APA Misses On The Opioid Crisis - Several Times

The above infographic is courtesy of the CDC (see attribution for the direct link).  To those of us involved in treating addictions talking with many people who are addicted to opioids, getting them to see the problem, and helping them prevent accidental overdoses and death is an everyday occurrence.  The prescription opioid problem is widespread and has been a reality for the last 15 years even though it seems to have hit the news in about the last 5.  That probably coincides with heroin use starting to escalate.  The driving force for that has been economics.  Heroin is generally available in most areas for about a quarter the cost of diverted prescription painkillers.  In the past 5 years I have probably given about 50 lectures on the topic to physicians and graduate students and been actively involved in the clinical care of individuals with heroin addiction only or heroin addiction in addition to a number of other addictions.

When I got a post from the American Psychiatric Association (APA) on my Facebook feed last week it piqued my interest.  Part of what I teach is how failed policy is the root cause of the opioid epidemic and what physicians can do on an individual basis to correct the problem.  I was very interested to see what the APA had to say at a policy level.  Reading through the document that is really a blog post from the Medical Director the answer is "not much".  It appears that the APA has joined a Task Force of other professional organizations that includes that other great laggard the AMA.  They will be working to identify "best practices" and implementing them as soon as possible. Using Prescription Drug Monitoring Programs (PDMPs) is encouraged.  There will also be the focus on stigma.  Dr Levin states: "The APA maintains that substance use disorder is a medical condition that can be successfully treated, and we are actively advocating on behalf of the patients who are too often stigmatized by their community and disenfranchised by insurance carriers who fail to comply with mental health parity laws."

While there is no doubt that most people are biased against people with mental illness and addictions as well as their psychiatrists - I don't think that stigma has any traction in terms of increasing access to care or more importantly access to quality care.  I could argue that the APA support for the collaborative care initiative colludes with stigma-like biases.  That takes the form of "you don't have to see a psychiatrist - take this checklist instead."  I won't get into that today, only to say that I wonder how many people with heroin or opioid addiction are being seen in primary care clinics and being treated for anxiety, insomnia, or depression?  From what I see the numbers are significant.  But it is hard to fault primary care doctors because unless they are the prescribers of opioids, they may not realize that their patient has a problem with them.  There is also the issue of institutional stigma versus public stigma.  Public stigma or the type of stigma that everyday people have is more elastic and it usually depends on their experience with the problem.  If you live in a family where a member has a severe mental illness or addiction - you know that these problems are real, life-threatening, and you are ready to let people know that.  Institutional stigma is the type of stigma that governments and businesses can have, especially health care businesses.  They might grudgingly admit that there is some kind of problem largely because there is such a large secondary impact on medical and surgical services.  In some trauma centers over half of all admissions are primarily due to drug and alcohol problems.  At the same time,  institutional stigma is impervious to change.  It is codified in some texts on healthcare management and as noted in the APA blog post - not even amenable to change when new federal parity laws are implemented.  In terms of managing health care systems there is nothing like having a certain groups of disorders to shift resources away from in a pinch.  Mental illnesses and substance use disorders are that group.  The other considerations would include:

1.  Irrational policy initiatives:  There is no doubt that several policy initiatives to liberalize opioid prescribing were responsible for the start of this epidemic in or around the year 2000.  Making pain the "fifth vital sign", encouraging the use of opioids for chronic non-cancer pain, treating minor conditions with opioids, and a widespread policy initiative that encourage more aggressive treatment of pain even though specific measures were not know are among these initiatives.  I use the word irrational here to mean speculative initiatives that were not based on science.

2.  A serious misunderstanding of the current problem:  When all else fails blame physicians.  That is a highly effective political strategy that worked to consolidate control of the health care system under business and government.  To many of the politicians involved it flowed directly from their negative campaigning experiences.  In this case, the opioid problem is being framed at some level as a problem of inappropriate prescribing by physicians.  Some physicians are being subjected to criminal prosecution for deaths and complications that have resulted from opioid prescribing.  There are no references to the policy changes that occurred in the late 1990's that led to this change in physician prescribing behavior - the loss of gate keep functions in particular.

3.  A misunderstanding of the epidemiology of the problem: The upper decile of opioid prescribers (total number of prescriptions) account for 50-60% of all opioid prescriptions.  These prescribers are almost all family physicians, internal medicine specialists, and mid-level prescribers.  Available databases allow for rapid identification and intervention with these prescribers and that is where resources should be focused and not on all physicians across the board.  A mechanism for feedback on an individual physician's or physician extender's ranking in terms of their prescription of controlled substances is needed as well as individual access to that information.

4.  A serious misunderstanding for the overprescribing problem in general exists: As I have previously pointed out, opioids are one small group of medications that are overprescribed in the US.  Practically everyone who wants this problem to go away sees it as a cognitive problem or knowledge deficit.  If the physician involved just knew more they would not prescribe pain medications this way.  In fact, it is a much more complicated interpersonal, social and intrapsychic problem for physicians.  Until there is a widespread acknowledgement of this - all of the CME courses in the world on appropriate opioid prescribing will not change a thing.

