At some point in their lives, 80 percent of adults will experience lower back pain. It’s the second most common reason that adults see a doctor and the most common reason for disability. It’s also a microcosm of all the things that are wrong with the U.S. health care system, including its contribution to the opioid crisis.
Having experienced lower back pain myself, I know that it can be truly debilitating. I would have done almost anything to rid myself of it. Lower back pain puts people in desperate and vulnerable positions, and it puts doctors under pressure to Do Something Now. From such a confluence arise many poor and potentially devastating treatments and choices.
Among the worst is doctors’ decisions to write opioid prescriptions as a treatment for lower back pain and their patients taking these drugs. Lower back pain is one of the most common reasons for an opioid prescription, but here’s the kicker: There’s no evidence that opioids are effective at treating this problem.
At best, opioids mask pain in the short term. It’s like turning up your car’s radio to drown out the horrible noises coming from under the hood while you drive: The radio might distract you, but the car’s underlying problem isn’t getting addressed and could cause serious harm. And taking opioids for lower back pain often means its cause is being ignored.
A trio of papers published last year in The Lancet examined global issues in the prevention and treatment of back pain. One of them confirms the prevalence of opioids in treatment, saying, “Non-evidence-based practice is apparent across all income settings; common problems are presentations to emergency departments and liberal use of imaging, opioids, spinal injections, and surgery.”
What works best for lower back pain is a combination of education and proper exercise, not the overprescription of opioid painkillers. Yet to this day, health plans pay for such non-evidence-based interventions like opioids and make it difficult and expensive for patients to access evidence-based interventions such as physical therapy. That doesn’t make sense until you look at the reason: For the carriers that administer health insurance plans, there is far more profit in pills than physical therapy. (This also explains why the three largest pharmacy benefits managers have recently merged with insurance carriers.)
Our entire health care system is built on a vast web of incentives that push patients down the wrong paths. And in most cases it’s the entities that manage the money — insurance carriers — that benefit from doing so. They negotiate prices with health systems and pharmaceutical companies, all of which share the objective of increasing revenues, to craft and sell health plans that offer trumped up “discounts.” As long as carriers negotiate a high price with a provider or a rebate scheme with a drug maker, they can still make a sizable profit even after a 50 percent discount.
This dynamic was accelerated by the Affordable Care Act’s Medical Loss Ratio, which requires that 80 percent of insurance premium dollars pay for medical expenses and that carriers pocket only 20 percent. It doesn’t take much to see that the higher the premium, the more they make from that 20 percent.
By being more concerned about profits than patients, most insurance carriers’ plans are flooding our society with addictive drugs. And employers are blindly buying in.
There is an alternative, and some innovative employers have already taken action.
Rosen Hotels, for example, created a health plan for its employees that prioritizes proper primary care to better meet their needs — lower back pain among them. A key component of the company’s health plan is that instead of sending employees to volume-centric providers like status quo carrier plans do, it sends beneficiaries to value-based primary care physicians who are rewarded for positive patient outcomes and who prescribe treatments to address pain over pills.
Among the many benefits Rosen Hotels saw from this, one of the most impressive is that despite having employees with physically demanding jobs, the company was able to reduce opioid prescriptions so that they are one-sixth of those seen among employees of most other U.S. companies.
An estimated 700,000 people are likely to die from opioid overdoses between 2015 and 2025, making it absolutely essential to understand the connections between insurance carriers, health plans, employers, the public, and the opioid crisis. We will never get out of this mess unless we stop addiction before it starts, as Rosen Hotels is doing.
The core thesis of my latest book, “The Opioid Crisis Wake-up Call,” is that the opioid crisis isn’t an anomaly. It’s a side effect of our health care system. And while the enormity of the opioid crisis can certainly be discouraging, there is a silver lining: Since it is a microcosm of even larger health care dysfunction, those who are able to use their health insurance plans to tackle the opioid crisis can simultaneously solve health care’s systemic problems.
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” (Health Rosetta Media, September 2018).