An opinion piece by Dr. Thomas Cohn
I spent Friday evening with my staff trying to get authorization for medications for one of my patients. The process started on Wednesday when we changed the opioid dosing to a more logical plan based on the needs of the patient. That is when the problem started with the insurance company. We obtained the first authorization for the long-acting medication, then the change for the short-acting medication was refused since the insurance company decided it was too high a dose for a month. We were given a peer review and scheduled a time for the review, but the insurance company physician did not call. We then were finally told on Friday at 3:00 p.m. that the doctor would talk to us and we called immediately.
This was a total sham, the doctor read the insurance company guidelines and said he had no ability to change what was written. Since I have done many reviews as both the reviewer and the one asking for review, the person reviewing can tell the insurance company the rationale for any decision for a patient if medically indicated. It did not seem like anyone at the insurance company cared about the patient.
Villianizing the Patient
For starters, a few patients have very significant medical conditions that may be appropriately treated with opioids. For cancer patients, there is no question that it is within reason to treat with these medications. Some patients also have severe medical conditions that are causing progressive deterioration of the body and likely will lead to death eventually, and opioids also are reasonable. Lastly, some patients have failed every other treatment or surgery and were left with such significant body dysfunction that opioids are the only thing that helps manage pain. These patients are extremely compliant, not abusing their medications, and are being treated by reputable providers, not pill mill doctors. Unfortunately, this patient fell into the class of having a nasty progressively deteriorating neurological condition that has been causing significant pain as well as difficulty with daily activities.
Trying to obtain understanding for the patient who needs medications is supposed to be relatively straightforward. There are guidelines on prescribing to reduce using medications inappropriately, especially in acute settings for starting an opioid regimen. For patients who have legitimate uses for these medications, they are supposed to be able to obtain them if the physician feels it is indicated. Again, this patient appears to have a very significant neurological disorder affecting the whole body, and it is causing significant pain that other treatments will not stop and other medications do not help.
As a pain physician, I was being asked by her other doctors to manage the pain medications. Being board certified in pain, one would think recommendations for medications would have good reasoning as well as being up-to-date with concerns of abuse. If another board certified pain physician saw the recommendations made, I am sure they would agree on the treatment. So when a peer review occurs and the physician says he can do nothing, it is clearly not a well-trained physician and they should not be reviewing such a complex case. The insurance company should fire such doctors from their review panels. Furthermore, it can put a patient in jeopardy since needed medications are not obtainable.
The insurance company also had a major fail in patient management. The doors close at 5:00 p.m. on Friday. All the phones start rolling over to automated voice call systems. There is no emergency contact person available to obtain authorizations. There is no contact person for any information so the patient can obtain the necessary treatment. Friday and the weekend comes, and you are out of luck.
The most infuriating aspect of the process is no one seemed to care at the insurance company, the pharmacy benefits company or the patient’s pharmacy. I was totally insulted by the Walgreen’s pharmacist who implied that they could not prescribe because physicians like me were causing the opioid abuse problem and patients like the one receiving the medications were obviously abusers. Statements like that are divisive and show clear ignorance and bias. Legitimate pain patients should not be made victims and neither should their physicians.
The opioid crisis is a problem related to addiction and only minimally related to pain management. In pain practices run by board certified physicians that are providing full service management strategies, opioid abuse is likely less than 5 percent of those patients using medications. When the need is legitimate, pain physicians should be given the ability to make the right recommendations and not need to waste time on approvals versus providing treatment. There are very few specialists in pain care, and providing appropriate medication management by these physicians should be encouraged.
Beyond just prescribing, the insurance companies need to step up and pay for the complex solutions like injections, behavioral health interventions, physical therapy, health clubs, dieticians and other integrative approaches to pain management. The patient and the physician trying to develop appropriate treatment plans should not be stymied but encouraged. The chronic pain patient and board certified pain physicians are not the cause of the opioid crisis. The opioid crisis is really a crisis that started from the lack of treatments for pain. Find the solutions for pain and the addiction crisis will start to crumble. Until we understand pain management, we may continue to have a opioid abuse crisis.