When CMS and CDC Conflict: Medicare and Opioids

A few weeks back, the National Alliance of Medicare Set-Aside Professionals (NAMSAP) published a press release calling for a revised approach to MSAs that include opioid medications.  Specifically, NAMSAP stated that it supports the following changes:

1. A hard cap of 90 MED based on the CDC guidelines for no more than one month when the Work Comp MSA includes a surgical projection; and/or,
2. A hard cap of 40 MED for no more than one month, followed by a 10% per week mandatory tapering and weaning plan, as recommended by the CDC, until fully weaned from opioids

I find this attempt at hoisting the federal government with its own petard laudable.  When the federal government's public health agency says one thing, but that same government's healthcare payment policy agency says another, they ought to be called to account for it.  Just about anyone who reads this blog with any regularity is familiar with the crushing clinical and financial burden of opioids in general, but also specifically in regard to MSAs.  Long term use of expensive and potentially addictive medication is driving huge pharmacy allocations and prohibiting settlements.  So good for NAMSAP for putting this issue front and center with more than just a tired complaint, but rather with a specific call to action.  Good stuff.

Only one small problem.  I don't think it has a chance at being implemented. 

There are plenty of smart people in our industry that have forgotten more about MSAs than I will ever know.  But if I were writing the CMS response to NAMSAP, I would probably write: “We recognize that some of the treatment for which we demand allocation is outside of evidence based guidelines.  We support any and all efforts to bring care for these injured workers within those guidelines.  However, we respect the sanctity of the doctor-patient relationship and should a projection include long term use of opioids above the evidence based threshold, CMS will still demand an appropriate allocation for those medications.”  

I think the NAMSAP idea is fantastic - it should start a necessary dialogue around conflicting federal government policies and the clinical and financial risks it creates for patients and payers.  But I believe it has little hope of changing CMS policy, at least in the short term.  Hasn't CMS historically deferred to the treating physician’s approach, even when it makes no sense? 

One might argue that this is different, people are dying of opioid overdoses and the Medicare eligible population is not immune from that phenomenon.

I hope I'm wrong.  

Michael 

Follw me on Twitter @PRIUM1

It's Actually NOT 10% of Doctors Driving the Opioid Epidemic

A brief research letter in the Journal of the American Medical Association published just yesterday highlights a fascinating phenomenon in opioid prescribing and does so against the backdrop of workers' compensation data from the California Workers' Compensation Institute (CWCI).

Recall that CWCI data indicates that 10% of prescribers are responsible for nearly 80% of the opioid prescriptions in the California work comp system (and 88% of opioid costs!).  That's an astounding statistic and one that has led many observers and decision-makers to conclude that the solution to mitigating the opioid epidemic is to change the behavior of a small subset of prescribers that were driving the utilization of potentially dangerous medications.  I've heard this from a multitude of sources: "It's a relatively small group of the prescribers who are really responsible for this problem.  How do we change their prescribing behavior?"

The authors of this recent research letter decided to test whether the same ratio was exhibited in a much broader data set: all Medicare claims.  Granted, this is a data set not representative of the work comp injured worker population, but it's still an interesting question: Do we see that 10% of prescribers to Medicare patients drive 80% (or more) of the opioid prescriptions?  The answer would lend itself to opioid misuse and abuse mitigation strategies that go far beyond work comp and speak to the national effort to curb addiction and overdose deaths.  What are we aiming for?  10% of prescribers? Or a broader group?

The answer: the top 10% of Medicare prescribers account for only 56.7% of all opioid claims. Not only is this far below the CWCI data point of 80%, but it's also significantly less than the percentage of overall prescriptions (opioids and non-opioids) written by the top 10% of overall Medicare prescribers (63%).

Does this mean the CWCI data is less accurate or less valuable to us?  Absolutely not.  On the contrary, the CWCI data should help focus our work comp specific strategies for opioid misuse and abuse.  But for those of us concerned with the broader, national (and, increasingly, international) issue of opioid misuse and abuse, this JAMA research letter suggests that a broader, more comprehensive set of strategies that span a wider swath of prescribers will be necessary.  

Perhaps of even greater consequence is the specialty make-up of the prescribers.  The number of opioid claims in the Medicare data set are overwhelmingly from general practitioners (note that this chart is on a log scale... look at the actual numbers... family practice and internal medicine doctors are responsible for about 28 million opioid claims vs. a little over 3 million for pain management and interventional pain management combined).  

Two conclusions:

1) We need broad-based strategies to confront the opioid epidemic, though in work comp our efforts may be focused on a smaller subset of prescribers.  

2) These broad efforts need to focus on education for general practitioners.  Chronic pain is fundamentally an issue of primary care and we would be wise to treat it as such.  

Michael 

On Twitter @PRIUM1