US System Lags in Back Pain Treatment

The US healthcare system is, in a word, dysfunctional.  We know this.  Many of us have experienced it first hand.  We spend a lot and have relatively little show for it:

There are many reasons for this that will require a plethora of future blog posts (political reasons, economic reasons, cultural reasons, etc.)  But today, we'll take a quick look at what happens in a country that adopts evidence-based guidelines in a rigorous, widespread, methodical way and tracks the results of those changes over time.

The Netherlands is a relatively small country northwest of Germany, making up the southern border of the North Sea.  Known for the laissez-faire reputation of its largest city, Amsterdam, the country's healthcare system has a few notable features that are anything but: health insurance is mandatory, the country has a well-established and well-organized network of 160 primary care centers, and both insurers and hospitals are mostly for-profit and compete for business among consumers.

Back in 2011, the Netherlands decided to address the rising cost and complications associated with low back pain.  They did so by essentially mandating adherence to evidence-based guidelines (through highly differential reimbursement - pay for the things that work, pay little/nothing for things that don't) and simultaneously incentivizing return-to-work within the social security and disability programs available to citizens.  Because of its relatively small size and well-organized primary care system, the country was able to gain real traction around evidence-based guidelines within the clinical community.  They reduced spend by 20% over 5 years (this included both direct spend - like clinical services - and indirect spend - like social insurance and disability payments).   

The closing paragraphs of a recent story addressing this study found in the pages of one of my favorite public health newsletters, The Back Letter, summarizes the potential obstacles and opportunities that the US healthcare system presents:

When these reforms were enacted, some providers and patients worried that they would negatively impact outcomes—by limiting their treatment options. But there has been no evidence that these changes have had a negative impact on the health and well-being of the general public. 

However, some of these policies might be difficult to enact in the US. Any suggestion of limiting treatment options in the US sparks protests about “rationing” and “denial of care.” And wholesale limitations on ineffective treatments for back and neck would draw huge opposition from drug and device companies, healthcare systems that employ ineffective treatments profitably, and professional societies whose members routinely offer ineffective or unproven care. 

How does one get a society with an entitlement mentality, with mistrust of any form of regulation, to accept evidence-based limitations on care? Perhaps the recent saga with opioids provides some insights – as the consumer tide has clearly turned against the excessive and deadly prescription of opioids for back and other chronic pain problems.
The key elements in bringing about this transformation in attitudes were vocal public advocates, compelling stories of bad outcomes, easily-understood information, and credible scientists taking strong public stands. These same elements might be brought to bear to reduce inappropriate levels of surgery, injections, pain interventions, and ineffective non-invasive treatments. 

However, the opioid debacle is an extreme situation, given its heavy death toll and destructive impact in every US state. Will healthcare providers, patients, policy makers, and payers be willing to make similar cutbacks to all forms of excessive back care? There is certainly a growing consensus that spine care has to be a primary target in efforts to dramatically reduce spending. However, how that process will play out remains to be seen.

 Who knew healthcare was this complicated?

Michael
On Twitter @PRIUM1

Drug Abuse and the 2016 Presidential Election

In last week's State of the Union address, President Obama mentioned prescription drug abuse as an issue where he saw opportunity for bipartisan compromise.  Notably, he mentioned this in the first three minutes of the speech.  And not coincidentally, he mentioned it in the same breath as another, related issue that will be a necessary component of prescription drug abuse mitigation: criminal justice reform.

Governor Chris Christie has made prescription drug abuse a centerpiece of his stump speech.  He regularly shares a personal experience of losing a close friend from law school to an overdose.  Just last week, Christie made headlines by shutting down a New Jersey prison in order to convert it to a drug addiction treatment facility.  "The victims of addiction deserve treatment..." he said.

In last night's Democratic primary debate, Secretary Clinton and Senator Sanders both touched on the subject.  After noting that she hears of horrible stories wherever she goes on the campaign trail and after advocating for first responders to carry and be authorized to use Narcan, she closed her comments along the same lines as Governor Christie: "We have to move away from treating the use of drugs as a crime and instead, move it to where it belongs, as a health issue.  And we need to divert more people from the criminal justice system into drug courts, into treatment, and recovery."  Senator Sanders added, after placing at least some of the blame at the feet of the pharmaceutical companies, that "we need a revolution in this country in terms of mental health treatment."

This is clearly going to be a 2016 presidential campaign issue.  Beyond the mere fact that crises often make for strange bedfellows (Clinton and Christie offering nearly interchangeable quotes?!?!), why are we hearing more about prescription drug abuse from candidates now than ever before?

