Health Plans Join Prescription Painkiller Abuse Battle

Christopher Cheney, for HealthLeaders Media , May 7, 2014

BCBS of Massachusetts' prescription policy also requires physicians to start pain medication prescriptions with short-acting formulations, which are generally less addictive than long-acting drugs. The policy shift, which applies to all members except cancer patients and the terminally ill, has resulted in a 50 percent reduction in prescriptions for long-acting painkillers, Dodek says.

And the health plan sends monthly letters to physicians about members who may be "pill shopping" for pain medication from several doctors simultaneously. "We see that in our claims pretty quickly," he told me, noting prescription claims are processed in real-time.

Another payer, Aetna, has launched "active surveillance" efforts on its members to help ensure that pain medications are not abused or diverted, Edmund Pezalla MD, MPH, the company's national medical director for pharmaceutical policy and strategy, told me this week. "We're looking for those [members] who have been getting a lot of narcotics at higher doses," he said. "We have a pharmacist who looks at this."

Pezalla says Aetna, which has 22.7 million medical insurance policy members and more than 600,000 physicians in the company's healthcare networks, reaches out to patients when painkiller abuse or diversion is suspected. "We offer patients counseling. We try to get to the patients, and assume they are people who need help." He notes that the health plan covers substance abuse treatment programs and can restrict a member's access to painkillers. "We can limit them to a single pharmacy or a single doctor."

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