the department.
Insurers say they have been addressing the issue on many fronts, including monitoring patients’ opioid prescriptions, as well as doctors’ prescribing patterns. “We have a very comprehensive approach toward identifying in advance who might be getting into trouble, and who may be on that trajectory toward becoming dependent on opioids,” said Dr. Mark Friedlander, the chief medical officer of Aetna Behavioral Health.
Aetna and other insurers say they have seen marked declines in monthly opioid prescriptions in the past year or so. At least two large PBMs announced this year that they would limit coverage of new prescriptions for pain pills to a seven- or 10-day supply. And several insurers have removed barriers that had made it difficult to get coverage for drugs that treat addiction, like Suboxone.
Many experts say they also are concerned about insurers’ limits on addiction treatments. Some state Medicaid programs, which pay for a large share of addiction treatments, require advance approval before Suboxone can be prescribed or they place time limits on its use, both of which interfere with treatment, said Lindsey Vuolo, associate director of health law and policy at the National Center on Addiction and Substance Abuse.
The analysis by ProPublica and The Times found that Medicare drug plans covering 33.6 million people include Suboxone, but two-thirds require prior authorization. Even when such requirements do not exist, the out-of-pocket costs of the drugs are often unaffordable, pharmacists and doctors said.
Source: ProPublica/The New York Times; September 17, 2017.