First, New Hampshire.  Everyone knows the Granite State figures prominently as the first primary - on February 9 - in both parties' nomination process (Iowa - on February 1 - is a caucus, not a primary).  What many may fail to recognize is that New Hampshire's citizens have been hit especially hard by the opioid/heroin epidemic over the last several years.  A quarter of New Hampshire voters believe prescription drug and heroin abuse is the single most important issue of the 2016 election, marking the first time in eight years a plurality of voters have ranked any issue more important than jobs and the economy.  If you're going to win the New Hampshire primary - from either party - you better be prepared to address prescription drug misuse and abuse.  

Second, it's not an exaggeration to say that we're losing a material portion of entire generation of Americans to this epidemic.  First, we saw the findings of a recent study from the National Academy of Sciences indicating that the death rate among white, middle-aged Americans has grown over the last two decades while the death rate among almost all other groups has declined.  Now, the New York Times has analyzed nearly 60 million death certificates collected by the CDC and found that the death rate among young, white adults has risen to levels not seen since the AIDS epidemic of the late 1980s and early 1990s.  This generation will be the first since the Vietnam War to experience higher death rates in early adulthood than the generation that preceded it.  The figures indicate that the 2014 death rate from prescription drug and heroin overdose among 25 to 34 year olds was five times its level in 1999.  

We have presidential candidates talking about this issue because it is the preeminent public health issue of our time.  If there's any comfort for us at all, it's that both parties appear to be taking it seriously.  If there's to be a concern, it's that whoever wins will need to make difficult decisions and real progress.  We're losing a generation of Americans.  

Michael
On Twitter @PRIUM1

Primary Care Physicians Aren't Prepared for Substance Abuse Issues

In the course of consuming news, studies, and other information related to prescription drug misuse and abuse, I sometimes come across seemingly unrelated data sets that paint a picture of broad, systemic issues.  Often, connecting these dots can illuminate a potential path forward, focus our efforts, and create progress toward solutions.  This week's example: 

Data Set #1

First, the CDC's latest data on drug poisoning deaths is disheartening.  After leveling off and even slightly declining in 2010-2013, the opioid death rate jumped considerably in 2014.  Meanwhile, heroin overdose deaths have continued a depressingly steady climb that goes back nearly two decades, but has clearly accelerated within the last 5 years.  Certainly, we have seen better days.  

Data Set #2

Health Affairs published an interesting piece in its December 2015 issue comparing primary care systems across 10 countries.  Primary care doctors were surveyed regarding general capabilities and attitudes.  While the survey was wide ranging, one of the categories stood out to me: the % of primary care doctors who report their practice is well prepared to manage the care of patients with complex needs.  Two key data points:

1. Patients with substance-use related issues:
• US primary care docs: 16% are well prepared.  This ranked near the bottom of the 10 country survey.  The UK was at the top of the list with 41% of primary care physicians reporting that they're well prepared to deal with substance-use related issues. 
2. Patients with severe mental health problems:
• US primary care docs: 16% are well prepared.  This ranked second to last (just behind Sweden at 14%) among the ten countries.  The UK also topped this category with 43% of primary care docs reporting they feel well prepared to deal with severe mental illness.  

To sum up... 

We have an escalating death rate from opioid and heroin overdose deaths in this country, driven in large part by substance-use related issues and mental illness.  And we have a primary care system not equipped to deal with the complexity of these patients.  

Help may be on the way in form of increased and mandated reimbursement for substance abuse and mental/behavioral health treatment via the Affordable Care Act.  But I'm struck by the fact that the vast majority of opioid prescribing occurs at the primary care level, not in the specialist's office.  If we're to make any progress, we need to focus education, resources, and tools within the primary care community so that a-heck-of-a-lot more than 16% of primary care physicians feel they're well prepared to help this complex group of patients.  

Michael 

On Twitter @PRIUM1

When Opioids Almost Kill You, Chances Are You'll Get More Opioids

I really wanted the first post of 2016 to be positive, uplifting, inspiring... but a study I read over the break was so unnerving, I had to go and ruin "return to work" day, already a day that lives in infamy, with even more depressing news.

Researchers at Boston Medical Center used a national database of prescription information to assess the likelihood of continued opioid prescriptions after a non-fatal overdose.  They looked at prescription information from 3,000 patients who experienced a non-fatal overdose between 2000 and 2012.  These patients were all prescribed opioids for chronic, non-cancer pain. 

Think about this: These 3,000 patients have already overdosed on prescription opioids. They are lucky to be alive. Surely, their healthcare providers will find another way, another mechanism, another approach to managing their pain. The risk here isn't illness or infection or a change in blood pressure... it's death.  

