Reducing Doctor Shopping Via Insurance Reimbursement Lock-In Programs
Some individuals engage in “doctor shopping” to obtain large quantities of prescription opioids to use or sell. One large U.S. study found that a small proportion (0.7%) of individuals prescribed opioids were apparently doctor shoppers, averaging 10 prescribers and 32 prescriptions. This practice poses grave risks to participants, including legal penalties, addiction, and overdose.
- Even when doctor shoppers are not detected by prescribers, they can be identified by the insurers who pay for prescriptions. Insurers can respond by restricting (“locking in”) reimbursement to a single prescriber or pharmacy for some period of time.
- Reimbursement lock-in authority was recently granted to the Medicare program and has been employed in most state Medicaid programs. It could also be attempted by private insurers.
- However, reimbursement lock-in can be surmounted if the individual has another reimbursement option, like cash or a second insurer.
Reimbursement lock-in programs are a simple and cost-effective method of intervening with individuals who obtain very large quantities of opioids from multiple prescribers or pharmacies.
Collaboration across insurers may increase the effectiveness of lock-in programs so that individuals can’t evade them by switching payors. This way, high-risk individuals (e.g., those who have overdosed) are more easily detected.
Key Policy Evidence:
- State-level evaluations generally find that being placed in a reimbursement lock-in reduces Medicaid enrollees’ number of opioid prescriptions, prescribers, and pharmacies.
- Studies in Connecticut, Iowa, and North Carolina estimated that lock-in programs reduced statewide prescription costs by a few million dollars per year.
- Some evaluations have reported that lock-in programs reduce emergency room visits.
- A 2008 study estimated that Iowa’s lock-in program saved the state $2 million annually.
- A study conducted in Washington State, whose comprehensive approach to combating the opioid epidemic included reimbursement lock-ins, showed that prescription opioid overdose death rates in Washington declined by 27% from 2008 to 2012, and overdose hospitalization rates declined for the first time in 2012.