In 2001, Mariah O'Brien was severely injured when the car she was riding in was hit by a vehicle traveling 70 mph on a Chicago expressway.
“I broke my neck in two places and my pelvis and my right leg,” she said. “I was flat on my back for three months and was on a lot of Vicodin at that point.”
O'Brien, 39, was prescribed the powerful pain reliever a second time last September after undergoing two surgeries to repair a torn anterior cruciate ligament. Both times, O'Brien quickly sought physical therapy to avoid opioid painkillers.
“I have three kids, so I can't really function if I was stoned,” she said. But getting her health plan to fully cover the cost of months of physical therapy proved to be a lot harder than getting a Vicodin prescription. “I ended up spending about $40,000 out of pocket.”
While patients like O'Brien often struggle to get reimbursed by insurers for the cost of non-opioid pain treatments such as physical therapy, consumer out-of-pocket spending for opioid prescriptions has declined over the years because of increases in coverage by Medicare and health plans. According to a study published in May in Health Affairs, out-of-pocket spending on opioids (measured per 100 morphine milligram equivalents) fell nearly 80% from 2001 to 2012.
By contrast, many public and private insurers place limits on the amount of physical therapy they will pay for. Medicare Part B reimbursement, for example, maxes out at $1,960 for physical therapy unless a patient qualifies for an exception.
And it's not only consumers who have a hard time finding alternatives to opioids. Even now that the overuse of the drugs is fingered as a culprit in the overdose epidemic, providers say they struggle to get paid by insurers for alternative therapies compared with the ease of prescribing an opioid.