On September 17, 2017 The New York Times and ProPublica collaborated on an interesting story. You may have missed it.

As everyone knows, we are in the midst of a horrific opioid addiction epidemic. Physicians are prescribing opiates for pain relief, and patients are becoming addicted to them. One-fifth of patients who receive an initial 10-day prescription for opioids will still be using opiates a year later. That is simply extraordinary.

Physicians are prescribing opiate formulations that are highly addictive. But they do not need to do that.

There are several newer formulations that relieve pain and are far less addictive than older agents. But they are prescribed uncommonly. Why is that?

It is not because physicians are uninformed.

It is because payers will not pay for the alternatives. The less-addictive opiates are more expensive, so payers have declined to support them. Patients get addicted because paying for highly addictive opiates saves the payers money.

The New York Times also noted that the treatment of opiate addiction is expensive. It is far cheaper for payers if physicians continue to prescribe opiates than if physicians enrolled a person into a drug addiction program.

What does that look like? Patients get more prescriptions for opiates instead of getting the help they need.

The Payers Are in Charge

If you are looking for someone to blame for the opioid epidemic, you can certainly blame physicians. You can blame pharmaceutical companies. But while you are at it, don't forget to include payers.

This conclusion should not be surprising. We live in a world where payers -- not physicians -- determine what drugs and treatments patients receive.

If patients have a life-threatening condition, it is not unusual for a payer to demand that a physician first prescribe a cheaper and less effective alternative. Physicians know that the drugs they are allowed to use may not work very well, but frequently, payers demand that they be tried first anyway.

What happens if the patient doesn't respond to the cheap drug?

Often, the physician continues to prescribe it, because -- to gain access to the more effective drug -- physicians need to go through a painful process of preauthorization. For many practitioners, it isn't worth it.

Don't patients eventually get the drugs that they need?

No. All too often, physicians stop trying. Or patients get frustrated and give up. Often, payers says "No!" no matter how many times they are asked. And if the drug is for a life-threatening illness and enough time passes by, then the patient may no longer be alive to demand that they get the right drug.

So we spend more for healthcare than any other country in the world, but Americans do not get the care they need. There is a simple reason. Treatment decisions are not being driven based on a physician's knowledge or judgment. They are being driven by what payers are willing to pay for.

How many people are affected by all of this?

Everyone.

That includes me and my family. That includes everyone that I know.

Medicine has made incredible progress in the last 20-30 years. But you are not likely to benefit from it.

Do you want to blame the high cost of drugs? You can do that, but if you do, you will be missing the point. We should expect better drugs to be more expensive than less effective ones. But we do not expect to have a company decide that we will get the inferior drug simply because they want to make a profit.

Are payers the leading cause of death in the United States? If you think this is a crazy question, please think again.