Archive for June, 2017

Physician Groups Issue Joint Statement on Better Care Reconciliation Act

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Physician Groups Issue Joint Statement on Better Care Reconciliation Act

June 29, 2017: Physicians Express Grave Concerns with the Better Care Reconciliation Act

Click here to see the joint letter to Alabama’s U.S. Senators

MONTGOMERY — We, the undersigned Alabama organizations, representing not just physicians but the thousands of low-income Alabamians served by them, want to express grave concerns with the Better Care Reconciliation Act (BCRA).

The BCRA fundamentally changes how Medicaid is funded, dismantling the program by capping its funding, shifting much of the financial burden to the states and likely leading to enrollment cuts — meaning less coverage for those who need it most. For those who ARE covered, the proposal will have devastating effects on the QUALITY of care provided by removing essential benefits of Medicaid — particularly for children.

Many do not realize that Medicaid is primarily a children’s program, particularly in our state:  71 percent of Alabama Medicaid recipients are CHILDREN, whose care is relatively less expensive and makeup only 20 percent of the state’s Medicaid costs. Children have unique health needs, and access to affordable, high-quality coverage is essential to keep them healthy; they are our future. Currently, Medicaid guarantees children comprehensive, medically necessary services, including EPSDT (early periodic screening, diagnosis, and treatment), which allows problems to be identified early so that children have the ability to thrive. Any efforts that take away these services or increase the number of uninsured would jeopardize children’s health.

Equally important, Alabama’s economic viability lies in the strength of its rural communities. The state’s physicians who practice in these areas depend on Medicaid for infrastructure dollars to keep their doors open. Even relatively small reductions in federal payments will force the closure of our rural hospitals and force physicians to leave these areas and likely, Alabama.

Will states be able to pick up the financial slack by raising taxes or reallocating state dollars from other programs? Will primary care physician payments be cut to the point where they can no longer care for their patients and pay their bills? In some states, survival may be a possibility, but in Alabama, as you know, funding for the current state share for Medicaid is a constant, year-to-year struggle in which there is no appetite for raising new taxes or revenues. With the unique way Alabama funds its Medicaid with Certified Public Expenditures, hospital/nursing home taxes, and the Children’s Hospital tax, Alabama stands to lose even more.

Simply put, the Better Care Reconciliation Act will be disastrous for low-income patients and ALL doctors who practice in Alabama and depend on Medicaid for healthcare system infrastructure.

In addition, we are concerned with other provisions of the legislation that would increase the number of uninsured (or underinsured), possibly eliminating the Essential Health Benefits (EHBs) and the loss of guaranteed coverage for those with pre-existing conditions.

We question the BCRA’s negative impacts on Alabama, oppose the legislation as currently drafted, and urge the Administration and Congress to continue working to fix the problems with the ACA in a way that does not increase the number of (non-voluntarily) uninsured Americans.

For more information, contact:

  • Mark Jackson, Medical Association of the State of Alabama, (334) 954-2500
  • Linda Lee, Alabama Chapter, American Academy of Pediatrics, (334) 954-2543
  • Jeff Arrington, Alabama Academy of Family Physicians, (334) 954-2570
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Are You a Medicare Provider Without an EHR?

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Are You a Medicare Provider Without an EHR?

You can still avoid the MIPS 4 percent penalty by participating this year!

In 2017 the TEST portion of MIPS allows a provider to submit one Quality measure (previously known as PQRS) for less than a 90 day period to potentially avoid a 4 percent MIPS penalty (to be incurred in 2019) on Medicare Part B claims. One example of this is G8427 – Current Medications Documented. Every office typically documents a patient’s Current Medications. If you submit this code on your claims, even if only for a short period of time, you will be participating in the test portion of MIPS and may avoid a 4 percent penalty on Medicare Part B in 2019.

Remember, you will need to do this for every TIN/NPI combination in your practice.

The graph below shows a broad overview of the current MIPS attestation guidelines. Each line gives a brief summary of the four different attestation paths an office can choose from for 2017. Based on your 2017 participation, the above information references the row with one star and explains the simple criteria required this year to easily avoid a 4 percent penalty which incurred in 2019.

Need help understanding these new MIPS requirements? Contact MediSYS today at 1 (334) 277-6201 or email questions to sales@medisysinc.com. Our staff has been assisting practices with various CMS incentive programs since their inception. We combine years of experience with ongoing support and detailed expertise for our clients at no additional support charges.

 

For information on MediSYS electronic health records and practice management solutions as well as outsourcing CCM services, please contact MediSYS at sales@medisysinc.com and visit the website at www.medisysinc.com. MediSYS is an official partner with the Medical Association.

 

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Taking CDI Into the Physician Office Setting

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Taking CDI Into the Physician Office Setting

 

CDI, or Clinical Documentation Improvement, is as familiar to physicians who practice in the hospital as other acronyms such as ICU, OR, ED – but in the physician office, CDI is relatively unknown. However, with the implementation of the Merit-Based Incentive Payment System, or MIPS, CDI in the physician office will become imperative.

