Stopping opioid overuse starts with primary care

The opioid crisis can be understood in a lot of different ways. It’s been described as a failure of policy, the collateral damage in the pursuit of irresponsible profits, or just the latest trend in an eons-old cycle of addiction. But one area that has not received enough scrutiny is the very nature of how healthcare is delivered and paid for in the United States.

While it’s hardly breaking news that these are problems in healthcare, the extent of their collateral damage is less well known. The continuation of fee-for-service delivery models — where insurers pay providers based on the quantity of the services administered, not the likelihood of those services’ efficacy — has initiated a cascade of unintended consequences. The opioid crisis is only the most recent and visible manifestation.

Yet precisely because of this crisis’ overwhelming visibility, the keys to fixing health care are hiding in plain sight. And the primary bulwark in the fight against opioid overprescription and misuse is value-based primary care.

In value-based primary care, providers contract directly with insurers, unifying the providers’, insurers’, and patients’ economic incentives to achieve a shared set of goals: lowered costs and improved outcomes across the board. It’s an uphill battle, to be sure. Too often, poor access to local providers (as seen in many rural areas) and prevent us from receiving the lowest-cost, highest-quality care.

Not only that, the incentives inherent in value-based primary care reward doctors for spending more time on individual appointments. It’s the direct opposite of the traditional model, in which more patients mean more treatment and more treatment means more money.

Even great people, when working inside a flawed system, will struggle to succeed. That’s what makes it so vital that we incentivize physicians to take up these value-based primary care models, and incentivize traditional payers to climb on board. If insurance organizations remain lukewarm, businesses will need to follow in the footsteps of General Motors, Boeing, Cisco, Intel, Walmart and others: going it alone by contracting directly with high-performing healthcare organizations.

Employers continue to serve as the de facto insurance companies for the overwhelming majority of working-age Americans and their dependents. With the help of appropriately compensated benefits consultants, employers turn a discerning eye toward the insurance policies available to them and locate where the value lies among the providers in their community, they can make more informed benefits decisions that lead to more effective care solutions, higher rates of employee wellness, and even a better bottom line.

Should payers hope to compete against business’ direct-to-provider contracting models, they’ll need to do as these organizations have done, and discourage providers from over-prescribing opioids for acute or post-surgical pain. In the first place, this means limiting coverage of opioid prescriptions to a period of several days. Even more importantly, however, it requires supplementing this shortened window by expanding benefits for physical therapy and other treatment options — ones that are scientifically demonstrated to reduce the actual causes of pain.

Recently, the Center for Disease Control (CDC) released new physician guidelines for prescribing and monitoring opioid use. These new guidelines, more specific and comprehensive than past recommendations, lower the threshold at which providers are advised to exercise caution, provide specific recommendations on balancing the benefits and the risks of prescribing opioids to particular populations, and focus on monitoring all patients — not just high-risk ones — for signs of opioid tolerance or dependence.

The guidelines are firm but sensible. They advocate for the primacy of what were once deemed “alternative” pain treatment measures over and above opioid prescriptions, while still conceding that there are indeed instances in which opioids provide an optimal solution for short-term pain management.

We need to remove opioids from their unduly privileged position as a first recourse in treating pain. We can reverse the trends driving more and more Americans to obtain unwarranted access to, and become unnecessarily hooked on, these deadly substances.

By leveraging their purchasing power, executives, physicians and other healthcare professionals all across America are re-seating local and independent value-based primary care at the helm of our health care model. While progress has been and is being made, much more is needed. It’s up to employers and the healthcare system to lead the way.

Dave Chase is co-founder of Health Rosetta, which aims to accelerate the adoption of simple, practical, non-partisan fixes to our health care system. He is also the 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).


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