Humans have used opioids to treat pain, both physical and mental, for more than 3,000 years. Ancient Egyptian documents like the Ebers Papyrus recommend using an extract of poppy seeds to calm crying children. In the “Odyssey,” Homer describes a drug “to lull all pain and anger and bring forgetfulness of every sorrow.”
Both the analgesic and addictive properties of these drugs have long been recognized, and the tension between relief and dependence now lies at the heart of our country’s opioid epidemic. Opioids are effective at easing pain, but the number of opioid overdose deaths has quadrupled since 1999, and a new report from the Centers for Disease Control and Prevention shows that an estimated 24,000 babies a year are born dependent on opioids.
There’s plenty of blame to go around, but one central concern is whether doctors are overprescribing opioids — and if we might inadvertently be offering them incentives to do so.
The Centers for Medicare and Medicaid Services currently makes incentive payments to hospitals based partially on how well they do on patient satisfaction surveys. These surveys ask patients how they feel their pain was controlled and whether providers did everything they could to help with pain.
Critics have argued that these incentive payments are making the problem worse — that questions like, “Did hospital staff do everything they could to help with your pain?” set unrealistic expectations and foster more aggressive opioid prescribing by clinicians to avoid financial penalties.
Last month, CMS announced a proposal to divorce incentive payments from the answers to the pain surveys while at the same time arguing that these payments have a “very limited connection” to survey responses. The proposal comes on the heels of the Promoting Responsible Opioid Prescribing Act, a bipartisan bill introduced in February, which, if passed, would have a similar effect.
Our work as physicians and as health policy researchers suggests that the move might help — a bit. But to truly curb the nation’s opioid epidemic while still ensuring that patients’ pain is adequately controlled, we also need a clearer framework for how and when to prescribe opioids, a definitive way to measure how appropriately physicians are prescribing them, and accountability for these measures.
On the surface, payments linked to pain scores are relatively small. Pain management accounts for less than 5 percent of Medicare incentive payments. (About 30 percent of a hospital’s total performance score is determined by patient satisfaction scores, only one-eighth of which is based on pain management.) But quantifying the dollar amount allocated to specific survey questions may ignore the outsized influence that these scores can have on prescribers’ psyches. Some polls have found that between half and three-quarters of physicians feel increased pressure to prescribe opioids because of pain-related questions on patient surveys.
Hard evidence on whether patient pain surveys actually lead to more opioid prescriptions — or whether withholding opioids results in lower patient satisfaction scores — is limited and mixed. But a recent study by one of us (A.J.) offers some new insights and a possible path forward.
This study looked at more than a half-million hospitalized Medicare beneficiaries, none of whom had recently been prescribed opioids. Nearly 15 percent of them left the hospital with a new opioid prescription. More than 40 percent of these prescriptions were still being filled 90 days later, suggesting that hospitalization may be an important risk factor for opioid dependence. Interestingly, even after accounting for patient diagnoses and severity of illness, the rate of opioid prescribing varied dramatically among hospitals — some were twice as likely as others to send patients home with a prescription for these potentially addictive painkillers.
Hospitals with better pain-control scores on patient satisfaction surveys were more likely to have prescribed opioids, but the strength of the association was small. That tells us that breaking the link between pain scores and incentive payments may be worthwhile, but it isn’t likely to make a big dent in opioid prescribing.
Patient satisfaction scores didn’t create the opioid epidemic, nor will removing them solve it. Nonetheless, removing payments for pain control may be an important step because even the perception that financial incentives are tied to pain scores may contribute to opioid prescribing.
Creating a gold standard
The central problem this research highlighted is that we lack a gold standard for defining the “appropriate use” of opioids. Without one, there’s no way to systematically measure opioid underuse and overuse.
In health care, variation in how often a treatment is used — like some hospitals prescribing opioids twice as often as others — often indicates overuse by some providers and underuse by others. But identifying which is which can be challenging.
If we want to make sure that people who need opioids get them while at the same time reducing the risk of dependence for others, we need validated tools that measure opioid underuse and overuse. This would make it possible for opioid prescribing to be used as a hospital quality measure — much like door-to-balloon time for angioplasty and cardiac stenting is for people having heart attacks — and for CMS to offer incentives for smarter opioid prescribing instead of more opioid prescribing.
A deeper understanding of appropriate opioid prescribing would also pave the way for creating validated public reports of opioid prescribing patterns by hospitals and health systems along with relative rankings. Such reports are already available at www.hospitalcompare.hhs.gov and other sites for things like hospital-acquired infections and 30-day readmission or death after being treated for a heart attack.
We support the CMS proposal to delink incentive payments from patient surveys of pain control. But a deeper problem remains: how to measure appropriate versus inappropriate opioid prescribing.
