Editor's Memo: Toxic Insurance Plans
As I write this memo, I have 2 patients who are hospitalized—the first, ostensibly, for seizures and the second for psychosis. Prior to hospitalization, both patients’ opioid prescriptions were only half-filled at the pharmacy because their insurance plans suddenly, without notice or warning, decided to limit drug coverage. In each case, some ancillary medications, in addition to opioids, were totally stopped.
More and more practitioners are encountering patients whose insurance plans have suddenly denied long-standing medication prescriptions. Examples of reasons given include: the plan does not cover compounded agents, brand-name drugs, non-oral agents, or anything used “off-label.” One of my patients, who had 75% of her intestines and rectum removed due to an immunologic disorder, was denied injectable opioids because her plan only covered oral drugs. Her insurance carrier did not even bother to find out why oral opioids were not an option in this patient, and, furthermore, the plan has no intention to accommodate this patient.
When I’ve called insurance plans to advocate for my patients, I usually receive 1 of 2 basic responses: “We don’t deny any drug, we just have limits on what we will pay for” and/or our “expert review committee” has determined that the patient’s pain treatment (no matter how long administered or effective it has been) is not “medically necessary.”
In my opinion, 3 things have become abundantly clear: first, some insurance plans put profits far above clinical safety and effectiveness. Second, physicians have no authority and little sway with many health insurance plans—we can only recommend and advise. And lastly, some insurance plans either disregard, or do not know, that serious toxicity may result from a sudden stoppage or withdrawal of opioids.
Physicians who prescribe opioids must not be a party to any motive to suddenly stop opioid therapy in cases where there has been good pain control. There are basic physiologic reasons why sudden stoppage of opioids may be toxic to the patient.1,2 Five physiologic functions must be altered for a patient to achieve long-term, therapeutic pain control with opioids: gastrointestinal absorption; hepatic-enzymatic metabolism; blood-brain barrier transport, receptor-site binding, and renal clearance.
When these are sufficiently altered to accommodate an opioid to produce good pain control without sedation or respiratory depression, they cannot change or revert rapidly to their prior state without causing complications such as seizures, psychosis, and cardiovascular events. In my experience, significant excess sympathetic discharge—with hypertension, tachycardia, and vasoconstriction—always follows too-rapid opioid reduction. Nausea and vomiting, with the possibility of aspiration, also are a risk. Patients with severe, chronic pain requiring opioids also are likely to have respiratory and cardiovascular impairment. The wise practitioner knows this and never tries to rapidly withdraw, or rotate, opioids in a patient who is doing well.
Where do we go from here? In the short run, we must try to keep our patients in a non-toxic state by substituting inexpensive opioids to replace those that were suddenly withdrawn or reduced, and/or by withdrawal of suppressive agents like clonidine. In the long run, we must encourage patients and their families to be aggressive with their insurance plans. In the past, patients have depended on physicians to be their advocate. Today, patients and their families have to know that practitioners have no authority and can only educate and recommend to insurance companies.
Call me out if you believe I’m wrong, but I have the feeling that many insurance companies have great disdain and mistrust of pain practitioners and their patients. Our patients and their families must now be taught that they are the ones who are paying for their insurance coverage, and they have to directly and forcibly confront their chosen plan if they want adequate pain care. It’s also time we encourage pain patients who require opioids to group together and start demanding their right to such care.