POINT OF VIEW: How insurers can help fight the opioid epidemic

Of the 98 million Americans who take prescription opioids each year, almost 3 million receive their prescriptions from five to as many as 20 physicians.

The practice, often called “doctor shopping,” allows opioid-addicted individuals to consume an enormous and dangerous number of pills with the unwitting help of doctors. Doctor shopping also lets drug dealers use the health care system to subsidize their business.

Fortunately, state Medicaid programs have developed a simple fiscal policy that reduces the problem - and it could even more effective if adopted across all insurers.

Doctor shopping is possible because none of the doctor shoppers’ prescribers knows that they are only one of many providers of opioids. Enter someone with full information: the insurer. Medicaid programs for example can examine all the separate billings and recognize that an enrollee is probably a doctor shopper. This allows the insurer to respond through “reimbursement lock-in,” meaning that the enrollee’s prescriptions for opioids will only be covered if they are written by a single provider of the patient’s choosing.

Evaluations of Medicaid lock-in programs generally show they decrease prescribing of opioids as well as other controlled substances, such as benzodiazepines. North Carolina’s program for example, reduced controlled substance prescriptions by 17 percent among Medicaid enrollees who had histories of unusually large numbers of prescriptions and prescribers.

Reducing prescriptions reduces costs to the payer, who in the case of Medicaid is ultimately the taxpayer. Locking patients with many prescriptions into single providers should also benefit patients by reducing their risk of overdose. However, in unusual situations lock-in could pose difficulties. For example, if patients suffered injuries while on vacation and needed an opioid prescription, the doctor who treats them may have difficulty reaching the approved prescriber back home.

Reimbursement lock-in programs can be evaded. Some individuals make cash purchases to surmount them. Other individuals covered by more than one type of insurance (e.g., the more than nine million individuals covered both by Medicare and Medicaid) may simply shift some of their prescription reimbursement enough to stay below lock-in thresholds. This tactic will become harder in 2019 when Medicare is slated to adopt reimbursement lock-in programs, and would become harder still if all private insurers followed suit.


Editor’s note: Humphreys is a professor of Psychiatry at Stanford University. He wrote this for The Washington Post.

Reader Comments ...

Next Up in Opinion

Editorial cartoon
Editorial cartoon

POINT OF VIEW: A solution to Florida’s dentist shortage

In 2016, nearly 167,000 Floridians with preventable dental diseases showed up in emergency rooms across the state. As a public health dental hygienist, I try to reach many of these individuals: Medicaid patients, patients on private insurance and patients with no insurance at all. Dental hygienists do much more than “clean teeth.” We are...
Letters Take responsibility for own decisions

Take responsibility for own decisions I am always amused by the various complaints about train/airplane/traffic noise lodged by those who choose to live near the source and their demands for relief. If one makes the conscious decision to live near the source of which they complain, they need look no further than the mirror for someone to blame. And...
Opinion: What is the real message of #MeToo?

The feminist website Babe published an account of a date gone bad. The pushback has been swift and sharp. I share some of the concerns of the critics, but I also think young women are sending a message that is being missed. The account by the anonymous “Grace” about a bad date with comedian Aziz Ansari was, if not “3,000 words of...
Editorial: County can ensure women, minorities fair cut of contracts
Editorial: County can ensure women, minorities fair cut of contracts

Palm Beach County isn’t wasting time. About $40 million of the money collected from the 2016 sales tax increase already has been spent, says County Administrator Verdenia Baker. A road project here, some bridge work there — it doesn’t take long for the expenditures to add up. Unfortunately, it’s still business as usual in the...
More Stories