Health Plans Are Trying to Battle Opioid Crisis, But Some Physicians See Prior Authorization Requirements as Another Roadblock
Economics Feature — November 2017
Tex Med. 2017;113(11):37–43.
By Joey Berlin
Gatesville pain physician Richard Hurley, MD, has watched opioids shift from drugs used in a fairly narrow set of circumstances to a dangerous national epidemic.
When Dr. Hurley, now president of the Texas Pain Society (TPS), finished medical school in 1977, only postoperative patients and terminal cancer patients received opioid pain medication, he says.
During the following decade, the incremental but dramatic transition began. Nowadays, patients' long-ago aversion to opioids trends in the opposite direction, Dr. Hurley says.
"In the late '80s and early '90s, I remember when I was prescribing pain medicines initially, most patients didn't want them. They didn't like the side effects," he said. "But by about 2014, and '15 and '16 and '17, patients expected it."
The increases in opioid overdoses and related deaths have caused physicians, lawmakers, and advocacy groups to pay attention, propose solutions, and take action. Increasingly, health plans are taking their own steps.
Recent changes by Cigna Health Insurance to its drug formulary and prior authorization processes are one example of how health plans are attacking the opioid crisis. But those changes ― including required prior authorization of new prescriptions for long-acting opioids and quantity limits for short-acting opioids ― highlight how one solution can create new obstacles for physicians.
Dallas psychiatrist Leslie Secrest, MD, chair of the Texas Medical Association's Task Force on Behavioral Health, says the focus needs to be on the best interest of patients.
"It's one of those things where you begin to ask physicians to carry that extra time and burden, and not necessarily always figure it into their remunerations necessary to go through these hoops," he said.
The Prior Authorization Approach
In August, President Donald Trump announced his preliminary intention to declare the opioid crisis a national emergency. That announcement was a reaction to a problem commanding more and more attention from medicine, policymakers, and other interested parties.
While the Centers for Disease Control and Prevention (CDC) says the number of opioids prescribed in the United States peaked in 2010, the number of opioid deaths quadrupled from 1999 to 2015. And 2015 saw more than 33,000 opioid-involved drug overdose deaths nationally, more than any year on record.
Most of the basic reasons for the trend are well-documented: Studies in the 1980s cast doubt on the danger of treating chronic pain with opioids; a feeling emerged that the medical community was undertreating pain; and the notion of pain as a "fifth vital sign" gained currency. Opioid use and abuse exploded.
The shift in thinking resulted in a landscape where "prescribing practices may have become too lax," says John Nguyen, MD, medical director of Integral Care, an organization that treats substance use disorders and mental illness in Travis County.
"More doctors were afraid to treat pain with non-opioids or nonpharmacologic interventions," he said.
Fortunately, Texas has one of the lowest rates of overall drug overdose deaths, according to CDC data. (See "Drug Overdose Deaths in Texas.")
During the past year, several health plans have publicly announced adjustments in their approaches to dealing with opioids. Cigna instituted changes effective July 1 as part of a "coordinated, comprehensive response" to the opioid crisis. Those changes included:
- Applying prior authorization requirements to prescription claims for customers new to long-acting opioid therapy ― those who haven't had long-acting opioids under a Cigna plan in the past 120 days;
- Applying quantity limits to claims for customers who haven't had short-acting opioid therapy in the past 90 days, with supplies exceeding 15 days requiring preauthorization; and
- Applying quantity limits to high-dose prescriptions and cough agents with codeine, both per Food and Drug Administration drug safety dosing recommendations.
Cigna isn't the first health plan to introduce prior authorization for opioids, and insurers have instituted various initiatives to battle opioids. (See "Plans for Prevention.")
Rick Watson, DO, Cigna's senior medical director for North Texas, told Texas Medicine that examining new opioid claims was part of Cigna's goal to reduce opioid prescriptions by 25 percent by 2019. Cigna said in April that 158 medical groups in Cigna Collaborative Care, which represents nearly 62,000 physicians, had signed a Cigna pledge to reduce opioid prescriptions and to treat opioid-use disorder as a chronic condition. By signing that pledge, practitioners say they will "support the CDC guidelines with us and prescribe opioids with caution," Dr. Watson said.
"What we're trying to do is minimize first-time exposures to the very addictive drugs," he said.
Exclusions from Cigna's new opioid policies include patients in hospice care and people with cancer and sickle cell disease. The prior authorization for new long-acting opioids claims would "help ensure dose, duration, and intent of the prescription are clinically appropriate," Cigna said. With regard to the limit for new short-acting opioid prescriptions, Dr. Watson says patients being treated "for something very minor ― an ankle sprain, some acute back pain … shouldn't require more than 15 days for that self-limiting condition."