Most physicians will fall under the MIPS provisions of MACRA, the Medicare Access and CHIP Reauthorization Act. CMS estimates that of the 1.3 million providers under MACRA, 1.2 million will be under the MIPS program. The Quality component of MIPS is familiar to most physicians, as it is similar to the previous Physician Quality Reporting System. One new aspect of MIPS, however, is the Resource Use or Cost. This component will be 10 percent of the physician’s MIPS score in 2018, increasing to 30 percent in 2019 and beyond. The Cost score will be derived from claims data and will be based on the CPT and ICD-10-CM codes billed. Correct and specific ICD-10-CM coding will be key to physician reimbursement in this model. Medicare, and other payers implementing similar reimbursement strategies expect that a patient with a certain diagnosis will incur an estimated cost. If the cost to treat the patient far exceeds the estimate, then the physician’s Resource Use/Cost score will be low – he/she will be considered to be an inefficient physician.

A specific example to illustrate this:  The physician treats a patient with diabetes. The only code he bills for this patient is E11.9 – Type 2 diabetes mellitus without complications.  However, this patient has diabetic retinopathy, diabetic neuropathy, and diabetic chronic kidney disease. The payer’s estimated annual cost for a patient with diabetes with no complications is $1,400, but this patient incurs much higher costs due to his complications.  The physician, therefore, appears to be inefficient, and his Resource Use/Cost score will suffer. The payer’s estimated cost for a patient with diabetic chronic kidney disease is $4,300. Had the physician coded as specifically as he could have, E11.319 for diabetic retinopathy, E11.40 for diabetic neuropathy, and E11.22 for diabetic chronic kidney disease, the higher cost would have been expected, and the physician would not be penalized for the care he is rendering.

One hindrance to CDI in the physician office setting is the use of electronic medical records and the implementation of “charge passing”, codes transmitting directly from the EMR into the practice billing system. Physicians may not choose the most specific, or even the most accurate, diagnosis code, but once those codes are passed onto the claim and filed to Medicare, there is no changing or correcting that information. Corrected claims will not be accepted for this purpose. Some practices use coders to review these claims before they are actually filed.  This usually does not involve 100 percent review of the documentation, but it would allow some coding errors to be caught. For example, if a coder noted the following diagnoses on the claim:  E11.9, N18.5, G62.9, he would be prompted to discuss with the physician that N18.5 – chronic kidney disease, stage 5, and G62.9 – neuropathy, are considered to be diabetic complications and should be coded as such. And if a coder is familiar with coding guidelines, understanding that certain diagnoses require additional codes, then when she notes G30.9 – Alzheimer’s disease on the claim, she can query the physician as to which additional code is appropriate, F02.80 – dementia in underlying disease without behavioral disturbance or F02.81 – dementia in underlying disease with behavioral disturbance.

This may require additional diagnosis coding training for physician office coders, and it will almost certainly require a change in mindset. Physician coders have focused on what is documented with the mantra “Not documented, not done.” But CDI requires a similar focus on seeing what is not documented, what should be there, what is likely true for that patient – and then querying the physician.

Electronic medical records have also contributed to some of the errors seen in that physician may not have been trained properly in diagnosis documentation and coding before having access to what is essentially the entire ICD-10-CM book in their EMR. The ICD-10-CM descriptions may not match the language the physician uses, although the code is correct. For example, in ICD-9-CM, the code for depression, unspecified was 311, and the description was Depressive disorder, not elsewhere classified. In ICD-10-CM, the code for depression, unspecified is F32.9, and the description is Major depressive disorder, single episode, unspecified. Physicians may not be able to identify the appropriate code without further diagnosis education. EMR vendors and office staff may try to set up shortcuts to assist the physicians in choosing the appropriate diagnosis code and create further issues. Two recent errors I have seen in my own auditing practice:  1.) physicians coding Crohn’s disease with small bowel obstruction when they intended to code for small bowel obstruction, unspecified and 2.) physicians coding psychophysiologic insomnia when they intended to code chronic insomnia. CDI in the physician office setting must include a detailed review of the ICD-10-CM code descriptions in the EMR.

CDI in the physician office setting does not have to be as formal a process as that seen in the hospital – it can be informal discussions with the physicians. It can be accomplished through real-time shadowing or end-of-day review, but it must occur before the claim is filed. A simple CDI process could look something like this:

  • Coder reviews record for correct coding based on physician documentation.
  • Coder talks with nurse and physician about code choices.
  • Coder identifies incorrect codes chosen – discovers confusing language in ICD-10 description.
  • Coder reviews with physician and makes changes in code descriptions to assist physician in most specific and correct coding.

The keys for coders will be continuing education, which may be in the form of informal chats with the physicians and clinical staff, review of ICD-10-CM guidelines and Coding Clinic guidance, review of medical policies which can be used to help guide physicians in documenting. And perhaps most importantly, respect for the physician’s priorities. The physician’s foremost interest is care of the patient, and CDI is simply helping the physician to understand that how he documents matters and providing the assistance he needs to make it so.

References

Medicare Quality Payment Program

Kim the Coder (also known as Kim Huey, MJ, CCS-P, PCS, CHC, CPC, CPCO, COC) works with clients to improve coding and documentation of services and to ensure compliance with Medicare and insurance company regulations. Ms. Huey is available for on-site visits for auditing and education as well as for on-the-record audits and general coding and reimbursement questions.

 

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A Risk Analysis Is Your Entity’s Annual HIPAA Checkup

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A Risk Analysis Is Your Entity’s Annual HIPAA Checkup

The Health Insurance Portability and Accountability Act (HIPAA) requires all covered entities to conduct an accurate and thorough assessment of potential risks and vulnerabilities to the confidentiality, availability and integrity of electronic protected health information (ePHI). This process must be documented as a Risk Analysis. Covered entities must develop a Risk Analysis at their inception and review the Risk Analysis at least annually to identify potential changes to their information systems, physical environment, and/or the regulatory environment that may affect how they handle ePHI.

