Surprising Ways Patients Are Funneled Into a Cycle of Opioids

Much of the discussion around preventing opioid misuse and addiction has centered on reducing the number of prescriptions, but what about how we pay for them? A recent study and associated commentary published in JAMA Network Open indicates that payers could play a meaningful role in helping to curb prescriptions through changing health plan design and reducing patient out-of-pocket spending.

The study, “Coverage of Nonpharmacologic Treatments for Low Back Pain Among U.S. Public and Private Insurers,” examines coverage policies across a nationally representative sample of commercial, Medicare Advantage and Medicaid plans. It finds, surprisingly, that nonpharmacologic therapies were often more expensive and required more bureaucratic steps than opioids, although both therapies have been shown to be as effective, if not more effective, for musculoskeletal pain. In fact, a recent meta-analysis published in JAMA, which included 96 randomized clinical trials, concluded opioids produced only small improvements for chronic noncancer pain and physical functioning and nonopioid treatments may be equally as effective.

Given the tendency for patients to choose the least costly and most convenient form of care, whether it is effective or not, health policies need to transform to make nonpharmacologic pain treatments more attractive and accessible.

Patients Bearing Greater Costs

The study’s lead author, James Heyward, MPH, a research data analyst at the Johns Hopkins Center for Drug Safety and Effectiveness, found a wide range of copayments for nonpharmacologic therapies for pain, such as physical and occupational therapy and chiropractic care. One commercial health plan, for example, required their members to pay as much as $60 per co-pay for chiropractic care, while the average Medicare Advantage co-pay for physical therapy visit was $40. Meanwhile, in the commentary, Christine M. Goertz, DC, Ph.D., and Steven Z. George, PT, Ph.D., cite research that shows health plans’ preferred generic opioid prescription costs members only $10 a month.

 The financial incentive to refill a prescription is reinforced with additional convenience and time-saving benefits. Although a follow-up chiropractic care visit, for example, typically only takes 10 to 15 minutes, patients still need to leave home or work and cope with weather, traffic and parking and then pay a significant co-payment, or pay completely out of pocket, in some instances. In addition, chiropractic care and physical therapy typically require several appointments before patients experience significant chronic pain relief. Physical and occupational therapy appointments also often require strenuous exercises to restore function.

 Nonpharmacologic treatments also undergo more scrutiny from payers. The Heyward study found that more than half of insurers placed visit limits on chiropractic care, as well as physical and occupational therapy, while others instituted medical necessity reviews and other preauthorization requirements.

 Eliminating barriers to safer care

To steer more Americans toward evidence-based and effective clinical pathways, health insurers and government healthcare policymakers cannot simply move opioids to a higher price tier or require a more rigorous preauthorization process for the medications. That will only result in greater pain and suffering. In fact, the Economic Policy Institute has found that increased cost-sharing in health plan policies tends to burden those patients who need the care the most, leading them to forgo care.

Instead, the study shows that health plans can take steps to help reverse the course. These measures could include:

1.    Reduce copays for evidence-based and effective treatments such as chiropractic care, physical and occupational therapy

2.    Decrease unnecessary administrative obstacles such as medical necessity reviews for these conservative, cost-effective treatments

3.    Eliminate visit limits to encourage members to make such therapies part of their long-term, chronic pain management strategy, preventing the need for pharmacologic interventions

4.    Increase collaboration and coordination between medical and pharmacy health plan leaders to encourage members to pursue nonpharmacologic interventions for chronic pain

5.    The Centers for Medicare and Medicaid Services should seek input from the entire spectrum of healthcare providers and professionals, including doctors of chiropractic, and physical and occupational therapists, as they design policies and guidelines for the newly passed “Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act.”

By incentivizing effective, evidence-based nonpharmacologic care, such as spinal manipulation, patients would be more willing to pursue these treatments for their pain. A recent study published in The Lancet points out the latest U.S., United Kingdom and Danish clinical guidelines for treating low back pain endorse spinal manipulation for acute and chronic low back pain.

As patients start to feel relief and increase their range of motion through such treatments, drug-free care would become part of their lifestyle and integral to their long-term, chronic pain management strategy.