The opioid crisis rages on, and there is plenty of blame to go around: pharmaceutical companies, drug distributors, reckless prescribers, the FDA. One entity that has been overlooked is health insurance, whose incentives pushed chronic pain patients to take opioids in the first place.
Check out your insurance plan and the copays you pay for different services. In one of ours, a generic medication costs $10 a month, at most. Physical therapy, which can be hugely beneficial for pain, costs patients $50 per session, assuming you have hit your deductible. Weekly visits would amount to $200 per month, or 20 times the cost of the drug.
It is no wonder chronic pain patients came to rely on opioids.
Making it worse is the fact that non-drug treatments and integrative approaches like acupuncture require more effort: They need time, transportation, and childcare, and may not be covered by insurance at all. But these treatments carry lower risks and more benefits than opioids, which remain a predominant treatment for chronic pain despite a decade of deprescribing. Moreover, the effects of non-drug treatments tend to last. For example, acupuncture has been shown to ease sciatica pain for a year after treatment.
We are chronic pain researchers, and one of us is a chronic pain patient. We understand the challenges that over 50 million U.S. patients with chronic pain must overcome to get the care they need. Many patients do not respond to opioids or other drugs used to treat pain, like gabapentin, and get stuck in a kind of medical limbo, where their doctors exhaust their treatments and feel awkward even seeing them. Those taking drugs can end up with few options.
That is why David Shulkin, the former Department of Veterans Affairs secretary, recently criticized the VA’s continuing reliance on opioids. He called for a more opioid-free approach, relying on integrative therapies and new drugs for chronic pain that appear to be safer. A wider array of pain management is crucial to preventing addiction and suicide, he recently wrote.
The cost of non-drug treatments
Public and private insurers are in a unique position to offer opioid-free approaches to more Americans. But why do they discourage non-drug treatments with higher levels of cost-sharing?
One argument is that treatments like physical therapy and acupuncture cost more than drugs, and those costs should be passed onto patients. But the costs of non-drug treatments pale beside those of common outcomes like spinal fusions, which are more often used to treat back pain in the U.S. than in comparable countries. Studies show that non-drug treatments reduce the escalation of care that brings on more invasive procedures, so in the medium to long run, these treatments may pay for themselves.
Requiring insurers to cover non-drug treatments similarly to drugs has precedent; it is called mental health parity, and it requires insurers to cover mental health similar to physical health.
The quickest way to achieve parity is to reduce copays for non-drug treatments so patients are properly incentivized. Researchers have shown that higher copay amounts drive the decision to use physical therapy versus opioids.
Bringing back interdisciplinary care
There is a second reason why insurance is partly to blame for the opioid crisis. The gold standard for chronic pain management typically uses many modes, drugs and non-drugs, which used to be provided by interdisciplinary pain clinics that convened physicians, physical therapists, and other providers for patients. Because of low reimbursement rates, among other factors, these pain clinics began disappearing in the 1990s. We used to have thousands and now we have fewer than 100. Opioids filled the void.
Insurers can bring back interdisciplinary pain care. One way is to embrace two payment codes that were recently adopted by Medicare and reimburse providers to manage chronic pain more comprehensively, from screening to treatment. This would give providers the time to walk patients through the risks and benefits of drugs versus non-drug treatments.
Another option is for insurers to move to bundled payments to pay for pain management, where providers are given a lump sum for a patient that covers a multimodal approach, including drugs and non-drugs. A prime example of this comes from BlueCross BlueShield in Vermont, which used bundled payments to cover a 16-week program for chronic pain patients.
You may wonder why insurers would agree to encourage non-drug treatments. Because they work better in the long run. Acupuncture, which involves inserting thin, sterile needles into specific points, treats chronic low back pain so well that Medicare started covering it in 2020. But reimbursement rates remain low and most licensed acupuncturists are not allowed to bill Medicare directly, deterring uptake.
Our final recommendation is to lobby your employers to cover non-drug treatments similarly to drugs and to urge them to help bring back interdisciplinary pain management. Most Americans get their insurance through work, and their employers pay directly for the health care their employees use. We know of at least one large employer that began covering acupuncture at an employee’s request.
To end the opioid crisis, we need to remember why it started in the first place: poorly treated pain. Incentivizing chronic pain patients to use non-drug treatments is an important next step.
Molly Candon is a health economist and patient advocate. Daniel Clauw is an anesthesiologist.