When performing a Risk Analysis, entities should review the HIPAA regulations and recommendations from the National Institute of Standards and Technology (NIST). Although federal agencies are the only entities required to comply with NIST, these guidelines act as the industry standard and should be followed by all covered entities.

Generally, a Risk Analysis is performed by the entity’s Security Officer. HIPAA requires each entity to have a designated Security Officer.  This designation must be in writing. The designated Security Officer must be familiar with the entity’s operations and competent in Information Technology. In accordance with NIST standards, the Security Officer should take the following steps to create or review the Risk Analysis:

  1. Determine where the entity’s ePHI is stored;
  2. Interview management to determine how workforce members utilize ePHI;
  3. Review access security settings and controls of the information systems;
  4. Determine the present and potential threats to ePHI;
  5. Determine the likelihood and impact of current and potential threats and assign them a risk level of high, medium or low;
  6. Document the Risk Analysis process and attach it to the updated Risk Analysis; and
  7. Work with management to resolve all threats within a reasonable period, with priority given to issues of higher risk and vulnerability.

Risk Analysis Content

A Risk Analysis shall include the evaluation of administrative, technical and physical safeguards.

Administrative Safeguards are defined as “administrative actions, and policies and procedures, to manage the selection, development, implementation and maintenance of security measures to protect electronic protected health information and to manage the conduct of the covered entity’s workforce in relation to the protection of that information.[1]  Administrative safeguards include the following:

  1. Assigned Security Responsibilities
  2. Security Management
  3. Information Access Management
  4. Business Associate Agreements
  5. Security Incident Procedures
  6. Security Awareness and Training
  7. Workforce Security
  8. Contingency Plans
  9. Evaluation

Technical safeguards are defined as “technology and the policy and procedures for its use that protect electronic protected health information and control access to it.”[2]  Technical safeguards include the following:

  1. Access Controls
  2. Audit Controls
  3. Integrity
  4. Person or Entity Authentication
  5. Transmission Security

Physical safeguards are defined as “physical measures, policies, and procedures to protect a covered entity‘s or business associate‘s electronic information systems and related buildings and equipment, from natural and environmental hazards, and unauthorized intrusion.”[3] Physical safeguards include the following:

  1. Facility Access Controls
  2. Workstation Use
  3. Workstation Security
  4. Device and Media Controls

The completed Risk Analysis must be maintained for at least six (6) years and should be kept in paper and electronic form.

Risk Analysis vs. Risk Management

Health care entities often confuse Risk Analysis and Risk Management. While a Risk Analysis serves to identify threats and estimate their risks, Risk Management is the process of managing identified risks. Risk Management consists of the development of policies and procedures that dictate how to address identified risks.

Several Risk Analysis Tools exist that entity’s can utilize. However, the Department of Health and Human Services (HHS) encourages entities to seek expert advise when completing a Risk Analysis to ensure that the Risk Analysis is accurate and thorough. Additionally, the National Institute of Standards and Technology (NIST) has produced a series of publications that can assist covered entities with understanding information technology security. Those publications can be viewed by visiting http://csrc.nist.gov/publications/PubsSPs.html.

A proper Risk Analysis is a necessity not only because it is required by HIPAA regulations, but also because it offers the entity the best opportunity to identify and deal with risks associated with the preservation of ePHI.  Finally, in the event a covered entity has to answer for a breach of PHI, the failure to produce a proper Risk Analysis could lead to sufficient justification for punitive action by HHS.

[1] 45 CFR 164.304

[2] 45 CFR 164.304

[3] 45 CFR 164.304

The Dunson Group is a health care compliance law firm in Montgomery, Ala., focused on helping health care providers meet regulatory requirements. Samarria Dunson, J.D., CHC, CHPC is attorney/principal of Dunson Group, LLC, and regularly contributes articles of special interests to physicians and practice managers.

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Meaningful Use and the Costs of Noncompliance

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Meaningful Use and the Costs of Noncompliance

It is something of an understatement to note that the U.S. health care legal landscape is currently experiencing a degree of transition and uncertainty. There is no shortage of changes to discuss, debate, and, perhaps, grow apprehensive about. One development that has been the radar of many physicians for several years now – and brought into new relief by more recent changes such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – is the Meaningful Use concept introduced by the Health Information Technology for Economic and Clinical Health (HITECH) Act.

“Meaningful Use” relates to physicians’ use of certified electronic health records (EHR) technology in the interest of interoperability and efficient electronic exchange of health information. The Centers for Medicare & Medicaid Services (CMS) offers an incentive program which offers incentive payments to eligible professionals and eligible hospitals who join and comply. Participation involves making “Meaningful Use Attestations” regarding compliance. Both compliance and noncompliance with Meaningful Use goals can represent a significant cost to physicians: compliance, as bringing a practice’s technological infrastructure up to the appropriate standards does not come cheaply; noncompliance, as those who choose not participate in CMS’s incentive program, face reductions in their Medicare and Medicaid payments. These reductions equal a 3 percent decrease in 2017.

