Health insurers should stop paying for painkiller abuse

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The contents of the nation's medicine cabinets are likely impacting the cost of your health insurance .

Back in 2007, the Coalition Against Insurance Fraud (CAIF), an alliance of consumer groups, insurance companies and government agencies, reported that misuse of prescription painkillers was costing health insurers more than $72.5 billion a year.

That figure likely has become much higher, since the number of people abusing opoids -- drugs intended to alleviate pain -- has been steadily rising. The most commonly abused opioids are oxycodone , marketed under the brand name OxyContin, and hydrocodone , marketed as Vicodin.


Indeed, last year the Centers for Disease Control and Prevention (CDC) issued a report in which it said the abuse of prescription painkillers had grown to "epidemic" proportions .

Here's a chart on commonly abused prescription drugs from the National Institute on Drug Abuse.

Statistics are alarming

"According to the CDC report, more people now die from misuse of prescription painkillers than from cocaine and heroin combined," says James Quiggle, spokesperson for CAIF.

The problem affects people of all ages and from all economic groups, Quiggle says.

Some people who become addicted to painkillers "doctor shop": They visit different doctors to get multiple prescriptions for the same drug. The average doctor shopper can cost insurance companies $10,000 to $15,000 a year, Quiggle says.

"When someone becomes drug-dependent, his insurance company is not only paying for his drugs, but also possibly for his rehabilitation and medical treatment, which adds to the health care costs that everyone helps pay," Quiggle says. Insurance companies must pass along the costs of the drugs and treatment to other customers as "part of their normal cost of doing business."

And those numbers don't include the cost of lost workplace productivity or the costs to the criminal justice system, Quiggle notes.

Burdening the health insurance system

Health insurance companies are aware of the problem and its staggering cost to all consumers, says Susan Pisano, spokesperson for America's Health Insurance Plans. "We strongly agree that prescription drug abuse is a concern, not only in terms of the extra burden on health care but most importantly in terms of patient safety," she says.

Still, painkiller abuse poses a dilemma for health plans. Insurers aren't able to refuse to pay for valid prescriptions that are covered under a policy.

Mary Ann Schultz, spokesperson for Blue Cross and Blue Shield of Illinois, says that if a patient has a prescription from his or her doctor and has drug or pharmacy benefits, the prescription has to be processed. "All medical decisions remain between the physician and patient," she says.

However, Pisano and Quiggle say there are steps that health insurers can take to monitor abuse and help curb it.

They include:

  • Educating providers. "Some make provider education, in terms of the appropriate use of painkillers and those drugs that are more likely to be addicting, a priority," Pisano says. Doctors are encouraged to only prescribe painkillers when they're certain they are necessary.
  • Requiring step therapy. Nicole Evans, spokesperson for the California Association of Health Plans, says many health plans require doctors to start patients on the lowest level of the painkiller that is least likely to be addictive and "to move the patients up only when necessary."
  • Limiting the duration of a prescription. Some prescriptions are not considered valid after six months and can't be renewed without a doctor's re-evaluation.
  • Monitoring usage. Some insurance claims departments and pharmacy benefit managers have data-mining programs to alert them when patients are filling a large number of prescriptions for painkillers or appear to be doctor shopping. "They need to identify patterns of potential abuse, so they can be caught as early as possible," Quiggle says.

More needs to be done

Quiggle says there needs to be more information sharing among insurance companies. Fraud and abuse can be the result of auto insurance, health insurance and worker's compensation insurance all paying for the same painkillers, he explains.

"If insurance companies would systematically share data, they could uncover far more patterns and cases of drug abuse than they are now and they might also discover large rings that are operating that they don't currently see," Quiggle says.

Law and drug enforcement agencies also are addressing the issue, Quiggle says. As of last year, almost every state had adopted or authorized prescription drug monitoring programs that track the distribution of prescription drugs and alert law enforcement officials to potential abuse.



The views and opinions expressed herein are the views and opinions of the author and do not necessarily reflect those of The NASDAQ OMX Group, Inc.



This article appears in: Personal Finance , Insurance

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