David L. Keller, MD

Physicians who prescribe opioids are being held partly responsible for the sharply rising rates of opioid abuse and fatal overdoses. The epidemic of opioid overdoes continues to worsen, despite restrictive measures by the DEA, such as the escalation of all opioids to Schedule II, including the least-potent, fixed-dose combination analgesics.

As a result, combinations such as hydrocodone/acetaminophen, formerly on the less-restrictive Schedule III, can no longer be routinely phoned in, nor prescribed in the less-expensive 90-day supplies offered by insurers.

While such restrictions on the availability of opioid pain medications may exert a beneficial effect on reducing the overdose rate, they also inevitably make it more difficult for patients to obtain opioids for the treatment of appropriate diagnosed pain syndromes.

“Illicit opioids” are illegal Schedule I drugs, such as heroin, or Schedule II drugs produced illegally. In recent years, the United States has been inundated with highly potent illegally manufactured fentanyl, which now accounts for the most overdose deaths.

One study of overdose deaths in the U.S. reported that, among the 42,249 opioid-related overdose deaths in 2016, 40.4 percent involved prescription opioids. This finding implies that these overdose victims died as a result of taking opioids prescribed by physicians, perhaps even taking them as directed.

However, the study’s authors were counting in this category all overdose victims who had any detectable prescription opioid in their blood, regardless of whether the opioid was actually prescribed by a physician or obtained illegally, and regardless of how many other drugs were present.

Thus, a victim could take one stolen or diverted 5 mg hydrocodone tablet followed by a fatal intravenous overdose of street heroin, and the overdose would be included among those “involved with prescription opioids.”

Physicians cannot control patients’ access to illicit non-prescription opioids, nor to prescription opioids obtained from illicit sources. Physicians can restrict access to appropriate doses of a single prescription opioid, in restricted quantities, to reduce the risk of overdose. Overdose with only one prescription opioid found in the blood of the victim, and with no other drugs of abuse, often is not reported, making the percentage of overdose deaths involving patients using only properly-prescribed prescription opioids difficult to infer, according to the CDC.

Physicians are frequently called on to treat acute moderate-to-severe pain not relieved by over-the-counter pain medications, but which we know from experience will be at least partly relieved by an opioid medication. We do not know the risk of a given patient ending up as an addict or overdosing if we prescribe an opioid for pain.

We do not know the risk that denying a prescription opioid pain medication will drive the patient into the hands of criminal drug dealers. Doctors risk being blamed for the unknown percentage of patients at risk of addiction and overdose, regardless of what we do, regardless of how prevalent abuse may be in a community.

The NIH and CDC have prepared a guide to prescribing opioid pain medications more safely. Physicians should read and adhere to these guidelines, despite the effort required to perform and document all of the recommended counselling, anti-drug-abuse contracts, pill counting, urine testing, and other potentially insulting measures. Many patients complain that they are made to feel like they are under suspicion.

Doctors and their pain patients will continue to suffer such inconveniences, insults, and financial burdens, until the epidemic of opioid overdoses ends in the United States.

David L. Keller, MD, is an internist in Lomita, Calif.

Articles

Doctors risk being blamed for the unknown percentage of patients at risk of addiction and overdose, regardless of what we do, regardless of how prevalent abuse may be in a community.

Physicians cannot control patients’ illicit opioid use

Welcome to Medical Economics' blog section

 which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions expressed here are that of the authors and not UBM / Medical Economics.

Physicians who prescribe opioids for the treatment of pain are being held partly responsible for the sharply rising rates of opioid abuse and fatal overdose. The epidemic of opioid overdoses continues to worsen, despite restrictive measures by the Drug Enforcement Administration, such as the escalation of all opioids to Schedule II, including the least-potent, fixed-dose combination analgesics.

As a result, combinations such as hydrocodone/acetaminophen, which were formerly on the less-restrictive Schedule III, can no longer be routinely phoned in, nor prescribed in the less-expensive 90-day supplies 

While such restrictions on the availability of opioid pain medications may exert a beneficial effect on reducing the overdose rate, they also inevitably make it more difficult for patients to obtain opioids for the treatment of appropriate diagnosed pain syndromes.

"Illicit opioids" are illegal Schedule I drugs, like heroin, or nominally Schedule II drugs produced illegally. In recent years. The U.S. has been inundated with highly potent illegally manufactured fentanyl ("IMF" or "fake fentanyl"), which now accounts for the largest category of overdose deaths.

 reported that, among the 42,249 opioid-related overdose deaths in 2016, 40.4 percent involved prescription opioids. This finding may seem to imply that these overdose victims died as a result of taking opioids prescribed by physicians, perhaps even taking them as directed. However, the study’s authors actually were counting in this category all overdose victims who had any detectable prescription opioid in their blood, regardless of whether the opioid was actually prescribed by a physician or obtained illegally, and regardless of how many other drugs were present in the victim's blood.

