During the birthing of ObamaCare, some members of Congress supported Sen. Chuck Grassley's (R-Iowa) assertion that death panels would emerge as a tool by the government to contain cost. Now some senators and seniors are worried about a new source of government interference.
Under the Trump administration and Health Secretary Tom Price, there is a proposal to mandate that all physicians follow the CDC Guideline for Prescribing Opioids for Chronic Pain released by the Centers for Disease Control and Prevention in 2016. This is based on Centers for Medicare and Medicaid Services (CMS) Opioid Misuse Strategy 2016. It seems contradictory that, while lawmakers complain about too much government involvement in healthcare, they are willing to mandate the CDC guideline even though there is little to no scientific evidence to support the guideline.
The proposal to mandate the CDC guideline through CMS was developed by The Healthcare Fraud Prevention Partnership (HFPP), which created a white paper called “Healthcare Payer Strategies to Reduce the Harms of Opioids.” According to its website, the HFPP “is a voluntary public-private partnership between the federal government, state agencies, law enforcement, private health insurance plans, and healthcare anti-fraud associations. The HFPP aims to foster a proactive approach to detect and prevent healthcare fraud through data and information sharing.” Strikingly absent from the development of the white paper were experts in pain management and practicing physicians who deliver pain care to patients.
The HFPP white paper provides details on which medications doctors would be permitted to prescribe. Considering the concern Congress has had about the potential interference of government and insurance in the doctor-patient relationship, it would seem inconsistent that they would now permit such a proposal to be advanced. The HFPP's white paper was drafted largely by insurance companies — called "Partner Champions" — including Aetna, Anthem, Blue Cross Blue Shield, Cigna, Highmark, Humana, Kaiser Permanente and Centene Corp.
Consider the uproar it would create if a consortium of pharmaceutical companies offered their strategy to combat the opioids crises and their recommendation turned into a government mandate. Both insurance companies and pharmaceutical companies are interested in profits, but they approach their interests from opposite directions.
Even more alarming is that the authors of the new policy, in collaboration with the U.S. Department of Health and Human Services, propose to tap pharmacists to look for suspicious patterns in patient profiles related to opioid use that would then be shared by insurance companies. This data would include sensitive prescription drug-monitoring program records.
To share this information would be disregarding confidentiality provisions put in place to protect patients. Insurance companies have a fiduciary obligation to their shareholders to increase profits; they have no corresponding responsibility to safeguard patient well-being.
Framed as fraud prevention, this data-sharing effort ventures into the practice of medicine by insurance companies with a financial interest in dictating coverage options. This potential conflict of interest could result in unintended consequences.
The CMS has positioned the proposal as part of an ongoing strategy "to combat misuse [opioids] and promote programs that support treatment." Decreasing unnecessary prescriptions for opioids is a worthy goal. However, the opioid problem is less about the amount of opioids prescribed than how they have been used.
Limiting opioid prescriptions won't solve the crisis, yet setting an arbitrary dose limits without ensuring those who need the medication continue to receive it at appropriate doses can have seriously harmful consequences. To reduce prescribing in order to meet the goals predefined by insurers without ensuring that those who need the medication continue to receive it at appropriate doses could have devastating consequences to people with pain.
The CDC guideline states that it is voluntary, and it is not intended for all prescribers or all patients. It would be a misuse of the guideline if the CMS were to exact penalties, as proposed — to include loss of coverage and denial of payment — on any physician or patient whose medical care decisions, in serving highly variable patients' needs, departed from the guideline.
If insurance companies use the CDC guideline to limit coverage for opioids, the companies should then be mandated to provide coverage for the alternative pharmacologic and non-pharmacologic therapies recommended in place of opioids for pain control.
For Health Secretary Tom Price to support a policy that allows insurance companies — and the government — to dictate to physicians how to prescribe opioids based on a guideline that has had considerable criticism within the pain community would be antithetical to long-standing beliefs of opposing government intervention in the practice of medicine.
Hopefully Secretary Price will remain focused on what he and all physicians want: the best possible care for their patients. Unfortunately, this care could be severely impaired if the government and insurance companies are allowed to dictate what providers are permitted to prescribe to their patients.
Dr. Lynn R. Webster is the past president of the American Academy of Pain Medicine; vice president of scientific affairs at PRA Health Sciences; author of “The Painful Truth” (Oxford University Press); and producer of a public television documentary by the same name. Visit him online at www.thepainfultruthbook.com.
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