Cigna is mindful of the albatross that new requirements can become for physician prescribers, Dr. Watson said, "and I think it shows through the exceptions that we've provided, [where] if someone has received medications in the last 120 days, there's no requirement for prior authorization."
"We're very sensitive to that need and don't want to place that administrative burden on the physician," he said. "It's really at the point of decisionmaking for a first-time person asking whether or not a more powerful medication is needed or a very long supply of a short-acting medicine is required. We know that both of those, because they're highly addictive, can lead to substance use disorders."
Prior authorization in general can be a roadblock for physicians in many cases. So, naturally, doctors have their reservations about adding more drugs to prior authorization lists.
Dr. Hurley, the Texas Pain Society president, says he went through the prior authorization process for a Cigna-insured patient in September and had to request preauthorization for a United patient not long before that.
"They wanted to know if we had an opioid agreement. They wanted to know what the diagnosis was. They wanted to know current medications. They wanted to know other forms of treatment. It can be quite burdensome if I had to do that for everybody," Dr. Hurley said. "Everyone is concerned with untimely deaths associated with opioid therapy, and we're all trying to stop overdoses. But requiring authorizations for short-acting or long-acting opioids is a burden to pain management clinics."
He believes the burden "could be astronomical" for large primary care practices. Dr. Hurley's pain management operation at Coryell Memorial Healthcare System in Gatesville does "a whole host of things" to mitigate the risk of opioid deaths, including monthly or quarterly drug screens, physical and psychological evaluations, and checking the prescription monitoring program (PMP) for all patients.
"We are prepared for that because we don't take care of hypertension, and we don't take care of diabetes. Our focus is on the pain symptoms and improved function," he said. "But if you have a large primary care practice in which you're taking care of every patient need, and now you've got to meet the same standards as we do in pain management, that may be really burdensome for a busy clinic."
Dr. Secrest, the Dallas psychiatrist, calls prior authorization requirements "an uncompensated mandate."
"The insurance company will carry the financial burden that is directly related to their operation, but they also don't often include much of the structural time [required], all of those sorts of expenses," he said. "It is another one of these unfunded mandates, and [it] gets in the way of really getting care to a patient that's appropriate."
Dr. Hurley says Cigna's new policies won't change the number of heroin deaths in the United States. Nearly 13,000 people died from heroin overdoses in 2015, according to CDC, a jump of more than 20 percent from 2014.
"It will not prevent suicides," Dr. Hurley said. "When depressed patients confuse suffering with chronic pain, some will just take a whole month's supply of their pain medicine to end their suffering. It will not prevent diversion. It will decrease the amount of diversion, but it won't stop it."
However, while Dr. Nguyen says he can't comment on the policies of Cigna or other health plans, he says Integral Care's prescribing policy "could perhaps be analogous" to Cigna's when a controlled substance is involved in treating patients. Those cases require "a little bit of extra monitoring by the physician," he said, "whether that's doing drug screenings, checking the monitoring program, or making sure there aren't other substances there that could increase the risk of overdose." Because Integral Care is a behavioral health agency, its physicians focus primarily on psychiatric conditions rather than pain management. But it does maintain a methadone clinic and prescribes drugs such as buprenorphine for opioid dependence and withdrawal symptoms.
"We've approached our new prescribing practices through education of our staff," Dr. Nguyen said. "And for the most part, our staff have been relieved that they can point towards the prescribing changes policy, or towards sources of education or resources so that they don't feel pressured to prescribe medications they're uncomfortable with.
"I wouldn't say it's decreased productivity or efficiency at all. In fact, it's perhaps allowed a little more willingness to open a conversation about safer alternatives that are still effective."
Embracing Nondrug Treatments
Those safer alternatives are what some physicians say they'd like to see more health plans authorize and cover more of ― treatments such as exercise rehabilitation and electrical stimulation.
Receiving authorization for nonpharmacologic alternative treatments has been "the biggest issue" with regard to opioids and pain management, Dr. Hurley says. Physical rehabilitation requires prior authorization, he says, and copays for it can be prohibitive.
"Exercise programs such as yoga or tai chi are not covered," he said. "Interventional pain-relieving techniques are limited, and some insurance companies reimburse those so poorly that many of our patients decide not to have them. Reimbursement for psychological care is almost nonexistent for patients with chronic pain."
He recommends health plans help make those types of alternatives more readily available to patients.
"It is ironic that health plans now want to demand prior authorizations for opioids and other controlled substances in new patients, but if approved, they want physicians to write prescriptions for a three-month supply," he said.
Looking at it from a psychiatrist's perspective, Dr. Secrest questions whether behavioral health disorders associated with chronic pain are being identified and adequately addressed.
"If you're not addressing the depression that's there, then quite often managing pain is going to be a challenge," he said. "It's these comorbid conditions that you ask us to begin to identify and begin to have strategies to treat those sorts of things."
