Far from being wonder drugs, opioids are powerful narcotics that provide a short-term fix for treating symptoms, without addressing most underlying causes. If we’re not careful, the steps we take to treat the opioid epidemic could go the same route, with the same sad results.
There are now literally hundreds of lawsuits against all the perceived villains in this crisis. For an issue this systemic, it’s justifiable to spread blame so wide. But if we are to satisfy our desire to help — not just achieve retribution — then any grand settlement must do more than just hit the right pocketbooks. It must ensure these massive payouts are spent in a way that will address the root causes of the crisis.
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The opioid epidemic is a microcosm of the broader dysfunctions within the U.S. health care system: our volume-driven, fee-for-service primary care model; the misaligned incentives of our pharmaceutical supply chain; irresponsible and unethical advertising standards; and finally, poorly managed employer-sponsored health insurance — the accelerant that took this problem from flame to conflagration.
Fee-for-service health care leads inevitably to overtreatment, given its reimbursement-based incentives to perform ever more tests, schedule more procedures, diagnose more conditions and prescribe more drugs. Given the consequent backlog of documentation required for practices to receive reimbursements, primary care suffers especially hard under the fee-for-service model. Doctors lack the time to truly talk to and understand the needs of their patients, and it’s all too tempting to write out a prescription in search of a quick fix. If the pills might help, they might as well be tried.
The real fix, however, is “value-based primary care,” which ensures payment is aligned with patient outcomes, not the volume of services provided. Any comprehensive settlement should guarantee that opioid overuse sufferers receive the best evidence-based care for what is a lifelong chronic condition.
This model also requires better sharing of information between all the types of coverage employers provide, including workers’ compensation. By combining the data-sharing tenets of value-based care with merged medical, pharmacy and workers’ compensation claims (all of which are now generally separate), inappropriate or duplicated prescriptions will be easier to flag. A common database can also provide a valuable source for drug manufacturers to see how their medications are being used, as well as guard against fraud, waste and abuse.
Along with workers’ comp, we’ll need to address an entirely different type of compensation — that between drug manufacturers, distributors, pharmacy benefit managers, pharmacies and insurers. There are incredibly rigorous rules regarding the compensation that physicians can receive from drug manufacturers. Yet many other players in this space — like the middlemen PBMs and insurers that negotiate “discounts” that never reach patients’ pocketbooks — don’t have the same disclosure requirements that should be inclusive of pricing, rebates and various compensation schemes to those in the supply chain. Similar rules should extend to all parties that share a financial stake in marketing or distributing opioids.
From the supply chain to the examination room, patient education and informed consent should be required for all opioid prescriptions. Equipping individuals with the right information also means unburdening them from misinformation — which should be accomplished by eliminating direct-to-consumer pharmaceutical marketing.
Countless 30-second ad spots have trained Americans to seek immediate relief for their every medical need, impairing physicians’ freedom to properly prescribe based on true medical needs. When combined with physician compensation that is unduly predicated on patient satisfaction scores, patients demanding a quick fix can put severe pressure on physicians to prescribe medications they wouldn’t be inclined to otherwise.
Finally, and perhaps most tragically, employers have become unwitting accomplices and enablers of the largest public health crisis since the 1918 flu epidemic. Overwhelmingly, those suffering from opioid overuse disorders are of working age or the dependents of current workers. It’s their dollars — paid out to employer-funded health insurance and funneled into a broken system — that have provided the resources needed to fund the astounding growth in opioid prescriptions. Even today, a quarter of all individuals in employer-based plans receive at least one opioid prescription every year — even though opioids usually aren’t the best evidence-based approach.
System change is a tall order. But we’ve successfully effectuated this kind of broad-scale transformation before — amid similar circumstances, and even alongside the same individuals. In the 1990s, Mississippi Attorney General Mike Moore took big tobacco to task for its role in a consumer scam that spanned multiple generations and spawned a paradigm shift in the way Americans think and talk about smoking today. The settlement, which forced tobacco execs to pay out to the tune of $246 billion, saw Moore rallying and mobilizing nearly all states in a sweeping class-action lawsuit, catalyzing a multi-industry transformation in the marketing, distribution and cultural perception of tobacco products.
Today, many of the same players are back to do for the opioid crisis what they did with the tobacco settlement. And we, in turn, need to do with the opioid settlement what opioids haven’t done for patients: catalyze long-term, broad-scale solutions — not just make things feel better for a little while. The time is now or never to get this right.
Dave Chase is co-founder of Health Rosetta, which accelerates adoption of simple, practical, nonpartisan fixes to our health care system, and he is also the author of the upcoming book “The Opioid Crisis Wake-up Call: Health Care is Stealing the American Dream. Here’s How We Take It Back.”
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