The bad news:

• Over 90% of these patients continued to receive opioids after their non-fatal overdose event
• 50% of these continued to receive the prescriptions from the same doctor
• 7% of the original group experienced a second overdose
• Two years after the first overdose, those with continuing opioid prescriptions were twice as likely to experience a second overdose event compared to those who were no longer receiving opioids. 

Why is this is happening?  

First, our fragmented healthcare system doesn't make it easy for prescribing physicians to discover the clinical events experienced by their patients outside of their immediate purview.  And patients may not want to disclose an overdose event for fear of having their medications discontinued.  I get that.  And it makes we wonder whether PDMPs should also include the ability for inpatient settings to report both fatal and non-fatal overdose events to the database so doctors can see this information whether its reported by the patient or not.  Linking electronic health records to PDMP systems would be a good start down this path.    

The second phenomenon driving these sorry statistics is that doctors are not comfortable weaning opioid (and other) medications.  No one, least of all me, would ever suggest immediate cessation of opioid therapy in light of a non-fatal overdose.  That's clinically irresponsible and potentially dangerous for the patient.  But the necessary steps forward are complicated: If the patient is on multiple medications that require weaning, which should we weaned first?  What titration steps should be used?  Is medication-assisted-therapy (MAT) an option?  Should I refer the patient or try to handle this myself?  These are hard questions and the primary care community, by far the most frequent prescribers of opioids, is currently ill-equipped to handle them.

Welcome to 2016.  Once more unto the breach, dear friends.  

Michael 

On Twitter @PRIUM1  

Will Robots Change Work Comp?

My answer: I don't know.  Yet.  But I'm going to be reading the latest issue of Foreign Affairs to inform my view.  The issue is titled Hi, Robot - Work and Life in the Age of Automation.  Still not convinced you should run to your local book store and pick up a copy?  Here's the table of contents:

The Robots are Coming

How Technological Breakthroughs Will Transform Everyday Life

by Daniela Rus (Professor of Electrical Engineering and Computer Science and Director of the Computer Science and Artificial Intelligence Lab at MIT)

Will Humans Go the Way of the Horses?

Labor in the Second Machine Age

by Erik Brynjolfsson (Professor of Management Science at MIT's Sloan School of Business) and Andrew McAfee (Principal Research Scientist at MIT's Sloan School of Business)

Same as It Ever Was

Why the Techno-optimists Are Wrong

by Martin Wolf (former World Bank economist and chief economics commentator for the Financial Times)

The Coming Robot Dystopia

All Too Inhuman

by Illah Reza Nourbaksh (Professor of Robotics at the Robotics Institute of Carnegie Mellon University)  

The Next Safety Net

Social Policy for a Digital Age

by Nicolas Colin (former senior civil servant in the French ministry for the Economy and Finance) and Bruno Palier (CNRS Research Director at the Center for European Studies)

I've not read all of the articles yet - the issue just arrived in my mailbox yesterday.  But these authors aren't light weights and Foreign Affairs isn't a trade rag.  These are serious insights from brilliant people provided in a well-respected setting.  We should be paying attention.   

And to give credit where credit is due, Jeff White of Accident Fund has been pushing all of us to think about these issues for a while now.  How will the nature of work change over the next 10 or 20 years?  How will the labor environment evolve?  Will technological advancement lead to significant unemployment?  What should we do now to prepare for the future of work?  

We need to be thinking about these questions and gathering insights from smart people both inside and outside of workers' compensation in order to properly prepare for what could be fundamental changes in the nature of work.  

Happy reading.

Michael

On Twitter @PRIUM1

Opioid-Related Emergency Room Visits Driving Costs

With all the focus on opioid overdose deaths, it's easy to forget that the actual death rate from opioid overdoses is surprisingly low.  In fact, the most common destination for most opioid overdoses isn't the grave - it's the emergency department, followed by an expensive hospital stay.

A new study published this week in the Journal of the American Medical Association estimates that there were over 92,000 ED visits related drug overdoses in 2010.  Of these visits to the emergency department:

• 68% involved prescription opioids (vs. 16% for heroin)
• 55% were admitted to the hospital where the average stay was 3.8 days, costing an estimated $1.4 billion in hospital care;
• 53% were women;
• 40% were in the South;
• Only 1.4% of overdose-related ED visits resulted in death, suggesting our healthcare system's growing sophistication in dealing with this crisis.  

Overall, inpatient and ED costs for overdoses resulted in $2.4 billion in healthcare expenditures in 2010.  

I wonder how many claims organizations examine this specific metric as a proxy for injured worker safety: ED visits and/or costs that are medication related.  

In other words, how much of that $2.4 billion did you pay for?  

Michael

On Twitter @PRIUM1