After decades spent fixing computer systems, I’ve learned one basic rule: when a system keeps producing the opposite result you want, you don’t keep tweaking it—you acknowledge it’s fundamentally broken and start over. Virginia’s Medicaid “double fail” policy is a perfect example of this kind of broken system.
Here’s how it works: if your doctor wants to prescribe a non-opioid pain treatment that’s not on Virginia Medicaid’s formulary, you first have to “fail” on two other medications before they’ll even consider covering a non-opioid. As someone who’s dealt with state policy for years and navigated pain treatment for everything from sports injuries to a debilitating autoimmune disorder, I can tell you this makes no sense—especially given Virginia’s track record.
As AFP staff writer Crystal Graham noted in her April 8th article, “For the first time since 2018, the number of drug overdose deaths nationwide has decreased, and both the state of Virginia and UVA Health are reporting similar trends.” However, Virginia had one of the highest Medicaid opioid prescription rates in the country in 2021, with 14.5 percent of all Medicaid claims being for opioids—that’s 2.8 million claims in a single year. We’re literally leading the nation in opioid prescriptions while simultaneously making it harder for patients to access alternatives. Meanwhile, West Virginia successfully implemented statewide programs specifically designed to reduce opioid prescriptions after recognizing the scope of their overdose crisis.
Think about that. We’ve spent over a decade acknowledging that overprescribing opioids helped create our addiction crisis, with over 75 percent of drug overdose deaths connected to opioid use. Politicians, doctors, and public health experts all agree we need to move away from opioid-first approaches to pain management. So what does Virginia do? Utilizes a policy that essentially forces patients down the opioid path by making alternatives harder to access.
It’s like having a fire safety system that requires you to get burned twice before it will turn on the sprinklers.
When patients are required to try addictive opioids despite newer, safer, FDA-approved options to treat pain, what happens? More chances ( and likely more occurrences) or people becoming addicted to opioids. We’re literally programming failure into healthcare while other states are finding ways to reduce their prescription rates.
This isn’t complicated. If we want to address Virginia’s opioid problem, we shouldn’t continue to operate within a system that steers people toward opioids.
Eric Payne is a non-profit consultant based in Richmond.
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