Working directly with sick or injured claimants offers disability claim analysts a unique perspective on the prevalence of opioid pain medications for treating chronic pain.
On one hand, the use of narcotics to manage symptoms can be helpful in determining the severity of the claimant’s condition and impact on their functionality. On the other hand, given the national opioid crisis, number of overdose deaths, and links to illicit drug addiction it begs the question “Is opioid use for pain management worth it?”
Given the alarming rise in opioid addictions and fatalities, insurers are now choosing to play a role in addressing the problem. While the industry is trying to become part of the solution, claims management faces new challenges when assessing treatment plans focused on alternative pain management options.
Finding consensus on what constitutes “appropriate care” is key for effectively managing disability claims related to chronic conditions requiring pain management.
What Is Chronic Pain?
The current Centers for Disease Control (CDC) criteria for chronic pain is “pain lasting greater than 3 months or pain that is in excess of expected recovery time”.  Meanwhile Merriam-Webster defines “chronic” as “(of an illness) persisting for a long time or constantly recurring”. Based on the literal definition of “chronic” the CDC’s criterion of 3 months seems to fall short of what should be considered “long term”.
For those suffering any amount of chronic pain, it can be debilitating. According to the CDC, about 11% of American adults experience pain on a daily basis. Finding relief from ongoing symptoms and regaining some level of function is clearly a priority. However the potential risk associated with opioids for pain management is not insignificant given the statistics.
The Opioid Crisis by the Numbers
According to research by the National Institute on Drug Abuse, the U.S. averages 115 deaths daily due to opioid overdoses. Here are a few more key statistics to consider:
- Roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them.
- Between 8 and 12 percent develop an opioid use disorder.
- An estimated 4 to 6 percent who misuse prescription opioids transition to heroin.
- About 80 percent of people who use heroin first misused prescription opioids.
The use of opioids for pain management is increasingly common among the disabled population. For example, more than 40% of Social Security Disability Insurance (SSDI) recipients are on opioid pain relievers, with 20% deemed chronic users of opioids.
The Insurance Industry’s Role
Blame is most commonly pointed at the pharmaceutical industry for misrepresenting their products and the insurance industry for limiting treatment options. Physicians also clearly play a role, as well as the patient themselves who ultimately must choose what course of treatment to follow given their unique situation. Regardless of who shoulders the blame, the government is now enforcing strict guidelines around the prescribing and use of narcotic medication.
Meanwhile the larger health insurance companies are not turning a blind eye to the opioid crisis. In a November 9, 2017 Forbes article it was announced that 16 health insurance companies have banded together to address the opioid crisis. Some of the participating companies include Aetna, Anthem, Inc., Magellan Health and UnitedHealth, estimating coverage of over 248 million patient lives. The group modeled eight principles based on the findings of Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health from 2016 that included recommendations based on extensive research in the field of addiction.
Cigna has also recently outlined a new drug prevention and treatment strategy in targeted U.S. communities. The plan will initially focus efforts in specific locations where the insurer has a large client base, and where there is a higher than average overdose rate. Cigna has enlisted employers, customers, prescribing clinicians, pharmacists and community-based organizations with a goal of decreasing the number of opioid overdoses by 25 percent among its commercial customers by December 2021.
At a high level, insurance companies are developing creative ways to integrate medical providers, local support programs and the insureds themselves in an effort to change the status quo, but how does that trickle down to the claim analysts in the trenches?
The new government guidelines will impact current and future chronic pain sufferers. Already we are hearing claimants complain that their doctor will no longer prescribe their pain medications and are instead recommending alternative treatment options.
Historically, if an insured is on multiple narcotic pain medications it may indicate that their pain complaints are validated by a medical professional; at the very least, even a non-clinician can deduce that the insured would have impaired functionality by virtue of the known side effects of narcotic use.
However, going forward clinicians and analysts will no longer be able to use prescription pain medications as a gauge for impairment. The insurance industry will need to come to terms with alternative treatment methods such as medicinal marijuana, nutritional supplements, acupuncture, chiropractic manipulation, exercise, mental health therapy and stress reduction, to name a few. With that being said, the level and intensity of treatment should be such that it reflects the severity of the subjective pain complaints.
The challenge for the insurance industry will be redefining what “appropriate care” means, determining the new criteria, and implementing them consistently across all product lines. If the guidelines are not clearly defined, clinicians and analysts will be unable to consistently administer or implement any change in current claims management.
Having worked intimately with a variety of insurance carriers in multiple product lines, I have yet to see any changes in the industry’s philosophical view on what constitutes appropriate care for chronic pain sufferers. Given the risks associated with opioid use for pain management, it’s time to reset expectations around appropriate care.
I look forward to witnessing the resulting changes to claims administration that will lend clarity around our handling of chronic pain-related conditions.