It appears that noncompliance with Meaningful Use standards carries more of a bite than some observers may have thought. In June of 2017, the Office of the Inspector General (OIG) released a report that Medicare made hundreds of millions of dollars’ worth of incentive payments to Meaningful Use attesters who failed to meet the necessary requirements. The OIG estimated a total of approximately $730 million dollars in inappropriate payments – more than ten percent of the total payments. CMS’s blunder largely resulted from its failure to conduct adequate documentation review, thus rendering the self-attestations of professionals prone to abuse. Note, too, that CMS is not the only authority to make inappropriate EHR incentive payments: the OIG faulted Texas in August 2015 for making such wrongful payments in an amount over $15 million through its Medicaid program.

This does not, of course, amount to a windfall for the physicians who received the wrongful payments. The OIG’s recommendation to CMS includes directing CMS to recover the wrongful payments it has identified (a small sample of the total), and to seek to identify, and then recover, the rest of the inappropriately directed federal funds. As is characteristically the case, government overpayments cannot be retained by the recipient. Thus, the takeaway from CMS’s improper Meaningful Use largesse should not be an observation that the government has, up till now, not been adequately reviewing Meaningful Use documentation. Instead, it should be that one can, of course, expect such mistakes to be corrected when discovered and that it is even more important to get Meaningful Use compliance correct now. What has been done in the past by a physician may not actually have sufficed. Additionally, part of OIG’s recommendation to CMS was to educate eligible clinicians on proper Meaningful Use documentation requirements. Physicians should look for and take advantage of such education.

This need to double down on one’s Meaningful Use efforts comes at a time when the reimbursement system is shifting to MACRA. The Medicare EHR Incentive Program is no longer a standalone program –it has been combined through MACRA with the Physician Quality Reporting System and the Physician Value-based Payment Modifier into a single program, the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program (QPP). Although hospital and Medicaid Meaningful Use programs are unaffected by MACRA, clinicians will make their Medicare Meaningful Use attestations through the QPP. This program still focuses on the use of Certified EHR Technology to support interoperability and healthcare quality objectives. The meaningful use measures are calculated and compensated somewhat differently under MIPS; one significant change is that a hybrid scoring system has replaced the previous all-or-nothing approach.

Although the manner of reporting Meaningful Use has changed somewhat, it has not become either less important or markedly simpler. Getting up to speed on the technological, administrative, and reporting features of establishing Meaningful Use now – when there is some clemency as far as timing goes worked into the transition period – is certainly advisable. The need to establish the goals of interoperability, efficiency, and care coordination that Meaningful Use seeks to advance is a need that is unlikely to diminish. The fact that CMS is now beginning to seek hundreds of millions of dollars in wrongful incentive payments only highlights that Meaningful Use compliance is an issue worth following in the always changing health care landscape.

Chris Thompson is an attorney with Burr & Forman LLP. Chris practices exclusively in the firm’s Health Care Practice Group. Burr & Forman, LLP, is an official Bronze Partner with the Medical Association.

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UPDATE: No Vote on Senate Health Care Bill Before July 4

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UPDATE: No Vote on Senate Health Care Bill Before July 4

REVISED June 28, 2017: Although Senate Republicans had initially promised a vote on its “Better Care Reconciliation Act of 2017,” now it appears that will not be the case prior to the July 4 recess. With the release of the Congressional Budget Office report on the act, it did not appear there would be enough support to pass the legislation. While the bill is not dead, it appears that Senate Republican leaders want more time for discussion.

The Medical Association continues to review the legislation as proposed, remains in contact with Alabama’s Congressional Delegation, and is closely monitoring the legislation as it moves forward.

June 23, 2017: On Thursday, Senate Republicans released a draft of its version of their legislation intended to repeal and replace the Affordable Care Act. The 142-page “discussion draft,” called the “Better Care Reconciliation Act of 2017,” resembles the version passed by the House in May by repealing the ACA’s individual mandate and several taxes on the industry. However, the proposed legislation has several differences as well.

Pertaining to Medicaid:

  • Medicaid expansion is phased out from 2020 to 2024.
  • Medicaid’s funding structure would change to a per-capita arrangement, creating deep cuts in funding beginning in 2025.
  • States would be allowed to require nondisabled, nonelderly, nonpregnant participants to satisfy a work requirement for eligibility.

For the individual market:

  • Subsidies would be based on income, not age, as included in the House version, and the subsidies will be less generous being capped at 350% of the federal poverty level.
  • In 2018 and 2019 $15 billion would be set aside ($10 billion in 2020 and 2021) for health insurers to “address coverage and access disruption and respond to urgent health care needs within states.”
  • The proposed legislation sets up a “long-term state stability and innovation program,” to be funded with $62 billion over eight years.
  • States will have flexibility to opt out of the ACA’s provisions regulating individual markets by tweaking existing 1332 waivers.

The Medical Association is reviewing the legislation as proposed, remains in contact with Alabama’s Congressional Delegation, and is closely monitoring the legislation as it moves forward.

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CMS Updates Proposed Rule for MACRA; Eases Burden for Some Physicians

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CMS Updates Proposed Rule for MACRA; Eases Burden for Some Physicians

The Centers for Medicare & Medicaid Services has unveiled a 1,058-page proposed rule updating the Medicare physician payment system implemented under the Medicare Access and CHIP Reauthorization Act of 2015 with changes to make it easier for small independent and rural practices to participate.

