To save money, insurance industry joins the war against pain patients

Click to access insurers_pire_4_web508.pdf

The Role of Insurers in Preventing Misuse and Abuse of Controlled Substances

Prescription opioid abuse cost the health care system $25.0 billion during 2009 (Birnbaum et al., 2011)…

As Dr. Len Paulozzi of the Centers for Disease Control and Prevention said, “There’s an awful lot of back injuries in the workers’ comp population and subsequent surgery related to back problems, and back pain is one of the most common indicators now of use of opioids in the
United States” (Johnson & Jergler, 2013). However, as a strategy to manage chronic pain related to tissue damage, controlled substances may not be particularly effective. Dr. Paulozzi continued: “Opioids might be good for use in the acute phase, say within six weeks after injury. But if it doesn’t improve the situation in the short term, continuation is not really indicated.” Worse, using opioids to control pain creates a condition called hyperalgesia, which makes patients more sensitive to pain from future injuries and less able to control that pain…

In 2011, the State estimated that giving permission to third-party payers to access the Prescription Monitoring Program database would yield reductions in total benefits paid for 3% of claims related to 2–3 opioid prescriptions, 5% on claims related to 4–7 prescriptions, and 7% on claims related to 8 or more…

States and insurers are implementing patient review and restriction programs. These programs, which a number of states have implemented, are sometimes known as Medicaid Lock-In Programs…

In Virginia, WellPoint Anthem Blue Cross and Blue Shield estimated that it saved more than $300,000 by restricting 100 patients to a single pharmacy…

MaineCare, which administers the State’s Medicaid program, has limited patients to 2 weeks of painkillers a year, although it does permit renewals in intervals of 2 weeks to patients who receive special permission. Patients with chronic pain that lasts more than 8 weeks are required to try such alternative treatments as cognitive behavioral therapy, pain acceptance therapy, and chiropractic treatment. Exempt from these rules are patients with AIDS or cancer or those in hospice settings…

PDMPs that include data pertaining to the patient’s means of payment can be used to determine if Medicaid patients are circumventing program restrictions by using cash to purchase controlled substances. Unfortunately, as of 2012, only slightly over half the states were sharing their PDMP databases with either their Medicaid or Medicare programs, and only Michigan allowed private insurers access to it (PDMP, 2014). Using its PDMP database, Washington State’s Medicaid program discovered that in the first 6 months of 2012, more than 200 patients had paid cash for dispensed controlled substances on the same day, and 500 patients had filled two or more opioid prescriptions for use during the same time period. The program also discovered that Medicaid patients were paying cash for prescriptions for controlled substances in 435 of its pharmacies, which indicated that they were out of compliance with their contracts (Best, 2012)…

Aetna’s Pharmacy Management Program is a four pronged effort to prevent the misuse and abuse of controlled substances. First, the program can limit coverage of any particular drug and can verify that the covered member needs the drug before approving it. The program also proactively notifies the pharmacist if the drug is prescribed at a level that may be inappropriate. Second, the program reviews each member’s prescription history before filling a new prescription. Third, members who are suspected of misusing controlled substances may be referred to a pain specialist or to Aetna’s Behaviorial Health or Case Management services, or they may be encouraged to enroll in a pain management program. Finally, the program may respond to members who decline offers of assistance by restricting them to a single provider or
by reducing coverage for refills. Following the inception of this program, opioid use among the carrier’s 4 million members declined 15% over the course of 2 years (Aetna, 2013).
Blue Cross Blue Shield of Massachusetts implemented a similar program…

Prime Therapeutics, a pharmacy consulting program, identified patients of concern based on a score developed from their use of controlled substances and doses of opioid analgesics in excess of 120 morphine milligram equivalents per day…

Found in the Search Terms for my blog:  “does workers comp ins. coordinate with my anthem for opiate scripts”

(5/21/2015) Opioid addiction suit puts workers comp payers on alert

Experts urge workers compensation payers to take steps to avoid overprescribing or doctor shopping following a state Supreme Court’s decision allowing patients to sue physicians and pharmacies for contributing to their addiction to opioids.

