While the brunt of the negative attention has focused on drug suppliers and prescribers, experts are now examining the role that insurers have played in the epidemic.
Health insurers could be stoking the opioid epidemic, according to a new study published Friday in the journal JAMA Network Open.
“Our findings suggest that both public and private insurers, at least unwittingly, have contributed importantly to the epidemic,” said study senior author Dr. G. Caleb Alexander, an associate professor in the Bloomberg School’s Department of Epidemiology.
That’s based on a 2017 analysis of 15 Medicaid plans, 15 Medicare plans and 20 private insurers, which revealed that many aren’t applying evidence-based “utilization management” rules that could cut down on opioid overuse.
“Opioids are just one tool in the pain management tool box, and unfortunately, many of the plans that we examined didn’t have well-developed policies in place to limit their overuse,” Alexander said.
The study comes even as a long-term uptick in opioid-related deaths has pushed dozens of states, counties, and cities to launch lawsuits against drug companies and distributors that make and provide the addictive prescription painkillers fueling the overdose crisis.
For the most part, the brunt of the negative attention has focused on drug suppliers and prescribers rather than on insurers, but the new findings by the Johns Hopkins Bloomberg School of Public Health probes what roles insurance plans could play in the epidemic.
The researchers identified specific utilization management tools that insurers may not be relying on enough, such as restricting the quantity of drugs doctors can prescribe, requiring prior authorization or mandating that providers begin with less risky drug alternatives.
Quantity limits are commonly used for opioids—but those limits might still be higher than they should be, the researchers found. Generally, insurers capped scripts at a 30-day supply instead of the shorter limit recommended by the CDC.
Across all the plans studied in Medicare, Medicaid and commercial insurers, doctors typically weren’t required to start with less addictive alternatives like over-the-counter NSAIDs before doling out more powerful opioids.
A median of just 9% of the covered opioids in Medicaid plans required doctors to start with something less risky first, the researchers found. For commercial plans, the median number was around 4%. Medicare plans typically had almost no so-called “step therapy” requirement.
The majority of opioid prescriptions didn’t require prior authorization, which is when the prescriber has to call the insurer for approval before writing the prescription. Some insurers, however, have begun putting such policies in place for patients with chronic, non-cancer pain.
“Insurers can either be part of the problem, or part of the solution,” Alexander said. “The good news is that an increasing number of health plans are recognizing their contribution to the epidemic and developing new policies to address it. The bad news is that we have a very long way to go.”
The analysis comes on the heels of a 2017 deep-dive by the New York Times and ProPublica, which found that many insurers limited access to less addictive —but more expensive—alternatives.
“This is not a hypothetical problem,” Rep. Elijah Cummings (D-Maryland), later wrote in a letter to insurance companies. “In my home state of Maryland, 550 people died of an overdose in the first three months of 2017 alone. Synthetic opioids like fentanyl are driving up the epidemic’s death toll, but prescription opioids contribute significantly to this crisis by fostering addiction and causing fatal overdoses.”