But Dr. Watson said Cigna's opioid policies have been "going very well."
"I've spoken personally with a few groups to clarify the prior authorization quantity limit changes and have not had any negative feedback regarding those changes," he said.
Cigna announced in April, about a year after its stated commitment to decrease customers' opioid use by 25 percent by 2019, that customers' use had already fallen 12 percent. In May, Aetna announced a 7-percent reduction in its monthly opioid prescription rate since August 2016.
"This is a societal problem," Dr. Watson said, "and when you have 91 people dying every day from an opioid overdose in the United States, this is something that all of health care has to be concerned about and take steps against preventing those needless deaths."
Joey Berlin can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.
TMA Part of the Fight
During the past two sessions of the Texas Legislature, TMA has thrown its support behind practical solutions to address opioid overdoses. In 2015, TMA supported successful legislation to expand access to the overdose-rescue drug naloxone. (See "A True Antidote," October 2015 Texas Medicine, pages 41–47.)
During this year's legislative session, TMA fought lawmakers' attempts to require physicians to check the state’s prescription monitoring program (PMP) before issuing a prescription for any controlled substance. TMA instead backed a technology-based solution to the opioid crisis, using the state's PMP to identify potential instances of harmful prescribing, diversion, and doctor-shopping. (See "Unwelcome Diversions," May 2017 Texas Medicine, pages 35–43, or visit www.texmed.org/UnwelcomeDiversions.)
Ultimately, legislation passed that will implement those technological suggestions but that also will require prescribers to check the PMP before prescribing opioids ― as well as three other drug classes ― beginning Sept. 1, 2019. TMA successfully fought for the 2019 delay to give stakeholders more time to study how to combat the opioid crisis.
TMA's Task Force on Behavioral Health also has been actively engaged in studying opioid abuse.
Plans for Prevention
Health plans besides Cigna recently have addressed the opioid epidemic by, among other things, announcing the removal of preauthorization requirements on treatments used to battle dependency. Some plans also have certain prior authorization requirements, invoking the Centers for Disease Control and Prevention (CDC) guidelines.
Aetna: In June, Aetna released a "comprehensive strategy" to “limit the use of opioids to only a short period," and to set “limits for opioid prescriptions to stop patients from receiving large quantities," Aetna's chief medical officer, Harold L. Paz, MD, said in a report.
The plan includes:
- Creation of a controlled substance use program to identify potential opioid-abusing patients, alert prescribers, and offer help through medication-assisted treatment combined with behavioral therapy.
- Ending preauthorization requirements on all products of buprenorphine, a drug used to treat opioid addiction.
According to Aetna, Dr. Paz sent personal letters in 2016 to "super-prescribers" of opioids, who Aetna says refilled prescriptions "at a considerably higher rate than their peers."
Blue Cross and Blue Shield of Texas: In a statement, Blue Cross and Blue Shield said it uses "utilization management and drug utilization review activities.” Blue Cross also created the Controlled Substance Integration Action Committee, which intervenes in suspected abuse and misuse cases and provides care education to patients and practitioners.
Blue Cross also says it works with physicians who prescribe opioids within the top 2 percent of their peers. "If the prescriptions are deemed excessive," Blue Cross said, "we will work with the provider, giving them a snapshot of their written prescriptions compared to what their peers are prescribing."
UnitedHealthcare: In a white paper, United said OptumRx, a pharmacy care segment of UnitedHealth Group, conducts, among other things, "a range of initiatives that ensure appropriate prescribing," including pharmacy and prescriber surveillance, dispensing limits and prior authorization, patient outreach, and case management.
United also has ended preauthorization requirements for opioid-dependence treatments on its prescription drug lists.
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AGs Urge Action From AHIP
In late September, 37 state attorneys general (AGs) sent a letter to America's Health Insurance Plans (AHIP), urging the organization to address the opioid crisis with its members.
The National Association of Attorneys General encouraged AHIP to "take proactive steps to encourage your members to review their payment and coverage policies and revise them" to encourage practitioners to prioritize non-opioid pain management for chronic, non-cancer pain.
The letter noted as many as 2 million Americans "are currently addicted to or otherwise dependent on prescription opioids," with 91 dying every day and an annual cost of about $78.5 billion to the U.S. economy.
The attorneys general said adopting an incentive structure "that rewards the use of non-opioid pain management techniques" would bring many benefits.
"Given the correlation between increased supply and opioid abuse, the societal benefits speak for themselves. Beyond that, incentivizing opioid alternatives promotes evidence-based techniques that are more effective at mitigating this type of pain, and, over the long-run, more cost-efficient," the letter said. "Thus, adopting such policies benefit patients, society, and insurers alike."
Texas Attorney General Ken Paxton did not sign the letter.
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