This week, the Obama administration announced several proposed changes to address the opioid and heroin crisis in this country, some of which may favorably influence the broken culture of pain management in the United States today. Given the government’s history of excelling in making the opioid problem worse not better, this is a very promising direction.
The administration’s announcement contained one detail in particular that may sound minor but actually is a significant victory for pain experts who have been pushing back against bad policy for years. Currently, the Centers for Medicare and Medicaid Services ties Medicare payments to patients’ responses about pain management during their hospital stay on the required questionnaires administered by the Hospital Consumer Assessment of Healthcare Providers and Systems. The new policy would abolish this connection. This is critical because, even though CMS has argued that patients’ responses have had a “very limited” connection to reimbursement, a majority of doctors and administrators know about the connection and have felt significant pressure to overprescribe opioids so that patient pain ratings are favorable. (This policy came into place after more than a decade of government-sponsored and Big Pharma–backed educational programs that had seemingly been singularly designed to increase opioid prescriptions to treat a perceived epidemic in undertreated pain.) The administration’s nod to outspoken and concerned physicians this week, while small, is significant. It reads as a victory for doctors who want to maximize their patients’ health, comfort, and safety, instead of just survey scores.
The administration’s announcement also included other steps forward, such as an increase in the number of patients that providers can bill Medicare for addiction treatment using the long-acting medication buprenorphine (suboxone). Under the change, which like the HCAHPS change is an executive branch rule that requires no congressional input, the Department of Health and Human Services will raise the cap on the number of Medicare patients that each doctor may be paid for treating from just 100 per year to 275. This could mean more patients receive access to medication that could help them kick their addictions.
The new rules are not perfect though. They require doctors and staff in the Department of Veteran’s Affairs and the Indian Health Service to use prescription drug monitoring programs every single time opioids are prescribed or refilled—in the case of Indian Health Services, they will have to do this any time opioids are prescribed for longer than a week. While this seems like a good idea that could limit addiction, the data don’t back such policies up. These programs have not had as much impact as many had hoped—instead they often just introduce administrative hurdles. Voluntary programs, however, have had success, lending credence to the idea that physicians use these policing tools effectively when they find them necessary. But if the government wants to tie its own medical providers up by requiring a higher click-burden and e-paperwork for all of its patients, at least we can be relieved that, for the moment, it has left the private sector alone.
The rules don’t require Congress’ approval, but the White House is calling on the legislative branch to act. President Obama has requested $1.1 billion in new funding for addiction treatment and related programs. Members of Congress met this week to continue to negotiate final terms of legislation known as the Comprehensive Addiction Recovery Act. In a year in which almost nothing was expected to get done, this bill actually stands a chance, because it stands at the nexus of criminal justice reform and mental health legislation, two of Speaker Paul Ryan’s stated major priorities. If enacted, CARA would, among other things, expand the availability of naloxone (the life-saving medication for opioid and heroin overdoses) and would make resources available so that addicted persons in our criminal justice system are treated and not just incarcerated. CARA would also prohibit the Department of Education from asking applicants about previous convictions relating to illegal drug possession and sales on their free financial aid application forms. While the Senate version of the bill passed in March, and the House version in May, a combined and reconciled version must be crafted before it reaches the president’s desk.
Naturally, this is where the problem lies.
There have been rumblings that Democrats might block the bill if the Republicans refuse to pay for it. For their part, the Republicans won’t vote to fund the provisions in CARA without offsets from other programs that would render it budget-neutral. The Congressional Budget Office estimates that the bill would cost about $1.2 billion over five years, though those numbers do not take into account the downstream savings that these programs might create, including fewer incarcerated Americans and fewer addicts relying on other related government programs.
Disclaimer: The opinions expressed in this article are solely those of the author and do not reflect the views and opinions of Brigham and Women’s Hospital.