The proposed rule would make changes in the second year of the Quality Payment Program as required by MACRA. According to a statement from CMS, the goal is to simplify the program, specifically for small, independent and rural practices, while ensuring fiscal sustainability and high-quality care within Medicare.

“We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient,” said CMS Administrator Seema Verma. “That’s why we’re taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork. CMS will continue to listen and take actionable steps towards alleviating burdens and improving health outcomes for all Americans that we serve.”

The proposal will allow for the exemption of small providers participating in the program by increasing the low-volume threshold to $90,000 or less in Medicare Part B charges or 200 or less Medicare patients annually. The original threshold was $30,000 in Medicare Part B charges or 100 Medicare patients. The agency believes the move will exclude about 134,000 clinicians from MIPS.

American Medical Association President David Barbe released a statement commending the CMS for hearing the concerns of practicing physicians. “Not all physicians and their practices were ready to make the leap, and many faced daunting challenges. This flexible approach will give physicians more options to participate in MACRA and takes into consideration the diversity of medical practices throughout the country,” he wrote.

The news may come as a relief for some clinicians. In March, Healthcare Informatics found 43 percent of more than 2,000 providers stated they needed help with MACRA preparation while 30 percent said that are not prepared at all. However, after exclusions, CMS estimates 36 percent of clinicians will be eligible for participation in 2018.

The American Academy of Family Physicians stated the regulation would help improve family physicians’ ability to participate in payment reforms successfully.

“We’re pleased that, consistent with the Department of Health and Human Services’ directive, CMS has taken steps to reduce administrative and regulatory burden,” John Meigs Jr., M.D., president of AAFP, said in the statement. “We’re equally pleased that CMS agreed with the AAFP recommendations on medical homes. For example, the financial risk borne by medical homes rolls out more slowly, providing more time for family physicians to move toward full participation in the Advanced Payment Model track. Equally important are the significant steps to reduce risk for practices of all sizes in the MIPS program.”

 

New Quality Payment Program Resources Available

The Centers for Medicare & Medicaid Services revamped the look of the Quality Payment Program website and posted new resources to help you successfully participate in your first year of the Quality Payment Program. READ MORE

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New Quality Payment Program Resources Available

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New Quality Payment Program Resources Available

The Centers for Medicare & Medicaid Services has revamped the look of the Quality Payment Program website and posted new resources to help you successfully participate in your first year of the Quality Payment Program.

CMS encourages you to visit the website to review the following new resources:

For more information, visit the Quality Payment Program website. The Quality Payment Program Service Center can also be reached at 1-866-288-8292 (TTY 1-877-715- 6222), available Monday through Friday, 8 a.m.-8 p.m. (ET) or by email at mailto:QPP@cms.hhs.gov.

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Opioids in Alabama: Where Do We Go From Here?

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Opioids in Alabama: Where Do We Go From Here?

The numbers are staggering. In 2015 alone opioid-related overdoses accounted for more than 33,000 deaths — nearly as many as traffic fatalities. Today more than 2.5 million adults in the U.S. are struggling with addiction to opioid drugs, including prescription opioids and heroin.

According to the Centers for Disease Control and Prevention:

  • About 91 Americans die every day from an opioid overdose (that includes prescription opioids and heroin)
  • Drug overdose deaths and opioid-involved deaths continue to increase in the United States
  • The majority of drug overdose deaths — more than six out of 10 — involve an opioid
  • Since 1999, the number of overdose deaths involving opioids — including prescription opioids and heroin) quadrupled
  • From 2000 to 2015 more than half a million people died from drug overdoses
  • In 2014, almost 2 million Americans abused or were dependent on prescription opioids
  • Many people receiving prescription opioids long term in primary care settings struggle with addiction, ranging from 3 to 26 percent in a review by the CDC
  • Every day, more than 1,000 people are treated in emergency departments for misusing prescription opioids

How did we get here?

In 2015, among 52,404 drug overdose deaths, 33,091 were from opioids that physicians prescribe such as hydrocodone. Studies suggest most of these involve diversion of legally prescribed pills, but some people died of the pills prescribed to them. Increasingly, as officials from the CDC recently testified before Congress, it is illicit drugs such as heroin and fentanyl that account for a rising tide of deaths.

Tracing America’s opioid epidemic goes back some experts say to the Roaring Twenties – a time when flappers danced to hot jazz, bootleggers sold black market alcohol in speakeasies run by mobsters, and morphine was handily prescribed for anxiety and depression.

“Opioids have been around for a very long time. Even back in the 1920s if you had depression or anxiety and you went to the doctor, you were likely to be prescribed a morphine-like medication,” said Daniel Doleys, PhD, clinical psychologist, director and owner of The Doleys Clinic in Birmingham. “Narcotics and opioid compounds do tend to stabilize different psychiatric problems, so oftentimes when we are prescribing these to patients, we think we are treating pain, but we may inadvertently be treating these underlying problems. The significance being that the patient may not show much improvement in pain or functioning, resulting in a lowering of the dose. This, however, can lead to re-emergence of the psychiatric symptoms and a plea from the patient and family to restore the medicine to its previous level. The potential impact of opioids on psychiatric symptoms, such as anxiety, depression, bipolar disorder, PTSD, and how this relates to the prescribing and overuse of opioids has not gotten much attention.”