5.  There is a widespread cultural problem:  Opioid hoarding in medicine cabinets across the country, neighbors sharing opioids and neighbors and family members discussing what is the best (translation best = most euphorigenic) is a major problem in the US.  Many politicians have agreed that America's "insatiable appetite for illegal drugs" fuels the international drug trafficking problem.  It also fuels the opioid epidemic.  There are very few initiatives focusing on cultural change.

6.  Misunderstanding the problems inherent in prescribing addictive drugs:  Most physicians are not aware of the unconscious and conscious elements that are activated in susceptible individuals when they take addictive drugs.  There are widespread misconceptions in this area that lead to the prescription of addictive drugs during active addiction,  not assessing the risk of prescribing addictive drugs to a person in recovery, and failing to assess some of the indirect signs of addiction in patients who deny that they have a problem with addiction.  There is also a belief among many physicians that if their goal is to help people that well intended prescribing will not lead to problems in the future.  

These are 6 areas that the APA could be focused on.  I don't think that you will see that analysis anywhere else.  I expect that "best practices" will fall disproportionately on the average physician and be a waste of time on their time and energy.  But it does fall back on the time honored political strategy of taking the heat off of the people who really failed and pretending it is a physician based problem.


George Dawson, MD, DFAPA


Attribution:

The infographic is from the CDC at this URL:  http://www.cdc.gov/vitalsigns/heroin/infographic.html#use

The CDC has done great work in this area and their site should be closely monitored for new data relevant to the problem.

AMA, DOJ, and managed care all on the same side?

That's right and they are all potentially aligned against doctors.

The lesson from the 1990's and again in the early 20th century was that politicians who were not competent to address health care reform in any functional way could come up with all sorts of off-the-wall-theories.  One of the most off-the-wall theories was that widespread health care fraud was a major cause of health care inflation.  It stands to reason if that is the case that is true, the perpetrators would be easy to find and put out of business.  To borrow typical language of the Executive branch it was a War on Healthcare Fraud.

To anyone who did not endure it, it is now a well kept secret.  The tactics of the government used in those days - entering clinics and doctors offices in an intimidating manner and taking out boxes and boxes of charts for review by special agents who were "coding experts" and then assigning some tremendous fine based on alleged "fraud" have been expunged from most places.  I sent two Freedom of Information Act requests to involved federal agencies and was told that information "did not exist" even after I provided the front page from one of the documents with the name of the agency.

It was quite a spectacle and it had doctors everywhere running scared.  After all, the interpretation of notes and linking them to billing documents was entirely subjective.  If a handful of notes was reviewed and bills were actually sent through the mail - racketeering charges via RICO statutes were possible and the fines would skyrocket to the point that nobody could ever pay them.  Federal prison was a possibility.  All for having a deficient note?

What followed was a carefully orchestrated set of maneuvers to render beleaguered physicians even weaker.  A decade of millions and millions of hours wasted on worthless documentation out of paranoia of a government audit.   Whose notes actually "fit" the government criteria?  The notes varied drastically from clinic to clinic and year to year in the same clinic.  And then a masterful stroke.  The government probably realized that their micromanagement of progress notes as leverage against physician productivity was probably undoable.  It would take far more agents than the budget would allow and they would no longer be able to demonstrate "cost effectiveness" in terms of recovered funds on the DOJ web site.

At that point they were able to turn this political device over to managed care companies who could selectively apply it anyway they wanted.  Some physicians noted that their documentation and coding scores by internal audit could be the best in the organization one year and the worst then next even though they had not changed any of their paperwork practices.  These audits to assure compliance with federal guidelines quickly became a mechanism for managed care organization (MCOs) to deny payment and "downcode" a practitioner's billing based on their review of chart notes.  Incredibly the MCO could deny payment for a block of billing submitted or pay much less than what was submitted.  Where else in our society can you decide to pay whatever you want for a service rendered?  That is the kind of power that the government gives MCOs.

Enter the new "partnership" to deal with health care fraud.  It is basically a coalition of the same players who have been using the health care fraud rhetoric for the past 20 years.  The DOJ, FBI, HHS OIG, large insurance companies and managed care corporations.  This quote says it all:

"The joint effort acknowledges the limitations of each health care insurer relying solely on its own data and fraud prevention techniques.  After a 2010 summit, 21 private payers and government agencies discovered that they were victims of the same scams.  As a result, the participants pledged to ban together against fraud."

The HHS Secretary chimed in:

"This partnership puts criminals on notice that we will find them and stop them before they steal health care dollars."

The newly elected psychiatrist-AMA president Jeremy Lazarus advises:

"Claims coding and documentation involve complicated clinical issues and the analysis of these claims requires the clinical lens of physician education and training."

Good luck with that Dr. Lazarus and heaven help any physician who gets caught under the managed care-federal government juggernaut.  And who protects physicians against those who are defrauding them by non payment or trivial payment for services rendered based on a totally subjective interpretation of a chart note?  Nobody I guess.  I guess we will continue to deny that is possible and a common occurrence.

This can only happen in a country where the government provides businesses with every possible bit of leverage against physicians and where most political theories about health care reform are pure fantasy.

George Dawson, MD, DFAPA

Charles Feigl.  New public-private partnership targets health fraud.  AMNews August 20, 2012.