Providers wres­tle with pain man­age­ment in face of opi­oid cri­sis

Modern Healthcare - - NEWS - By Vir­gil Dickson and Gregg Blesch

Pub­lic health of­fi­cials want physi­cians and hos­pi­tals to re­think the way they man­age pain as Amer­i­cans be­come in­creas­ingly anx­ious about the rise of over­dose deaths tied to opi­oid drugs.

Many of those deaths are tied to heroin use, but the Cen­ters for Dis­ease Con­trol and Preven­tion re­ports more than 165,000 peo­ple died from over­doses in­volv­ing pre­scrip­tion opi­oid painkillers be­tween 1999 and 2014.

But health­care providers say they’re put in a tough po­si­tion by pa­tients who’ve come to ex­pect ac­cess to the pow­er­ful drugs to make them com­fort­able. Last week, the Obama ad­min­is­tra­tion re­sponded to calls to elim­i­nate what many have ar­gued pro­vides a fi­nan­cial in­cen­tive for hos­pi­tals to pre­scribe opi­oids: the role of pain man­age­ment in Medi­care’s Value-Based Pur­chas­ing Pro­gram.

The Joint Com­mis­sion’s 2001 pain-man­age­ment stan­dards are cred­ited for ad­vanc­ing the no­tion of treat­ing pain as a “fifth vi­tal sign,” and a se­ries of ques­tions about pain man­age­ment were in­cluded in the sub­se­quent Hos­pi­tal Con­sumer As­sess­ment of Health­care Providers and Sys­tems, or HCAHPS, sur­veys de­vel­oped by the Agency for Health­care Re­search and Qual­ity and en­dorsed by the Na­tional Qual­ity Fo­rum. Now those sur­veys drive 25% of a hos­pi­tal’s score un­der Medi­care’s Value-Based Pur­chas- ing Pro­gram, which re­wards or pe­nal­izes hos­pi­tals based on qual­ity and ef­fi­ciency met­rics.

“Ag­gres­sive man­age­ment of pain should not be equated with qual­ity health­care,” a coali­tion of pub­lic health of­fi­cials and physi­cians wrote in a pe­ti­tion to act­ing CMS Ad­min­is­tra­tor Andy Slavitt.

While Medi­care of­fi­cials agreed to re­move the pain-man­age­ment do­main from the value-based pur­chas­ing score, they clearly re­main du­bi­ous that the pro­gram is a fac­tor in over­pre­scrib­ing, not­ing in a news re­lease that “there is no em­pir­i­cal ev­i­dence of this ef­fect.”

Some hos­pi­tals, the CMS says in the draft reg­u­la­tion propos­ing the change, have been dis­ag­gre­gat­ing their HCAHPS scores to as­sess and mo­ti­vate in­di­vid­ual clin­i­cians and spe­cific de­part­ments. “The HCAHPS sur­vey was never in­tended to be used in these ways,” the agency notes. The CMS also points out that pa­tients di­ag­nosed with sub­stance abuse dis­or­ders are ex­cluded from the scor­ing and that the sur­vey “does not spec­ify any par­tic­u­lar type of pain con­trol method.”

The agency is now field-test­ing new ques­tions about pain man­age­ment, per­form­ing sta­tis­ti­cal anal­y­sis and col­lect­ing in­put from stake­hold­ers. It’s also work­ing on new mea­sures of con­cur­rent pre­scrib­ing of opi­oids and ben­zo­di­azepine in hos­pi­tals and out­pa­tient set­tings and as­sess­ing how psy­chi­atric fa­cil­i­ties mon­i­tor ad­verse drug events of opi­oid and psy­chotropic drugs.

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