Earlier this week, the LA Times had a good article on a study that traced where people who overdosed on prescription drug opiods got their pills:
The study, published Monday by the Journal of the American Medical Assn., echoes a 2012 Times investigation that found drugs prescribed by doctors caused or contributed to nearly half of the prescription overdose deaths in Southern California in recent years. The Times also revealed that authorities were failing to mine a rich database of prescribing records to identify and stop reckless prescribers…
Prescription drugs — mostly narcotic painkillers, such as OxyContin and Vicodin — contribute to more than 16,000 fatal overdoses annually and are the main reason drugs have surpassed traffic accidents as a cause of death in the U.S.
If drugs are being prescribed, this implies a good proportion of the drugs are being paid for by some insurance program. The question is what can insurance companies and state/federal insurance programs do to minimize overprescription of opiod pain mdiciation?
There are two classes of actions that can be taken. Medicaid has a system in place to identify patients who doctor shop for extra pills. Doctor shopping means they frequently go to different providers for the same diagnosis, or show up to the emergency room with a pain complaint that can not be otherwise specified. Medicaid or managed care organizations managing Medicaid patients perform statistic analysis for outliers, and then have a system that locks a patient to a single primary care provider at a signle location who can prescribe to only a single pharmacy. This type of care-lock can last for several years. It has been shown to reduce diversion and overdoses by making several classes of drugs far less available.
Commercial programs have this as an option. However, since they are in the member satisfaction as well as the health provision/maitenance business, restricting member options even when it is for their own long term good is not popular. I think there is an opportunity on the provider side of changing the opiod prescribing culture which would be far more effective in limiting diversion.
Right now, opiod prescription culture is extraordinarily varied. When my wife gave birth to Kid #2, she was sent home from the hospital with a bottle of 800mg Motrin and a prescription for twelve Vicodins. When I had my vasectomy, I came home with a bottle of 800mg Motrin and a prescription for fifty Vicodins.
I do not care how much I overestimate the relative pain of the two scenarios, I was in significantly less pain and less damage than my wife was three days after giving birth. I never filled the prescription as a bag of frozen peas, rest and Motrin was sufficient. When I returned to work, I talked with a pharmacy auditor, and she said that this disparity was well within normal treatment routines.
Insurers could put into place policies that they will only pay for a short initial prescription of opiod painkillers with a follow-up visit within a week for a larger prescription. This would eliminate the fifty pill prescription that I received as a prophylactic against potential pain and replace it with an eight or twelve pill prescription to cover the option of pain treatment needs.
The biggest problem with this system is two fold. First, it will increase member complaints. In a group market, this might not matter all that much if the complaints are randomly distributed as one more person complaining to Jan in HR won’t change the decision structure at renewal time. However in an increasinly individual market where insurance is not tied to employment (a net good thing), this will lead to membership loss if only one insurer in a region limits opiod prescription. Here would be a good case for government regulation to solve a collective action problem.
The larger problem is a cost effectiveness issue from an insurer’s point of view. Opiod painkillers are cheap. Percocets cost, at a retail pharmacy, less than a dollar a pill, or ten cents per miligram of oxycodone. Other opiate pain killers are similarly priced. Going to a short regimen, follow-up visit, long regimen scenario means paying for a lot of additional follow-up visits. There will be cost savings as may fill an eight pill prescription instead of a forty pill prescription that they otherwise would have received and never go for a follow-up to get an additional thirty five pills. However, there are increased costs of the follow-up visits. These individuals will cost the insurance company an extra hundred dollars or so for the office visit plus the regular prescription drug costs. This is counterbalanced by whatever the decreased probability of overdose treatment costs thgat are avoided by a new system of opiod pain medicine management.
This is probably a situation where the net social benefits of reducing overdoses and deaths from overdoses are much higher than the benefits that are received by the payers.