Thus, a victim could take one stolen or diverted 5 mg hydrocodone tablet (a “prescription opioid") followed by a fatal intravenous overdose of street heroin, and the overdose would be included among those "involved with prescription opioids."

The data for this study were derived from death certificates of the overdose victims, a source which does not record how much of the opioid in their blood was from medication prescribed by a physician. And while we can infer that many patients had multiple opioids in their blood, there is no breakdown of which opioids were present at levels likely to have caused the fatal overdose.

Physicians cannot control patients' access to illicit non-prescription opioids, nor to prescription opioids obtained from illicit sources. Physicians

 restrict access to appropriate doses of a single prescription opioid, in restricted quantities, to reduce the risk of overdose. Overdose with only one prescription opioid found in the blood of the victim, and with no other drugs of abuse, often is not reported, making the percentage of overdose deaths involving patients using only properly-prescribed prescription opioids difficult to infer, 

 that "roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them, between 8 and 12 percent develop an opioid use disorder, and an estimated 4 to 6 percent who misuse prescription opioids transition to heroin."

Physicians are frequently called on to treat acute moderate-to-severe pain not relieved by over-the-counter pain medications, but which we know from experience will be at least partly relieved by an opioid medication. We do not know the risk of a given patient ending up as an addict or overdosing if we prescribe an opioid pain medication.

We do not know the risk that denying a prescription opioid pain medication will drive the patient into the hands of criminal drug dealers in an effort to alleviate their pain with illicit opioids. Doctors risk being blamed for the unknown percentage of patients at risk of addiction and overdose, regardless of what we do, regardless of how prevalent opioid abuse may be in a particular practice or community.

 to prescribing opioid pain medications more safely, along with 

. In the current crisis of increasing overdose deaths, physicians should read and adhere to these guidelines, despite the increased time and effort required to perform, and document, all of the recommended counselling, anti-drug-abuse contracts, pill counting, urine testing, and other potentially insulting measures. Many pain patients are offended by such enforcement measures, complaining they are made to feel like they are under suspicion.

Unfortunately, doctors and their pain patients will continue to suffer such inconveniences, insults and financial burdens, until the epidemic of opioid overdoses ends.



David L. Keller, MD, FACP, is an internist in Lomita, Calif.

Physicians and their pain patients will continue to suffer such inconveniences, insults and financial burdens, until the epidemic of opioid overdoses ends.

Doctors’ risks in prescribing opioids

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

 is not going to hold down the increasing cost of Medicare by adding over 1,600 pages of new regulations to the program. Instead, the Centers for Medicare & Medicaid Services (CMS) should have reduced the cost of traditional Medicare by eliminating the requirement for detailed documentation of evaluation and management (E/M) charges.

Physicians ready practices for 2018 MACRA rule

		Physicians are hard-pressed to examine and treat each patient, plus provide detailed E/M billing documentation, while keeping up with patient flow. Doctors type furiously during the entire office visit, focusing attention on the computer instead of the patient. The chart should be a concise record of important findings, results and conclusions, for clinical use only by physicians, not a compendium of details intended to support billing. Payment should be based on the time spent treating the patient, and the services rendered, as attested to by the physician. The reduction in the time spent on justifying E/M billing would reduce the cost of traditional Medicare, and reduce the amount of typing required. Instead, CMS will retain the requirement for full E/M documentation, and then pile onto that the additional documentation burdens of MACRA, which will require even more typing during the office visit.

		Can doctors be trusted to self-assess the value of each patient encounter? Who is better qualified? It is insulting and ridiculous for a doctor's progress note to have its "complexity of medical decision-making" downgraded by a CMS auditor who has a high-school diploma and 6 months of training in CPT billing. Rather than requiring each note to be free-standing proof of the level of work performed, let the doctor bill based on the time spent treating the patient, and the complexity of the patient's problems. CMS can also add up the estimated time for every appointment, and check that the total does not exceed the doctor's recorded office hours that day. The patient's complaints, ICD-10 codes and medication list can be used to determine complexity.

		We are told that MACRA will save money by 

. Evidently, someone at CMS imagines that improving the quality of medical care can make it less expensive. Improving quality is a worthy goal, but one that generally requires increased spending.

