Insurance Companies, The Next Group to Join the Fight?


Insurance Companies, The Next Group to Join the Fight?

I came across the above articles and I found them interesting, although a bit worrisome. Due to the ever increasing addiction to prescription pain medicine, someone new has stepped in to join in the fight. They are health insurance companies.

Companies such as Aetna, Blue Cross Blue Shield and Cigna have taken measures over the past several years to prevent deaths and keep addiction numbers from growing by monitoring the overprescribing of prescription painkillers such as oxycodone, hydrocodone and morphine. Their reasons may not be altruistic, but it makes good business sense. The cost to public and private insurance companies of prescription painkiller abuse, treatment and “diversion” (when patients sell the medication instead of taking it) is an estimated $72.5 billion a year.

Because these insurance companies play a big financial role in health care, they might be able to make some of the most impact, says Dr. Andrew Kolodny, a senior scientist at Brandeis University’s Heller School for Social Policy and Management. “They’re paying the bills,” Kolodny said. “They’re paying for the medicines that people are getting addicted to. They’re paying for the doctors’ visits where people are getting medicines prescribed.”

For years, these companies have had access to prescription information for its customers. Any time you fill a prescription using your insurance, the company knows about it. The new measure will flag those customers who are deemed high-risk — either for getting large amounts of opioid medicines, for getting narcotics from different doctors or for being on the medicines for a long time — and getting in touch with those customers’ doctors. They reach out to the doctors who are prescribing to these patients to let them know such a history exists. This enables doctors to make appropriate decisions based on a patient’s history.

If the doctor believes that addiction may be an issue, the insurer can help get him or her get information about covered treatment options. If the doctor feels the patient still needs to be prescribed long-term narcotics, the insurer can limit where the patient is able to fill the prescription and which doctors are able to prescribe narcotics to them. This way the doctor can closely monitor the patient’s use and make valuable decisions regarding their care. If the patient goes to other doctors or pharmacies asking for narcotic painkillers, the insurer cannot tell the pharmacy not to fill a prescription; they would simply not pay for it.

There are databases that look at what kinds of prescriptions a patient has been filling — called Prescription Drug Monitoring Program databases (I’ve talked about this in previous blogs)—that generally pull together data in each state. But it’s difficult for some doctors to know what prescriptions patients are filling in other states.

The insurers also offer information on “medication-assisted therapy” — which combines therapy with addiction treatment medicine such as Suboxone.

So how do insurers propose to reduce addiction based on monitoring prescriptions? If a patient is getting more than 30 days worth of prescription painkillers, the doctor has to get prior authorization from the insurance company and must assess the addiction risks for that patient. Oftentimes, patients are required to sign “treatment plans” in which they acknowledge that they know about the risk of addiction with opioid medicines and promise to get these prescription painkillers from only one doctor. Insurer’s aim is to reduce the number of opioid prescriptions written to its customers by 25%, back to the number of prescriptions that were being written in 2006, which the insurer calls “pre-crisis.”

Preauthorization, as many of us know, can be a cumbersome and time consuming process. It is easier to write a prescription for 29 days to bypass that requirement. Prescribers do not have a lot of time to do a risk assessment for each patient that requires opioids. Signing a document can be done without much thought by someone who just wants the painkillers. If patients pay cash for their medication and don’t use their insurance (as many do), they will not be flagged. Insurance companies that base their decisions on money instead of patient need cannot see what issues that patient may be experiencing. These are some of the problems I see with the insurance companies making such decisions. But I also think this may be a valuable tool in the fight against over-prescribing. Awareness is often key in realizing the scope of a problem. Maybe some prescribers will use the information provided to get their patients help if addiction exists.

I think we can use all the help we can get in the fight against addiction. But, we need to be careful. What we do with that information will effect the quality of life for patients. Insurance companies will base their decisions financially. Prescribers must base their decisions on the needs of the individual patient. It takes time to evaluate each patient and to decide if the patient is truly in need or if they are drug seeking, or both. Do they need other services such as physical therapy or other pain management techniques? There are many things that can be done to help those with chronic pain and prescription medications are only one piece of that. Let’s prescribe responsibly.

About the Author

Kristin Waite-Labott is a registered nurse and recovering addict who has firsthand experience with the challenges of addiction. She now works as the Head Nurse Coach at Veritus, a virtual treatment program for nurses with substance use and mental health disorders, and is dedicated to helping nurses overcome addiction and making a difference in the lives of others. Kristin is passionate about addressing the growing problem of addiction among healthcare professionals and encourages open discussions and action to prevent it from spreading further.

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