Nearly 30 people filed eight civil actions in Mingo County, West Virginia, Circuit Court between 2010 and 2012 that alleged a medical center, three physicians and four medical centers “negligently prescribed and dispensed” drugs that led them to abuse and become addicted to opioids, court records show.

Most were prescribed Lortab, Oxycontin and Xanax for injuries caused by automobile or workplace accidents. Most also admitted “their abuse of controlled substances predated their treatment,” and they engaged in “illegal activities associated with the prescription and dispensation of controlled substances,” according to the West Virginia high court’s May 13 split decision…

“It’s a slippery slope,” said Phil Walls, chief clinical and compliance officer at Tampa, Florida-based pharmacy benefit manager myMatrixx, the marketing name of Matrix Healthcare Services Inc. Pharmacies worried about the potential liability might refuse to fill — or even stock — some opioids, which could make it difficult for injured workers who really need the drugs to get them, he said…

What payers in most states can — and should — do to curb overprescribing is to ask workers comp physicians if they’re accessing prescription drug monitoring programs, experts said.

If not, “that obviously doesn’t mean they are prescribing inappropriately or egregiously, but it does mean they aren’t paying as close attention as they should,” Mr. Pew said. “It indicates a lack of due diligence on behalf of the physician and is an immediate red flag.”

Another way payers can prevent egregious prescribing is by requesting physician profiling reports and other data from their pharmacy benefit managers, experts said.

Only a small number of physicians and pharmacies actually engage in inappropriate or egregious prescribing and dispensing, Mr. Walls said.

An FBI raid eventually led some of the West Virginia physicians to lose their medical licenses and serve prison time, while one pharmacy and its pharmacist were “subject to disciplinary and/or criminal action,” according to records.

3 thoughts on “To save money, insurance industry joins the war against pain patients

  1. Well, I’m not sure I think PDMPs are completely evil. When someone fills multiple opioid prescriptions at several different pharmacies on the same day, or gets multiple prescriptions for the same opiates from several different doctors in just a few days, this does seem like they are one of the abusive people we need to weed out.

    I agree that just one such incident (or even a few) could be an explainable screw-up, but this is how the abusers are gaming the system. I’m all for weeding those people out so that the legitimate patients can get their meds, aren’t you?

    I also agree it’s a horrible intrusion of privacy, but how else can they find and stop the abusers that are making life so hard for us? If docs could rely on the PDMPs and freely prescribe opioids to those that don’t show abuse, that would be wonderful for us.

    (I already learned way back in 2001 that insurers could find prescriptions I filled over a decade ago, like migraine meds, and deny coverage based on that. But I was also able to explain that it was just a trial that didn’t work and then got coverage.)

    So of course, a system mistake should be able to be contested as I was able to do, but there are abusers out there that show up with multiple prescriptions for massive amounts of opioids and just fill them at one pharmacy after another day after day. We should be figuring out how to stop that.

    How else can we identify the abusers? I’m sure PDMPs are abused as are all of our medical (and financial) records, but I just don’t have any other ideas.

    Liked by 1 person

    • I’ve posted a lot about PDMPs and how I feel about them. They’re a black list for pain patients and I think that’s wrong. You might have been able to rectify a negative response, but not everyone can. And the kind of information that’s being included, like labeling someone a drug addict, is something that doesn’t ever go away. Since I don’t plan on using opioids or other prescription drugs again, it shouldn’t affect me, so I guess I can afford to complain about them.

      Relying on PDMPs (and drugs tests, pain contracts, etc.) will not allow doctors to freely prescribe opioids again. That’s just wishful thinking. PDMPs that have been in use for years are not stopping who you label illegitimate patients. And they’re only decreasing the number of overdoses by a small percentage. Criminalizing the use of any drug, including opioids, is the main problem, and PDMPs help do that.

      Pain patients should be fighting for their rights, not allowing them to be trampled on by the drug war.


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