10 things physicians need to know about MACRA in 2018

		Consider the example of screening postmenopausal women for osteoporosis, and treating osteoporosis with bisphosphonates to prevent fractures. Most good doctors do this already, but the bad doctors who don't are probably saving money for Medicare by not ordering all those DEXA scans and bisphosphonates. The patients of bad doctors require more hip replacement surgeries in later years, but this does not raise the cost of bad care enough to make preventative DEXA screening and treatment pay for itself. That is why the estimated cost per quality-adjusted life year (QALY) for DEXA screening is about $50,000. Good medical care is generally more expensive than bad care. Even taking low-dose aspirin, for secondary prevention of myocardial infarction, has an estimated cost of $11,000 per QALY.

Next:  "Only a bureaucratic zealot could believe (this)"

		MACRA's 1,600 pages of new regulations increase the crushing burden of documentation without improving quality of care or reducing costs. Some of the best clinicians in my community are solo practice specialists I chose to treat me, based on my observations as a referring general internist. They have all complained to me that they have already been hit with substantial Medicare fines for non-compliance with the electronic health record (EHR) mandate, and now, MACRA. One of my doctors steadfastly refuses to abandon her neat, legible and well-organized paper charts. Another specialist made an expensive investment in an EHR, only to find that it was burdensome, interfered with patient care, distracted him from concentrating on important issues and was too costly. After one year, he fired his IT consultant and tossed the whole system out of his office. His brilliant and astute clinical care is not being assessed accurately by CMS. He will retire earlier than he had planned, because MACRA fines have cut his already thin operating margins.

This is why we need to accelerate value-based care

 that her agency's regulations are too burdensome, her reassuring reply was that MACRA will ease that burden when it is fully implemented. Only a bureaucratic zealot could believe that adding 1,600 pages of regulations will relieve regulatory burden.

		The most significant improvement introduced in this year's MACRA update is that more clinicians will be exempted from its mandates. By that metric, MACRA can achieve its maximal improvement by exempting all clinicians from its regulations, I concur.

		We are told that an ever-increasing portion of each clinician's pay will be based on how low they can drive their average spending per Medicare beneficiary. That approach will definitely reduce the cost of the Medicare program, but I do not want to be treated by any doctor who is incentivized to reduce spending on tests and treatments. I do not want to be treated by a doctor whose hidden agenda is to save money on my care. I want to be treated by doctors who will offer me the most beneficial interventions for my condition, and my doctors should derive neither profit nor loss from the interventions they order.

How can physicians combat industry shortages and meet patient demands?

		Traditional Medicare incentivizes medical testing, in certain situations where a practice owns a lab or imaging facility. Again, doctors should never be financially rewarded or punished for the cost of care they provide. The cost of a patient's care should have an entirely neutral effect on physician income. Doesn't it make sense to get rid of rules that let doctors profit from ordering tests, before we adopt rules that levy fines on doctors for ordering tests?

Next: The fatal bias of patient satisfaction 

The fatal bias of patient satisfaction scores

		Let me close by condemning MACRA's reliance on patient satisfaction surveys as a factor in physician compensation. The fact that a clinician retains a patient who is free to choose a different clinician tells you everything you need to know about patient satisfaction. Patients vote with their feet, and they do not hesitate to vote themselves a new doctor if their needs are not being satisfied. Traditional Medicare allows patients to switch doctors freely, a freedom which may exact some cost in continuity of care, but which increases satisfaction for patients and doctors alike.

My proposal to change the American healthcare system for the better

		Surveys are fatally biased by the fact that angry patients are much more motivated to fill out a survey than are satisfied patients. Read the handwritten comments by the patients and ignore the standardized rating numbers they circled. The comments tell the true story:

		• The patient had to wait for over an hour (because their stingy HMO forces the doctor to overbook to pay the overhead).

		• The doctor's medical assistant was nasty to the patient (because most doctors today have no control over the hiring and firing of ancillary staff).

		• The billing department turned their account over to collections (because the front desk staff failed to contact the patient when their bills were "returned to sender" by the post office).

		• The doctor refused to refer the patient for acupuncture or to prescribe medical marijuana (for a condition lacking evidence of benefit of either treatment).

		Doctors prefer to satisfy their patients as much as possible, but there must be limits.

David L. Keller, MD is a retired internist who resides in Lomita, California. 

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is not going to hold down the increasing cost of Medicare by adding over 1,600 pages of new regulations to the program. Instead, the Centers for Medicare & Medicaid Services (CMS) should have reduced the cost of traditional Medicare by eliminating the requirement for detailed documentation of evaluation and management (E/M) charges.

Author | David L. Keller, MD

Articles

Physicians cannot control patients’ illicit opioid use

Doctors’ risks in prescribing opioids

MACRA will not save money