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Policy & Management
AUGUST 16, 2018
Did Insurers’ Policies Fuel the Opioid Epidemic?
Insurers’ policies for chronic pain medications are missing important opportunities to steer patients to safer and more effective treatments than opioids, according to a study by researchers at Johns Hopkins Bloomberg School of Public Health.
The study found that many insurers failed to apply evidence-based “utilization management” rules to discourage opioid overuse, and many rules were applied as often to nonopioids as opioids.
“Our findings suggest that public and private insurers, at least unwittingly, have contributed importantly to the [opioid] epidemic,” said study senior author G. Caleb Alexander, MD, the co-director of the Johns Hopkins Center for Drug Safety and Effectiveness, in Baltimore. “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.”
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For the study, published online June 22 in the journal JAMA Network Open, the researchers examined 2017 coverage policies of 15 Medicaid plans, 15 Medicare Advantage plans and 20 commercial insurers, in what they said was one of the most comprehensive examinations of pain policies ever done. Their analysis found gaps in each of the three common types of opioid utilization management:
Quantity limits. Restrictions on the number of pills that can be dispensed are commonly employed for opioids, but the researchers frequently found these limits were for a 30-day supply instead of the shorter supply recommended by the “CDC Guideline for Prescribing Opioids for Chronic Pain.” The authors noted that since the study was initiated, several major insurers have begun implementing more stringent quantity limits on first prescriptions.
Step therapy. Step therapy requires that pain management start with a less risky drug, such as a nonsteroidal anti-inflammatory drug, and allows a more risky opioid only if the first drug is ineffective. But the researchers found plans rarely employed step therapy for opioids. Among the Medicaid plans, a median of 9% of covered opioids required step therapy; among commercial plans, the median figure was 4%; and Medicare plans had virtually no step therapy requirements for opioids.
Prior authorization. Prior authorization was applied to only a minority of covered opioids, although the authors acknowledged that here too, some insurers have begun implementing policies such as requiring prior authorization for patients with chronic noncancer pain.
“To their credit, while every health plan we examined was actively trying to combat the epidemic, their focus was generally on utilization management and identifying high-volume prescribers and patients, rather than on comprehensive strategies to improve the treatment of chronic pain,” Dr. Alexander said in a statement.
Defending Their Approach
Several payors and pharmacy benefit managers interviewed said within the last year, they have put in place opioid management programs aimed at addressing the epidemic.
“In February 2018, our [pharmacy benefit manager], CVS Caremark, implemented an enhanced opioid utilization management program for all commercial, health plan, employer and Medicaid clients unless a client chose to opt out,” said CVS Health spokeswoman Christina Beckerman. “Our program aligns with the CDC guideline and includes limiting to seven days the supply of opioids dispensed for certain acute prescriptions for patients who are new to therapy; limiting the daily dosage of opioids dispensed based on the strength of the opioid; and requiring the use of immediate-release formulations of opioids before extended-release opioids are dispensed.”
Ms. Beckerman added that since the program was put in place, the number of opioid-naive patients with an acute condition receiving an opioid prescription fell by 70%. More than 94% of those who do receive an opioid prescription get a seven-day supply or less.
Express Scripts launched its Advanced Opioid Management program in September 2017, according to Snezana Mahon, PharmD, the vice president and general manager of clinical solutions. The company’s strategies included seven-day limits on initial opioid prescriptions for opioid-naive patients and alerts when morphine equivalent doses exceeded recommended levels. Since the program was implemented, Express Scripts has reduced the average day supply per claim by 60%, down from 18.6 to 7.5, with 95.9% of reprocessed scripts reduced to seven days’ supply or less.
