Monthly Archives: September 2016

We are the “Kings of Pain” Pills: Addressing The Opioid Epidemic In the United States

Opioids are common pain medications that are used for the treatment for mild to moderate pain. These medications are highly addictive and bind to particular receptors in the brain and spinal column that produce a feeling of euphoria along with the relief of chronic pain. However, in the US they are becoming a leading cause of death due to overdoses. Opioids—such as oxydocodone, Percocet and others—are now gateway drugs to heroin and other narcotics. They are also becoming a drug of choice for those who have not abused drugs in the past. Now they are gaining increased in popularity due to ease of access– and their street value continues to grow. The sad fact is that in the last year, drug overdoses killed more people in the US than car crashes.

While some physicians are very diligent in the way in which they prescribe opioid type pain killers–others are not. Drug companies that make these compounds for profit have misled physicians with small studies touting opioid safety and many physicians have not done their due diligence in evaluating the addictive nature of pain medications. All of these factors have led to a practice of indiscriminate and irresponsible prescribing practices.

What are the Facts Regarding the Abuse of Opioids?

As a society, we are quick to accept a pharmacologic approach to treating any ailment. As a people we demand an immediate fix for any medical problem and often do not consider any other alternatives. Drugs are much cheaper way to treat chronic pain as opposed to a more comprehensive multi-disciplinary approach. Time with therapists, treatment plans involving meditation, yoga and exercise are not widely supported—it is simply easier to take a pill. Currently, the US accounts for over 75% of the world’s total opioid prescriptions. In the last year, over 260 million opioid prescriptions were written in the US alone according to the American Society of Addiction Medicine. Currently, drug overdose is the leading cause of accidental death in the US today. Of the nearly 50 thousand overdose related deaths in 2014, opioid overdoses accounted for over 18 thousand—only 10 thousand were due to heroin.   In the last decade, opioid overdose rates have risen more than six fold. Women tend to be more at risk than men with overdose rates from prescription pain relievers up 400% over the last decade (as compared to 230% for men).

What Role to Doctors Play?

Obviously, physicians and other healthcare professionals are the source of opioid prescriptions. Don’t get me wrong—opioids do in fact have an important role to play in medicine in the short term treatment of acute pain related to accident, injury, surgery or the like. However, chronic opioid use must be avoided. These medications have numerous side effects and can be highly addictive in some patients. As a physician, it is incumbent upon me and my prescribing colleagues to choose the best treatment for a particular patient. It is never OK to enable abuse through writing recurrent, long term narcotic prescriptions. Unfortunately, financial pressures in medicine have created situations in which physicians feel as though they MUST write prescriptions of this type or fear losing patients to another provider who will. In addition, many patients with chronic pain require a great deal of time and effort during the course of a busy office day. Rather than spend the necessary time to create a more holistic and multi-disciplinary treatment plan, many physicians find it easier to simply write a prescription and move on the the next patient—thus enabling addiction.

What Is Our Government Doing to Address Opioid Addiction?

In March 2016, President Obama announced a new initiative (and new funding ) to combat opioid abuse and addiction. Currently, the FDA and DEA is considering regulations that will require “retraining” of doctors who prescribe opioid medications. Healthcare providers may be required to undergo re education in order to maintain a particular DEA prescribing certification. Many state medical boards already track opioid prescribing patterns and will often reach out to physicians who have unusual prescribing practices or prescribe higher numbers than their peers. Many of these physicians may be subject to disciplinary action.

Research dollars are being spent to investigate new types of pain relievers with less abuse potential and greater efficacy. Other studies are being conducted that will help better understand this type of addiction and how best to treat it. In addition, government dollars will be allocated to improve access to addiction treatment programs and the FDA will require new labeling of opioid prescriptions that will make their abuse potential much more clear.

Finally, drugs that reverse narcotics overdoses, such as naloxone (also called Narcan), are making their ways to city streets. It is imperative that we provide first responders as well as others in areas of high abuse rates with easy access to this life saving antidote during an overdoes. IF we do not, many more will die before we can change the course of the opioid epidemic in the US today.

What’s Next?

While these proposed government sponsored initiatives do have some promise, it is unlikely that any of them will have an immediate impact. It is important that we continue to educate the public as well as healthcare providers to the risks associated with taking opioids. In addition, we must make it easier for physicians to develop a more comprehensive and multi-disciplinary approach to pain management. Those physicians who do not carefully prescribe narcotics and instead do so indiscriminately, must be sanctioned and must no longer be allowed to prescribe these medications. We must also address the behaviors of those who are addicted to these drugs—we must identify sources of these drugs in the community and eliminate them from circulation. We cannot wait for government to act FOR us and fix the problem through bureaucracy and legislation—as physicians and as citizens we must act on our own. While ultimately research into better ways to treat chronic pain and the management of addiction will produce new ways to treat our patients, we must all work together NOW in order to halt the alarmingly high rise in opioid use in our country today. Ask your physician for alternative ways to treat pain. If you are concerned you or your friends and loved ones are suffering from addiction—say something—get involved and help.

