By DAVE CHASE
Today’s opioid crisis is one of the most dire side effects driven by our dysfunctional U.S. healthcare system. A recent JAMA Surgery report found that many surgeons prescribe four times more opioids than their patients use. This opens the door for misuse and abuse later on. In fact, the total combined cost of misuse, abuse, dependence and overdose is about $78.5 billion.
Unfortunately, there’s a direct connection between the low-quality care many patients receive, and the astounding rates of opioid addiction. Often, insurance plans offer access to high-cost, volume-centric physicians and include high deductibles — creating an expensive cycle that doesn’t focus on patient outcomes. Instead of taking the time to figure out what is actually ailing a patient, these overworked and nearly burnt-out doctors get them in and out the door with a referral and a prescription for more pills than they could ever need.
What may surprise you is that employers play a large part in setting the stage for addiction. Millions of Americans get their health insurance from their employer, and a majority of those plans are fully-insured. To determine what insurance plan they offer, employers work with a benefits broker to purchase one from a carrier like Aetna or Cigna. Each year, employers and their broker join together for an annual dance — the broker tells them that healthcare costs are rising so their insurance rates have gone up, usually by 5-20 percent. The employers don’t know better than to accept these increases, filtering them down to employees in the form of higher premiums. Despite costs constantly going up, the quality of care does not follow.
The reality is, cash prices for healthcare services haven’t actually gone up by much. Employers have been asleep at the wheel — but they can begin to enact change immediately. By working with a transparent benefits advisor, employers can design health insurance plans that incentivize their employees to visit high-quality, value-based primary care providers and Centers of Excellence: organizations with proven records of positive patient outcomes that are less likely to overprescribe unnecessary, addictive drugs.
Most employers trust that their broker has done their research, shopping around for the most affordable and effective health plans. Unfortunately, some benefits brokers don’t have their clients’ best interests at heart. They may be following hidden financial incentives to keep employers on expensive plans with poor offerings because they receive commissions and bonuses from certain carriers. Employers should ask their brokers to disclose this information (it should include whatever bonuses their office receives from carriers, which heavily influences what they present to clients), and also see how quickly they are willing to meet. The sooner they are able to, the more time they can go through the pros and cons of multiple plans before making a final decision.
When comparing plans, it’s important to keep in mind that high cost does not mean high quality. And further, most status quo plans cover the same low-quality care that has largely led to the opioid epidemic. Poor primary care is a product of the fee-for-service model under which most primary care practices operate. In this system, the more tests, procedures, scans, and other services a physician orders, the more money their organization makes — and employers and patients pay for. Many of these are unnecessary and often require follow-up or referral appointments. More people needing to see a doctor means it takes longer to make an appointment, waiting rooms are crowded, and the appointments themselves are usually ten minutes or less.
Short appointments prevent physicians from having enough time to get to the root cause of a patient’s problem. And because lower back pain (LBP) is a common issue, especially among older and working adults, physicians hoping to satisfy patients quickly prescribe them painkillers like hydrocodone, oxycodone, morphine or benzodiazepines. This, despite the fact that we know these drugs aren’t effective in treating pain, only masking its symptoms.
By comparison, in a value-based primary care setting, doctors are incentivized to spend more time with patients because they are rewarded for positive outcomes. These physicians have a better chance of getting it right the first time – reducing the need for follow-ups, unnecessary tests, and patient costs. For a patient with LBP, a value-based primary care physician may find out that the patient is sitting too much or isn’t educated on the proper exercises to prevent or relieve back pain. Rather than write an opioid prescription (likely including too many pills), a physician focused on value may show the patient how to change their technique to prevent further damage, plus recommend a physical therapy or stretching program. In my book on the employer role in the opioid crisis, nothing created more fertile ground for the opioid crisis than an undermined primary care model. It’s just one of the twelve major drivers of the opioid crisis, but it’s a particularly critical element to preventing addiction upstream.
This kind of care better employees’ health and for employers’ bottom lines because in order to provide access to value-based primary care, employers can cut ties with their old fully-insured health plans and instead work under a self-funded health plan. This type of plan is one in which an employer pays for their employees’ healthcare using their own money. This may sound risky, but that’s why such employers purchase stop-loss insurance – coverage that kicks in after certain claims thresholds. And for those employers concerned about this being too much work, a third-party administrator (TPA) will process claims and provide administrative support for a monthly fee.
Under a self-funded plan, employers will no longer have to budget for those annual 5-20 percent premium increases. Plus, employers can have more control over the quality of care their employees receive. In addition to encouraging their employees to visit the value-based primary care providers they’ve identified, they could also send their employees who need high-cost, high-risk surgeries to Centers of Excellence, which are often recognized for their high success rates for certain procedures. Employees who go there are likely to save money in the form of fewer complications, readmissions and prescriptions. Boeing did this for its employees, sending those in need of cardiac or spine care and hip or knee replacements to Mayo Clinic in Phoenix and Scottsdale, Arizona.
The health plans employers offer, and the low-quality, status quo care that they provide, have all contributed to today’s opioid crisis, including rampant overprescribing. Fortunately, a solution exists: health plans that provide access to value-based primary care. All employers have to do is put it in motion.
Dave Chase is co-founder of Health Rosetta, which aims to accelerate the adoption of simple, practical, non-partisan fixes to our health care system, and the author of “The Opioid Crisis Wake-Up Call: Health Care is Stealing the American Dream. Here’s How We Take it Back.”