According to Dr. Doleys, the altruistic nature of medicine itself could be one of the primary factors involved in today’s opioid crisis. Physicians are trained in the healing arts and simply want to heal their patients.

“You cannot cure suffering, and that’s part of the problem. You have a lot of well-intended clinicians who feel their job is to cure suffering. But, you cannot cure all suffering,” Dr. Doleys explained. “A certain amount of suffering is not necessarily a bad thing. It motivates us; it drives us. In our attempt to try to cure suffering, we have become co-dependent with the patient and taken their problem and made it our problem. So, we’ve communicated with the patient that I have something here that I’m going to give you. We will start with two of these pills a day. It may or may not be enough, but we’ll see. The message to the patient may be, if two isn’t enough, we can increase the dose. The often unrecognized position assumed by the well-meaning doctor is that I’m committed to saving this patient from suffering, and if this patient is still suffering, then I need to keep going until I find a cure.”

More emphasis needs to be placed on clarifying expectations, goals and patient responsibilities as it relates to their treatment. All too often patients are allowed to become ‘passive recipients rather than active participants’ in their treatment, according to Dr. Doleys.

What is so special about opioids?

In 1986, pain specialists Russell K. Portenoy and Kathleen M. Foley published “Chronic Use of Opioid Analgesics in Non-Malignant Pain: Report of 38 Cases” in the journal Pain.

“We conclude that opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse,” the authors wrote.

Dr. Doleys said of the study that with 67 percent of patients reporting a fairly good outcome with little adverse effects, although at doses much smaller than we typically see today. The study became “the lightbulb” that began a trend for opioids, which were originally prescribed only for malignant pain, to be used with other types of chronic pain.

“Questions soon began about how our bodies have these receptors which we already know will react to specific medications. We have these medications, but we are not helping people who are suffering and dying with pain,” Dr. Doleys said. “There was an increased awareness of people in pain from other sources rather than cancer, and the concerns began to grow about the under-treatment of pain, and some concerns were valid and almost criminal.”

In the 1980s, physicians began facing mounting pressures from not only their patients who were suffering from chronic pain issues, but also from advocacy groups and the federal government over the under-treatment of pain as a serious medical issue. By this time, there were about 100 million Americans reportedly suffering from chronic pain-related issues, according to the Institute of Medicine. With advertisements blasting away on television further advocating for the treatment of pain and applying even more pressure to the medical community to aggressively treat chronic pain, physicians were caught in the middle.

Pharmaceutical companies saw an opportunity and began producing more and more opioid medications, touting these new medications to physicians and federal regulatory boards as being safer than other painkillers on the market at that time. Unfortunately, this was not the case. When the dust settled and some of these companies were brought to court over their false advertising claims, millions of patients were addicted to their products.

Where the pendulum of prescribing opioids once swung toward over-treating chronic pain issues is now swinging back in a new direction, new issues are being uncovered – specifically addiction.

How opioids kickstarted the national conversation of addiction

“There is one positive outcome of the opioid epidemic. It has raised the awareness and acknowledgment that addiction is a disease. A national conversation has been initiated as a result of the severity, morbidity and mortality associated with opioid misuse and addiction,” explained addiction medicine specialist James Harrow, M.D., PhD. “We have been reluctant to acknowledge that addiction is a chronic, primary brain disease as opposed to what many people still believe is a voluntary process and that sufferers can just stop. That’s not the way it works. It is a biopsychosocial-spiritual disease that is chronic, relapsing and potentially lethal.”

According to Dr. Harrow, addiction is no different than other chronic diseases such as diabetes, asthma or hypertension. Addiction is preventable and when a patient has the illness, it is treatable with resultant long-term abstinence and remission. Those who are affected will be at risk of relapse to their drug of choice or other substances including alcohol for their lifetime. One of the problems we encounter is that addiction medicine is not taught in medical school.

“Medical education provides little to no training for what is probably the most prevalent disease in our nation today,” Dr. Harrow said. “The teaching of addiction is beginning to develop gradually within medical schools. However, if we do not educate medical students early in their training, then it is more difficult to assimilate the understanding of the disease when they enter practice.”

As with any other disease, physicians are not immune to the disease of addiction. Looking at the national population of physicians in the United States, roughly 900,000 doctors, the lifetime prevalence of addiction of practicing physicians is around 15 percent or about 135,000, Dr. Harrow said.

“Physicians may see themselves as superhuman, but that’s not the case. They may not be able to see themselves as being able to have these diseases, but they can and do,” Dr. Harrow said.

Because physicians face the same diseases as the patients, including addiction, that’s where the Alabama Physician Health Program steps in. APHP was created by the Alabama Legislature as a means for the Alabama Board of Medical Examiners and the Medical Association to address problems such as chemical dependence or abuse, mental illness, personality disorders, disruptive behaviors, sexual boundaries, etc. All information is privileged and confidential. The success rate of APHP for five years of monitoring is 85-90 percent with physicians successfully returning back to practice versus the long-term success rate of other programs of about 60 percent.

A clinical tool to aid in the war on opioid abuse

The Prescription Drug Monitoring Program is housed in the Alabama Department of Public Health and developed to detect diversion, abuse and misuse of prescription medications classified as controlled substances under the Alabama Uniform Controlled Substances Act. Under the Code of Alabama, 1975, § 20-2-210, et.seq, ADPH was authorized to establish, create and maintain a controlled substances prescription database program. This law requires anyone who dispenses Class II, III, IV and V controlled substances to report the dispensing of these drugs to the database.

