Private insurers, Medicare and Medicaid policies often missed opportunities to combat the opioid epidemic and encourage patients to take safer, more effective alternatives to prescription opioids, according to a new study.
Although insurers have made an effort to discourage opioid abuse by placing quantity limits, beginning therapy with less risky medications or requiring preapproval for prescriptions, they applied the same rules to non-opioid treatments and made it just as difficult for patients to access opioid alternatives, according to the study published Friday in JAMA Network Open.
"At least unwittingly, insurers have contributed to the opioid epidemic," said study senior author Dr. G. Caleb Alexander, associate professor in the Bloomberg School's department of epidemiology and co-director of the Johns Hopkins Center for Drug Safety and Effectiveness. "Our findings highlight important ways coverage and reimbursement can be better aligned with the evidence base."
All in all, the researchers from Johns Hopkins Bloomberg School of Public Health reviewed coverage policies of 50 health plans, which included 20 commercial insurers, 15 Medicare Advantage plans and 15 Medicaid programs across 16 states from June to September of 2016 for drugs to treat chronic lower-back pain. They found private and public payers covered an average of 72% of opioid drugs and 75% of non-opioid pain medications studied. Commercial plans covered 77% of opioid medications, while Medicaid covered 63%, and Medicare Advantage plans covered 57%.
Payers most commonly used quantity limits on opioid prescriptions to manage utilization. Commercial plans relied on such restrictions for an average of 70% of their covered opioids, Medicare Advantage used quantity limits for 100% of their covered products and Medicaid used limits an average of 69%, according to the study.
But those limits failed to distinguish between the first prescription and subsequent prescriptions in all cases, even though laws passed in the last year across the country require a 7- or 10-day prescribing limit for a first opioid prescription, researchers said.
"Many of the plans that we examined didn't have well-developed policies in place to limit their overuse," Alexander said.
Nearly 92 million adults in the U.S. took a legitimately prescribed opioid in 2015, according to a 2017 study published in the Annals of Internal Medicine, with more than 11 million reported misusing a prescription opioid.
More than 1.5 million American adults with some form of health insurance were estimated to have had an opioid use disorder in 2015, according to an analysis released in March by the healthcare finance and delivery analytics firm Milliman. Of that number, more than 41% were covered by commercial insurance, more than 42% were Medicaid beneficiaries, and nearly 16% were covered by Medicare.
Payers rarely used step therapy, a practice where providers are required to use less powerful medications before moving on to more powerful drugs. Medicaid plans used step therapy for an average of 9% of covered opioids, while commercial plans employed the practice an average of 4%. Step therapy requirements were not enforced by any of the Medicare Advantage plans studied.
Cost of the drugs is also a factor. Both public and commercial plans typically covered opioids with an average co-pay of $10 to $15 for a month's supply. The study found most opioid and non-opioid drugs covered by commercial insurance had an average co-pay of $10. For Medicare Advantage plans, most opioids were categorized in either tier 2 or 3 and most non-opioids were in tier 2, which have higher co-pay costs. Making non-opioid treatments as readily accessible as opioids would make a significant difference toward encouraging prescribers and patients to use such alternatives more frequently, Alexander said.
"We've spent so much time focused on opioids, but they're just one tool in the toolbox," he said. "We have to make other tools easier to reach for and use."
Since the study period, insurers have made substantial changes to their utilization management policies that Alexander said could make significant strides toward reducing the level of misuse of prescription opioids. Many have taken a similar approach to Cigna's 2016 goal to reduce opioid treatment among its members by 25% by 2019.
In March, Blue Cross and Blue Shield Association adopted step therapy for pain treatment as their new standard, following the Centers for Disease Control and Prevention's 2016 guidance that opioids should not be used as the first pain management treatment for a patient.
"On the other hand, we've been watching this epidemic get worse, hidden in plain sight for 20 years," Alexander said. "I think insurers deserve credit for recent changes, but there's a lot more that insurers can do."
A CMS spokesperson said the agency is working with beneficiaries, states, providers and private plans to combat the crisis.
Cathryn Donaldson, spokeswoman for America's Health Insurance Plans, said their member organizations have dramatically reduced opioid prescribing in recent years, and all stakeholders must cooperate if they are to make more progress.
"The bottom line is, we all need to work together to reduce opioid addiction, and insurance providers are committed partners who have long been on the front lines," Donaldson said.
