2018 Year in Preview

Opioids, Part 1

Health insurers pushed to take steps to curb the epidemic

Joseph Burns
Contributing Editor

Do something!” seems to be the message to health insurers about the opioid epidemic from patients, physicians, and addiction experts.

The numbers alone suggest a pressing need to take action. A staggering 33,000 Americans died of opioid-related deaths in 2015, the most recent year for which complete data are available. The number of deaths from opioids are likely to be even higher in 2016 than in 2015 once the final count for that year is in.

Drugs involved in U.S. overdose deaths, 2000–2016

Source: National Institute on Drug Abuse

Blame for the epidemic had focused on drugmakers, drug wholesalers, and physicians who prescribed opioids too liberally. This fall, fingers pointed at health insurers. Investigative reporting showed that coverage policies that restricted access to less addictive medications might have helped fueled the epidemic. Managed Care and other outlets also reported on how prior authorization and other policies created barriers to addiction treatment. “With no relief from the epidemic in sight, we will see continued pressure on insurers to do what they can and to consider changing their UM policies as we enter 2018,” says John Santilli, a pharma industry consultant for Access Market Intelligence.

Insurers were on the receiving end of many of the 56 recommendations in the report issued by the Trump administration’s commission on opioids in November. The commission proposed, for example, that insurers modify payment policies that discourage the use of nonopioid treatments for pain and remove pain survey questions from patient satisfaction scores so providers won’t have an incentive to prescribe opioids.

Some of the recommendations from the Trump commission overlapped with those from a report issued two days earlier by the Clinton Foundation and the Johns Hopkins Bloomberg School of Public Health. The Clinton–Hopkins report called on insurers to cover naloxone, the drug that can reverse an opioid overdose in an emergency.

Perhaps most concerning to insurers was the emphasis the Clinton–Hopkins report put on a story reported jointly by ProPublica and the New York Times that showed that many insurers may worsen the opioid epidemic by not covering pain medication like a buprenorphine patch, sold under the brand name Butrans, that is less addictive than many opioids.

In our April 2017 issue, Managed Care covered the problem caused by health insurers limiting prescriptions or requiring prior authorization for treatment drugs for opioid addiction.

David Aaron Cooke, MD, an internal medicine specialist and assistant professor at the University of Michigan commented on the ProPublica and Times article, “It is indeed much easier to get insurers to pay for more addictive and risky treatments than safer ones. They dislike paying for Butrans in any form, despite the fact that it is a lower risk opioid than the alternatives.” In a telephone interview with Managed Care, Cooke said he has often had patients do well on Butrans but then health insurers often stopped covering it. Instead, insurers switch patients to medications such as Purdue Pharma’s MS-Contin or methadone, both of which have much higher risks of addiction than the buprenorphine patch, he said. When insurers do not act quickly to cover appropriate medications for addicted members, those members frequently overdose and many die, Cooke added.

Two other reports in the fall also addressed steps health insurers can take. Research presented at the annual meeting of the American College of Emergency Physicians showed that 55% of patients who visited the emergency room for substance misuse had mental health issues and 60% were severely traumatized as children. One takeaway: Greater access to mental health providers are needed nationwide.

The Government Accountability Office also weighed in with a report saying that HHS should establish performance measures with targets that would encourage access to medication-assisted treatment for opioids.

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