Mandatory reporting began April 1, 2006. For those physicians who are eligible to use the PDMP, but are not yet registered, access is easy. Registering to access the PDMP database can be done by:

  • Go to www.adph.org/pdmp
  • Click on PDMP Login found in the orange menu banner on the left
  • Click on Practitioner/Pharmacist
  • Click on Registration Site for New Account
  • Enter newacct for the User Name and welcome for the Password
  • Complete the registration form and click on Accept and Submit

You will receive two emails when your application is approved; one with your user name and a second with a temporary password. Each physician can designate two delegate users per office. These delegate users have their own usernames and passwords to access the PDMP system.

If you have trouble using the PDMP, help is at your fingertips. Assistance with passwords, connection issues, search and query issues, and most other PDMP problems is just a phone call away at (855) 925-4767 and follow the prompts or by email at alpdm-info@apprisshealth.com.

The Alabama PDMP anticipates switching to new software later this year. The new software is user-friendly and has additional features that will aid prescribers and dispensers in making the best clinical decisions for their patients. More information about training will be emailed to users in the coming months.

Where do we go from here?

It would seem there’s a story on the news every day about opioid abuse. A new statistic, a new arrest, a new death toll, yet no new solutions even though every state and every organization has a task force or study group working on the nation’s epidemic.

Stefan Kertesz, M.D., MSc, is associate professor at the University of Alabama-Birmingham School of Medicine and director of the Homeless Patient-Aligned Care Team at the Birmingham Veterans Affairs Medical Center. His 20-year career has combined research and clinical care focused on primary and addiction care of vulnerable populations with funding from the National Institute on Drug Abuse and the U.S. Department of Veterans Affairs. In 2016, he provided peer-reviewed and public media reviews of several facets of the opioid crisis, the rise of illicit fentanyl and heroin deaths, and how new policies affect patients with pain conditions. He may not have any new solutions, but his close study of the opioid epidemic has uncovered some interesting insights.

“We as doctors played a significant role in developing the opioid market, even though at this point we’re not the ones sustaining it,” Dr. Kertesz said.

In fact, one of Dr. Kertesz’s chief concerns stems from the revised CDC Guideline for Prescribing Opioids for Chronic Pain, issued in March 2016, which might have caused a “pendulum swing” from the status quo of prescribing of opioids for chronic pain to a stricter guideline for their use. The CDC Guideline provides recommendations for primary care physicians who are prescribing opioids for chronic pain outside cancer treatment, palliative care and end-of-life care. This pendulum swing toward an effort to curb prescribing habits might be putting more patients at risk than physicians might know.

“As physicians today execute a hard shift on opioids, I plead for caution,” Dr. Kertesz said. “Patients with chronic pain have reported enormous suffering, some committing suicide as they see their lives turned upside down by doctors pressured to reduce their medications. Opioid prescribing ran up even more because of the use of the pain score…a subjective single number. Now there is an emergence of academic physicians who have dedicated their work to fighting addiction, including some who even worked on the CDC Guideline. They see that clinical practice has sprung ahead of data, that it has begun to look like someone has shouted fire in a crowded theater, creating a social stampede. This does not reflect the cautious, patient-centered care urged by the CDC.”

Dr. Kertesz is not advocating a return to the old days of prescribing opioids. Far from it. He works in Jefferson County, one of Alabama’s hardest hit counties where deaths by heroin, fentanyl and other prescription medications are disturbingly high. In fact, he’s doing everything he can, short of shouting from the rooftops, to inform government officials and colleagues about changing the opioid epidemic. He’s written opinions and reports for STATNews, Pain News Network, Huffington Post, and Politico. He’s given interviews for state and national news agencies. He’s published numerous peer-reviewed papers and articles. And, earlier this year, he issued a briefing for Surgeon General Vivek Murthy. The message should be clear: We need a better message.

“Saying that opioids are just as addictive as heroin is fantasy, the same as solving opioid overdoses in doctors’ offices alone when most individuals with opioid addiction did not start out as pain patients,” Dr. Kertesz explained. “When Surgeon General Dr. Vivek Murthy made an under-appreciated declaration that we cannot allow the pendulum to swing to the other extreme here, where we deny people who need opioid medications those actual medications, as an addiction professional, I agree.”

How the Medical Association continues to be a leader in the fight against Alabama’s prescription drug abuse epidemic

In Alabama, our situation is equally staggering. According to the Alabama Department of Public Health, 762 Alabama residents died between 2010 and 2014 due to drug overdose, which included prescription drug overdose. In 2014 alone, there were 221 deaths due to drug overdoses.

“A group of us from the Medical Association met with some DEA officials and sheriffs who told us that Alabama was number one for hydrocodone until 2001,” said Association President Jerry Harrison. “We fell out of the top slot for a few years, but we got it back. We recognized that Alabama was in a very bad place, and we knew we had to take action.”

The Medical Association helped pass legislation in 2013 to reduce prescription drug abuse and diversion. That legislation resulted in Alabama having the largest decrease in the southeast and third-largest in the nation regarding the use of the most highly-addictive prescription drugs.

In 2016 the Medical Association launched a new public awareness campaign called Smart & Safe, which is the only prescription drug awareness program in Alabama spearheaded by physicians. Smart & Safe promotes safe prescription use, storage and disposal of medication by providing helpful tips, news and educational opportunities online at www.smartandsafeal.org.

