The opioid crisis roller coaster continues. And if all the events leading up to this point were just us slowly progressing bit by bit up the steepest incline, we might have just reached the tipping point.
This week, 60 medical professionals and pharmacists were charged for their role in pushing excessive opioid prescriptions—more than 350,000 scripts and 32 million pills—and committing healthcare fraud. Assistant Attorney General Brian Benczkowski, head of the Department of Justice’s Criminal Division whose Appalachian Regional Prescription Opioid Strike Force conducted the investigation, said, “You can rest assured, when medical professionals behave like drug dealers, the Department of Justice is going to treat them like drug dealers.”
But if these actions were outright criminal, how do we think about those who have been merely negligent, like the employers from whom millions of Americans get their health insurance and who ignored all the warning signs from some of these very physicians, nurses and pharmacists?
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The majority of employers have been unknowingly contributing to the opioid crisis. They spend nearly $20,000 for family healthcare coverage per employee, and instead of taking a closer look at what exactly they’re paying for, most just accept whatever their insurance carriers put forward. As a result, employers keep forking over billions of dollars for the expensive, low-quality care that floods our system with deadly, addictive opioids—130 Americans die each day—and face a growing legal risk from wrongful death lawsuits by surviving family members who have lost a loved one to an overdose.
Here’s how this poor-quality care happens. Most employer plans cover care that utilizes a fee-for-service payment model in which there’s no connection between costs and outcomes. Patients are billed for every service/procedure/scan a physician orders, even if they’re unnecessary and inefficient, and physicians are incentivized to find quick, easy answers. This system is extremely expensive for both employers and patients, it’s rarely thorough and it frequently forces patients to make follow-up and referral appointments because their condition didn’t improve the first time.
Perhaps the greatest example of how this low-quality care directly contributes to the opioid crisis is the treatment of lower back pain, which 80% of adults will experience at some point in their life. Lower back pain is the second most common reason people visit the doctor, and it’s one of the top drivers of opioid prescriptions even though they aren’t effective in treating the root cause of someone’s pain, just masking its symptoms. Nevertheless, physicians hoping to satisfy patients rarely think twice about sending them to the pharmacist for relief.
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So how do we fix it? By changing the behavior of those same employers.
It starts with paying for value, not volume. Employers should work with non-conflicted benefits advisers to identify value-based care centers in which physicians are rewarded not for how many tests they order, but for how positive their patient outcomes are. Physicians operating under this model can spend more time with patients and are more likely to offer alternative treatment options to problems like lower back pain.
Instead of prescribing painkillers, they might recommend physical therapy or help the patient identify what lifestyle factors (lifting, sitting, etc.) could be causing that pain. Great side benefits of employees receiving proper care include far better health outcomes and a greatly decreased risk of addiction, and employers such as Rosen Hotels & Resorts are spending 55% less than the average employer on health benefits.
Once employers have this new plan in place, they can encourage their employees to use it by waiving co-pays for their visits to the value-based physicians they’ve identified. They can make smart healthcare decisions free or nearly free and make decisions that will likely lead to low-quality care and perhaps opioid addiction cost a pretty penny.
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Some employers worry that this will put them in the healthcare business, to which I respond, “You already are.”
Healthcare is the second-largest cost item in many companies. It’s easy enough to outsource claims processing to an independent third-party administrator, and stop-loss insurance—coverage that kicks in after a set amount—provides a backstop against truly catastrophic claims.
Right now, we’re in a pivotal position. The federal government is going after the criminal actors, but much more will be needed to fix the rest of this broken system. Can we really prosecute and punish our way out of this problem? Or, do we go about slaying this healthcare beast once and for all by changing the very way healthcare is procured, produced and received? I choose the latter.
Dave Chase is co-founder of Health Rosetta, which aims to accelerate the adoption of simple, practical, nonpartisan fixes to the U.S. health care system, and author of “The Opioid Crisis Wake-Up Call: Health Care is Stealing the American Dream. Here’s How We Take it Back."