From the
PRESIDENT
ROBERT “BOB” H. COUCH, MD, MBA
GLMS President | [email protected]
To listen to Dr. Couch’s article as a podcast or watch
the video, visit our link on www.glms.org.
LOOK IN THE MIRROR
O
ne of the hardest things to do is to look
in the mirror. It takes courage to look
beyond the reflection. It’s important to
do this because we must examine how we fit
into one of the largest public health problems
facing our city, state and nation.
I’m talking about the opioid epidemic, and it
is an epidemic. We are losing 78 people a day
to this plague. Drug overdose has become the
leading cause of accidental death in the United
States. In 2014, more than 47,000 persons died
from overdose, and almost half of them came
from overdoses of opioid analgesics.
There have been dramatic increases in the
number of opioid prescriptions written in the
last 15 years. In that period of time, the amount
of prescribed opioids has increased four-fold.
There hasn’t been a reported increase in the
amount of pain that our patients are experiencing, but our prescribing practices have changed.
The Veterans Health Administration
launched the “Pain as the Fifth Vital Sign” initiative in 1999. The Joint Commission joined in
the next year, establishing a new standard that
patients have a right to appropriate assessment
and management of pain. The net effect has
been to increase the prescribing of opioids.
The pressure for physicians to recommend
opioids has only increased. In 2002, CMS partnered with the Agency for Healthcare Research
and Quality, another agency in the federal Department of Health and Human Services, to develop and test the HCAHPS survey. HCAHPS is
the Hospital Consumer Assessment of Healthcare Providers and Systems survey which was
the first national, standardized, publicly reported survey of patients’ perspectives of hospital
care. In 2006, this became part of the Inpatient
Prospective Payment System, which required
hospitals to collect and report HCAHPS data in
order to receive their full payment from CMS.
Failure to comply resulted in a two percent
overall payment reduction.
The Affordable Care Act of 2010 required
that HCAHPS performance be included in hospitals' incentive payment calculation as part of
the Value Based Purchasing program beginning
with hospital discharges in October 2012. A
central part of Value Based Purchasing and
patient satisfaction surveys concern how well
a patient’s pain is managed. A 2015 report from
the Hastings Center questioned the utility of
using a patient’s experience of their care to determine reimbursement. The report suggested
that the current institutional focus on patient
satisfaction and on surveys designed to assess
this could eventually compromise the quality of
health care while simultaneously raising its cost.
CMS is paying for patient satisfaction, but
satisfaction is poorly defined. Patients should be
satisfied with good outcomes, but those are not
predominantly measured. Patients or families
might be “satisfied” with interventions that
they want, but are medically unnecessary and
may negatively affect health outcomes. Lastly,
patients may be less concerned with factors that
contribute to their dignity and well-being, such
as good communication among their providers and being treated with respect, than they
are with other factors such as good parking or
designer hospital gowns. The data is lacking on
how these last factors improve outcomes. It is
clear to me, however, that trying to improve
satisfaction by measuring pain control has had
a negative impact.
Where has this gotten us? In the last 15 years,
from 1999 to 2014, the incidence of deaths
from prescription drug overdoses more than
doubled. In that same time frame, the incidence
of heroin deaths increased over six-fold. As
an emergency physician, I see the result of the
opioid epidemic every day. It’s not unusual for
me to see multiple heroin overdose patients in
a single shift in the ED.
How do we fight this epidemic? We take
action. While there are several approaches,
there is no universal solution.
First, CMS needs to delink patient satisfaction surveys from hospital Value Based Purchasing formulas. Their unintended consequence is to pressure physicians to use more
opioids. We need to walk back the idea that
pain is the fifth vital sign. In the ED, I often
see patients who tell me their pain is a “10”,
while eating a sandwich and channel surfing the
TV in their room. We can’t continue to legitimize something so subjective. It is important
to treat pain, but not as an end to increasing
reimbursement.
The Kentucky Board of Medical Licensure
has several resources on their website, including
information about the requirements of House
Bill 1, passed in 2012, and how to be in compliance. While some appropriately suggest that
the passage of HB 1 and its tighter control of
prescribing is a factor in the heroin epidemic,
we as physicians are still bound by its obligations. We are required to use KASPER when
prescribing opioids, and it has been enhanced
by listing information about a patient’s daily
morphine equivalent dose, a factor that can
help establis