AÂ bill has been introduced in Congress that will eliminate the financial penalty (in the form of reduced Medicare reimbursements) hospitals payÂ for failure to keep patients pain-free.
Currently the amount of money Medicare pays a hospital is affected by the results of a patient satisfaction survey known as the “Hospital Consumer Survey of Healthcare Providers and Systems.â€ Â If a hospital does poorly on the survey, they receive less money from the government than if they ace the survey. Â Hospitals devote an enormous amount of time and resources to score wellÂ on this survey as well as to do well on numerous care benchmarks and quality indicators (Door-to-Balloon times, hospital readmission rates, infection rates etc) that are also tied to reimbursement.
The survey has threeÂ pain management questions:
1. During this hospital stay, did you need medicine for pain?
2. During this hospital stay, how often was your pain well controlled?
3. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?
This bill does notÂ remove these questions from the survey; but it excludes them from the survey tally. Â Hospitals can use the questions to monitor their care, but they will not be financially penalized for doing poorly on them.
The goal is to help prevent hospitals from pressuring their doctors to over prescribe pain medicine in the interests of performing well on the survey. Â Without such pressure, it may be theÂ individual physician’sÂ medical preference that the patient not be given opiods or that the patient be given opiods in smaller amounts and for shorter durations. Â It may, in some cases, be better for the patient to endure short term pain to lessen the risk of the patient developing an opiod addiction. Â Some people have argued the cost of even one out of 100 patients developing an opiod addiction resulting in their death from overdose, as well as the destruction caused by the addiction on their families and society, will always outweigh the benefit of pain relief to the other 99.
Here is the specific language of H.R. 4499, The Promoting Responsible Opiod Prescribing Act of 2016:
H.R. 4499 Text
Exclusion of certain pain-related measures
For value-based incentive payments made with respect to discharges occurring during fiscal year 2016 or a subsequent fiscal year, the Secretary shall ensure that measures selected under subparagraph (A) do not include measures based on any assessments by patients, with respect to hospital stays of such patients, ofâ€”
the need of such patients, during such stay, for medicine for pain;
how often, during such stay, the pain of such patients was well controlled; or
how often, during such stay, the staff of the hospital in which such stay occurred did everything they could to help the patient with the pain experienced by the patient.
The bill enjoys bipartisan support and is endorsed by groupsÂ such as theÂ American Medical Association, the American Hospital Association, and theÂ American Association of Orthopedic Surgeons.
Does this bill, which still has to be passed, mean the eventual end of pain scales as we know them? Â Not necessarily, but it bears watching. Â Perhaps the same forces behind this bill will apply pressure to groups such as the Joint Commission, who accredit hospitals, to also lessen their emphasis on aggressive pain management.
The revolution in pain management, which I have been a leading advocate of, turns out to have beenÂ largely fueled by a well-funded media campaign launched by drug companies out to bolster profits. Â Seemingly out of nowhere pain became the 5th vital sign. Â Â Pain had to be assessed and reassessed with frequency and it had to be treated according to the patient’s self reported pain-level. Â And the hospitals’s performance on pain management not only became critical to their accreditations but to their financial health.
Today I don’t have as much confidence as I did in knowingÂ what it best for the patient in terms of receiving opiods or not and under what conditions. Â I continue to administer Fentanyl or Morphine to patientsÂ per our paramedic treatment guidelines. Â When a patient has a bone sticking out of theirÂ leg, I have no doubt opiods are needed. Â But a patient with chronic pain for a month that is a bit worse today and the patient is only three blocks from the hospital when we pick them up, I am not as quick as I was to reach for my controlled substances kit.
Like many things, our pain management efforts have likely gone too far, helping fuel the current epidemic of overdose death from prescription opiods and heroin. Â Our reaction to this epidemic will likely go too far in the other direction. Â Hopefully, we will find the proper medium.
I don’t know if this bill will pass or if it does pass what its ultimate consequence will be. Â Better long-term care of patients? Â Or an excuse to neglect patients with a legitimate need for opiods? Â Clearly change to ourÂ our current pain care standards is underway.