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Doctors Glued to Computers—And Patients Left Out : The Impact of Electronic Medical Records (EMR)

In 2009 the Health Information Technology for Economic and Clinical Health Act (HITECH) was signed into law by President Obama and this law quickly changed the way medicine in the United Sates is practiced. The law was a first step in requiring all physicians to utilize electronic records. The President promised that creating and electronic record mandate for physicians would result in a national, universal electronic medical record system and improve care and communication. Ultimately, the legislation that required EMR implementation in 2009 began the process of penalizing physicians who do not use them and started a lucrative business for healthcare IT vendors such as Allscripts, EPIC, Cerner and many others. The requirements to implement EMR resulted in thousands of physician practices having to make harsh financially motivated decisions—either close the doors or sell out to larger healthcare systems.

What are the Benefits of EMR? What are the Practical Drawbacks?

Certainly, EMR systems do have their benefits—standardized documentation and portability all improve care. When a patient travels and has an illness care is improved when another hospital and provider can easily access long-term medical records. Communication between physicians of different specialties and organizations is significantly improved. However, EMR vendors have not yet created exchangeable, universal systems as Mr Obama promised they would. Each vendor creates their own platform and continues to compete with other EMR makers by creating different interfaces—Each EMR platform has its own idiosyncrasies and none is perfect. The Obama administration failed to put any mandates on EMR vendors—they were allowed to produce whatever they liked. The burden of integration has been dumped squarely in the laps of healthcare providers. In addition, EMR systems have been designed as billing tools and NOT for clinical documentation. Hospital systems are able to reduce billing and coding staff and now force physicians and other healthcare workers to perform this role as well. Because of the design focus of EMRs to capture maximal billing they are often clinically irrelevant and woefully inefficient in the clinical setting.

There is a significant learning curve for physicians and other healthcare workers when changing from one system to another. These transitions often bring operations to a crawl as productivity and efficiency decline for several weeks to months—ultimately negatively impacting patients.

How Has The EMR Requirement Affected Physicians and Patients in the Last decade?

This past week, a study published in the Annals of Internal Medicine found that physicians are spending twice as much time logging data into electronic medical patients as they are actually spending time interacting with patients. In the study, investigators observed nearly 480 hours of clinical time from the practice of 57 physicians across multiple specialties—including family medicine, internal medicine, cardiology and orthopedics. Investigators found that during a day in the office, physicians spent 27% of their time seeing patients and 49.2% of their time on the EMR or doing deskwork. In addition, these physicians also did 1-2 hours of EMR time at home during family time every single night. Ultimately the study found that for every hour physicians spend providing direct face to face patient care, they then spend TWO hours working on the EMR. Obviously, this type of scenario is unlikely to be sustainable. Physician burn-out and dissatisfaction with their job is at an all time high—more younger doctors are retiring early and looking for employment in other industries. More importantly, many patients are beginning to feel isolated and unable to develop any type of meaningful relationship with their physician.

What’s Next?

We must get back to a patient centered focus for the US healthcare system. We cannot allow a computer screen and government mandates to separate docrom patient. We must demand that physicians be given the time and space to interact with patients in a meaningful way that allows for a human connection. While documentation and EMR technology is an important part of clinical medicine, we must not allow the computer to be the focus of the clinical visit.

Here’s what I think needs to be done:

  1. Keep laptops out of a physicians hands in the exam room
  2. Require universal connectivity and easy interaction between different EMR platforms/vendors
  3. Reward physicians for quality CARE, not for quality EMR notes
  4. Make EMR interfaces more clinically relevant, easier to use, and more efficient (NOT AS BILLING TOOLS)

These are not easy goals to achieve. However, we must work diligently to make changes or patients will become more isolated and medicine will no longer be a human interaction between doctor and patient. These changes will only be possible if all of us work together—patients and doctors–to demand legislative reform.