Opioids are necessary in some situations, dangerous in many, and both necessary and dangerous in others. Only by clearly identifying where on the spectrum each patient falls can we effectively and safely treat pain during hospital stays and prevent addiction-related tragedies afterward.
Dhruv Khullar, MD, is a resident physician at Massachusetts General Hospital and Harvard Medical School. Anupam B. Jena, MD, is an associate professor of health care policy at Harvard Medical School, an internist at Massachusetts General Hospital, and a scientific advisor at Precision Health Economics. He has received consulting fees from Pfizer, Novartis, Bristol-Myers Squibb, Vertex Pharmaceuticals, and Hill Rom Inc.
This article was updated to include Dr. Jena’s financial disclosures.
You are bigoted government puppets not physicians. I am a professional nurse watching the government using the CDC and FDA to permeate a myth; this epidemic you write of is not about the economics of the ACA thank God soon to be ddeleted , ended, and usurped but your Hippocratic oath first and foremost do no harm. Those with intractable pain myself being one due to a work injury in 1998 cannot walk, function or live without this pain relief. The myth being permeated with massive OD rates is people (addicts/other) ODing on opioids who are not legally prescribed said medications not pain patients and this buy in by writers who call themselves physicians is UNLAWFUL and does not support the scientific proof that opioids for intractable pain are the safest method of treating this disorder (not symptom) and MOST of all since your article reeks of financial incentive (the poor doctor the heck with the patient) that the COST is cheaper to have those in IP on opioids increasing ability to work for those not as damaged as I have become (Central Pain Syndrome) and the incentives led to by dirty DC and Clinton who consults with big drug companies on how to SHORTEN INVENTORY to increase unit price to extremes leading to decreased labor and production and HIGH PROFITS with less work, manufacturing cost and PATIENTS end of story. You reek and my hope for all of you is at the very least a brief bout with IP maybe not systemic RSD which is another diagnosis I have but a nice fat renal stone hanging mid way in your posterior ureter while you not only are rejected in the ER (oh you have WC in a state 1800 miles away we cannot treat you because don’t tell them its all about the hospital being paid) but because you need to know what anyone with IP knows that there is no life but only suicide left to communist abuse of progressive medicine in today’s America you all are idiots!
There is an element of wealth inequality in this pain killer controversy . Right now the wealthy don’t even have to gestate their own babies – through gestational surrogates – The Wealthy can and do tailor their national and international pain killing medical needs to suit their purposesSo I’m just flabbergasted and angry when any Doctor questions or decides in any way what I think my sixty two year old body needs in pain relief as I wait two and a Half years on Medicaid to get a inguinal herna repair as it gets larger . American Doctors are moral hypocrites and I for one would never use the word Professional .
Its very simple …STOP making such a big deal out of this. Even in the most generous statistics, addiction is nowhere near the issue that undertreated pain is. There are people here having their lives ruined (I’m many cases permenantly) through no fault of their own, because of this opiophobic circus. These articles are posted OVER AND OVER AND OVER, paying someones paycheck I’m sure, at the expense of legitimate patients. The rules and rugulations regarding opioids cannot get any stricter than they already are, as they have already rendered the therapy USELESS in most cases. Mind your own goddamn business and leave medicine to folks who understand it. This is a medical delema not a moral or political.
You are AWESOME and my own personal hero! THANK YOU for the voice of reason. I wish someone who COULD help would LISTEN.
Pain patient w/of care – just
one of the uncounted
‘Inadvertently’ should not appear in this article at all. If you think anything, especially the wording of survey questions, is done ‘inadvertently’ then I think you don’t fully understand the industry you write about. You need to be cautious of the capitalistic world we live in.
Drug companies reside in one of the largest markets (monetarily speaking) in the U.S., if not the world. So it would not at all surprise me if these surveys were written – or supervised – by an overlying board. A board full of members in which you could probably find many strong connections to drug companies. If not the CEO her/himself.
If someone leaves the hospital with the most minuscule amount of pain and they claim, “more could be done to help with the pain” this will obviously lead to an increase in opioid prescriptions. The medical field is a service based industry, clearly they will do anything and everything to reach perfection in those surveys. I’m not saying we are in the middle of this epidemic because of the surveys, because like you said, there is plenty of blame to go around. But the surveys are clearly not helping us get out of it either. They need to have no connection to the prescription of opioids, either on-purpose or ‘inadvertently’.
And damn, I looked at your SM after writing this. Lot of impressive credentials. SO HOW THE HELL CAN YOU BE SO NAIVE?!?! …oh right you’re a contributor for the NY Times, so you’re part of the problem. Just keep feeding us lies.
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