Last year, the American Medical Association also partnered with the Medical Association to create a new clinical tool in the fight against prescription drug abuse. The collaboration produced Reversing the Opioid Epidemic in Alabama: A Health Care Professional’s Toolbox to Reverse the Opioid Epidemic, a downloadable document housed on the Smart & Safe website, contains handy reminders about Alabama law pertaining to prescribing opioids, tips for disposal of medication, statistics and useful links.

“When we started the prescribing lectures, we encouraged physicians to prescribe dangerous combinations less. We discussed the impact of the combination of pain medications and nerve medications because adding together one and one does not equal two…one and one can equal three or four in the damage or the potential damage they do to the patients. We have presented this course to almost 5000 prescribers now, and we’ve had an impact there,” Dr. Harrison said.

This year marks the ninth year of the Association’s Prescribing courses. By the end of the year, the Association will have completed 31 courses, and until 2013 Alabama was one of the only states offering an opioid prescribing education course when the FDA developed the blueprint for Risk Evaluation and Mitigation Strategies for producers of controlled substances.

“We have to as a medical profession realize what we were taught 18-20 years ago, that we were not adequately treating pain and to increase the dosage of the pain medicine until there is a side effect, is no longer adequate. When you wake up in the morning and the first thing you think about should not be to reach for your pain tablet before you have your breakfast because you have to get going. I often wonder just what’s causing your pain first thing in the morning?” Dr. Harrison questioned. “You have to question your patients and be honest with them: Is that your pain talking, or is that your opioid rebound pain? When you and your patients start to look at that from a different point of view, then you can work together to decrease the amount of opioids used. Life is not pain-free, and opioids are not a cure for pain. It’s like licking the red off your candy. You’re making it so that the pain medicine doesn’t work for you as well as it used to. The more you take now, the less it’s going to work for you in the future. We’re part of the problem. And, if we’re part of the problem, we should be part of the solution.”

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AARP: States Lag In Keeping Medicaid Enrollees Out Of Nursing Homes

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AARP: States Lag In Keeping Medicaid Enrollees Out Of Nursing Homes

By Phil Galewitz, Kaiser Health News | June 14, 2017

States are making tepid progress helping millions of elderly and disabled people on Medicaid avoid costly nursing home care by arranging home or community services for them instead, according to an AARP report released Wednesday.

“Although most states have experienced modest improvements over time, the pace of change is not keeping up with demographic demands,” said the report, which compared states’ efforts to improve long-term care services over the past several years. AARP’s first two reports on the subject were in 2011 and 2014.

The organization ranked states’ performance on long-term care benchmarks such as a supply of home health aides, nursing home costs, long nursing home stays, the employment rate of people with disabilities and support for working caregivers.

With 10,000 people a day turning 65 and the eldest baby boomers beginning to turn 80 in 2026, the demand for long-term care services is expected to soar in coming years.

AARP officials said the House’s bill to repeal the Affordable Care Act would worsen the situation by capping annual federal revenue for states’ Medicaid programs. That bill is now before the Senate.

“The proposed cuts to Medicaid — the largest public payer of long-term assistance — would result in millions of older adults and people with disabilities losing lifesaving supports,” said Susan Reinhard, senior vice president and director of the AARP Public Policy Institute.

The report found strikingly wide variances in the share of state Medicaid spending for long-term care directed to home- and community-based services for elderly and disabled adults in 2014, the latest year for data covering all states. Minnesota, the top-ranked state, spent about 69 percent, but Alabama, ranked last, spent less than 14 percent.

Nationwide, the average edged up from 39 percent in 2011 to 41 percent in 2014.

Only nine states and the District of Columbia spent more on home- and community-based services than on nursing home care, according to the report. Such services include home health care, caregiver training and adult day care.

People turning 65 this year face about a 50-50 chance of needing long-term care services in their lifetime, AARP officials said.

Trish Riley, executive director of the National Academy for State Health Policy, said states face several obstacles to expand home- and community-based options. They include a strong nursing home lobby that does not want to give up its Medicaid dollars and a shortage of transportation and housing options, particularly in rural areas.

An Alabama Medicaid spokeswoman said the state is working on the issue highlighted by AARP but refused to comment on its report.

John Matson, a spokesman for the Alabama Nursing Home Association, rejected the notion that nursing homes are to blame. “We think it’s a shift that needs to happen in Alabama. We can’t build enough nursing homes to meet [the needs of] everyone that is coming,” he said.

The state’s effort to shift Medicaid patients from long-term care into managed care organizations starting next year will help, because those entities will have a financial incentive to keep people at home for care when possible, Matson said.

Reinhard said many states have struggled to expand home- and community-based options for Medicaid enrollees needing long-term care because that is an optional benefit. Nursing homes are mandatory under federal law. While states focus on Medicaid coverage for children and families — as well as non-disabled adults covered by the Medicaid expansion under the Affordable Care Act — adults with disabilities have received less attention.

“Long-term care is a stepchild of the program and not a top focus for states,” she said.

To view the full report, go to www.longtermscorecard.org. The report was funded by the AARP Foundation, The Commonwealth Fund and The SCAN Foundation.

KHN’s coverage of aging and long-term care issues is supported by The SCAN Foundation.

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

pgalewitz@kff.org | @philgalewitz

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