 

{This blog was originally published in my column on Bold.Global on Monday September 12, 2016}

Major Insurers Bail on the ACA—Limited Choices and Patient Struggles Ahead

(This blog was originally published on September 5, 2016 on Bold.Global)

In the last several months three major players in the Obamacare exchanges have publicly  reported millions of dollars in losses and have made plans to either pull out completely (or significantly decrease participation) in the ACA insurance exchanges. Humana, United and Aetna account for the majority of the policies written under the affordable care act and will no longer be participating in open enrollment in 2017. All three insurers have cited overwhelming losses and a responsibility to their shareholders at the motivation for the change. The mass exodus of larger insurers has created a situation where nearly 1/3 of the individual counties in the United States will have only ONE choice in the exchange—effectively creating monopolies for these insurers. The insurers that remain are already asking for substantial premium increases—in some areas premiums may rise nearly 40%. In an effort to cut costs even further, those insurers that remain are negotiating contracts with healthcare systems that will accept rock bottom reimbursements. Many major healthcare systems are not able to participate in the exchanges. This has left many Obamacare participants with very narrow “in network” choices and some areas are faced with only ONE healthcare system and its affiliated physicians.   By limiting the network choices, the insurers are able to better control costs due to the fact that more expensive physicians and hospitals can be left out. When an insurer contracts with a particular hospital system and affiliated physicians, they are able to require referrals for specialists and the often offer incentives to primary care doctors for limiting costs (with no measure of quality).

What is the obvious Fallout from NO competition??

  1. Diminished Choice

As mentioned above, the remaining insurers must cut costs. The ACA exchanges have been flooded with older, sicker patients that require more care and create a higher cost burden. In order to manage these costs, insurers are negotiating contracts with single healthcare organizations in an effort to limit costs. These contracts will eliminate choice for most of those insured through the ACA. There is a shift towards HMO style plans and there are now fewer PPO (Preferred Provider Organization) options. PPOs allow patients to make choices in providers and HMOs typically have far fewer choices. In many states, there are no PPO choices—overall 15% of customers will have NO PPO to choose from. As you may expect, the profit margins for HMOs tend to be much higher for the insurers.   In 2016, HMOs represented 65% of all ACA plan choices. Non HMO plans tend to have higher premiums and are subject to more frequent and more significant premium increases as these insurers accumulate sicker, more expensive customers.

  1. Less Quality

Whenever there is a lack of competition, quality tends to suffer—no matter what the industry—and Medicine is not immune. Cost cutting measures and incentives for physicians to “do less” can result in a lower quality of care. For the most part, insurance companies are not concerned with the health of the insured—they are focused on the cost and the risk. In an ideal world, medicine would focus on prevention rather than treatment. However, many insurers do not cover important preventative tests and prescription drugs that are designed to modify risk.

  1. Increased Cost

Insurance companies are “for profit” businesses with shareholders to which they must answer. The job of the insurance executives is to maximize profits and minimize risk—Do not be fooled, insurance companies do not care about the well being of their customers. When insurance companies such as those who are taking losses in the exchanges find that their bottom line is negatively affected, they quickly raise rates, increase co-pays and raise deductibles.

  1. Less Access

As insurers limit their networks, patients will find that they have less access. When exchanges only offer one choice of hospital system and affiliated physician groups, patients will have difficulty finding a primary care doctor or may experience waiting lists to see specialists. Ultimately, patients will be separated from their long time physicians (unless they are lucky enough to find that they remain in network). Many physicians will ultimately retire or choose not to participate in the exchanges due to lower reimbursement rates—in some cases the exchanges reimburse at rates lower than Medicare and Medicaid—which are already 30% lower than private insurance rates. Major academic medical centers—such as UCLA and Northwestern for example—and countless others, are not participating in the exchanges due to reimbursement concerns. Academic centers often have cutting edge therapies and experimental protocols for cancer and other devastating diseases. Because of network and cost containment issues, those insured by the ACA will not have access to this type of care.

WHAT needs to be done?

It is clear that the ACA is NOT working. While we have millions of newly insured Americans, many of these newly insured remain effectively “uninsured” due to the inability to meet deductibles, and the limited access to care. It is vital that we insure all Americans—but we must do so in a way that preserves patient choice and helps improve quality of care—all while being fiscally responsible. We must work to better regulate insurers and make sure that the focus of care pivots to PREVENTION in the next decade. Physicians should be measured on how well they PREVENT disease as well as how well they TREAT disease with the highest quality care. We must also require individual accountability for patients. Those that make healthy lifestyle choices should be rewarded with lower premiums. Those that choose to continue high risk behaviors—smoking, poor diet, etc—should pay more.

Ultimately, Congress will have a choice in 2017. They can either bail out a broken ACA by pouring more good money after bad—OR—they can actually legislate and reform the law, making it more effective for all parties—insurers, patients and physicians.