From time to time, I read letters written by treating physicians to PRIUM reviewing physicians. These letters represent a great deal of what is wrong with pain management today. While not emblematic at all of the best practitioners out there, these letters nonetheless reflect the thinking of too many physicians treating chronic pain patients.
These prescribers try to strike deals. Some offer to wean the opioids in exchange for pre-authorization of injections or other procedures. A recent letter suggested that, if we were so concerned about the opioids, the doctor would be happy to wean them... if he could make a little money in the process doing some procedures.
Some suggest they're doing the payer a favor already. Methadone is a lot cheaper than Oxycontin, right? So we should all just be grateful that the 800 mg MED is coming from a cheap source and not an expensive name brand drug. As if incredibly dangerous drug regimens are somehow made more appropriate because the monthly cost is lower than it might be.
Some note the nobility of our efforts, but label them as futile from the start. They suggest outright disbelief that a particular injured worker will ever be able to reduce intake of opioids, however medically unnecessary the drugs may be. The doctor is happy to refer them to a comprehensive pain management program... and they'll be equally happy to begin prescribing opioids again when the program fails. The prevailing attitude: these patients can't live without these drugs, so let's just prescribe away the pain.
Here's the thing, payers: You're financing all of this. Make no mistake: If you stop paying for it, there will be noise. Nasty phone calls, unsettling letters, complaints left and right. But there are ways to cease payment without creating emergent clinical events for the injured worker. There's a right way to do this. And while I wish there was a simple solution to this very complicated problem, there's not. The solution is sophisticated, multi-faceted, and requires clinical, medical/legal, and jurisdictional expertise. There are no cookie cutters here... just a lot of claims and a lot of hard work to do.
Ask yourself this question: When will the real liability of continued payment for a dangerous drug regimen outweigh the perceived liability of NOT paying for it?
No more deals. Let's get to work.
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