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CMS, Joint Commission pressed to change policies that promote opioid pain medicine overuse

Over-prescribing opioids results from linking hospital reimbursement rates to patient satisfaction with pain treatment, petitioners said.

Susan Morse, Managing Editor

Dozens of medical organizations and consumer advocacy groups have sent a letter to the Joint Commission, and a petition to the Centers for Medicare and Medicaid Services asking for policy changes in an effort to reduce the over-prescribing of opioid pain relievers, according to Public Citizen, one of the groups involved.

The petition, which was sent Wednesday to CMS acting administrator Andy Slavitt, calls for the removal of pain questions from the Hospital Consumer Assessment of Healthcare Providers and Systems Survey, the agency's patient satisfaction query used to determine hospital reimbursement rates.

CMS financially incentivizes hospitals to obtain high scores on HCAHPS Survey questions, the petitioners said.

"The questions on the survey pertaining to treatment of pain have had the unintended consequence of encouraging aggressive opioid use in hospitalized patients and upon discharge," they said.

Petitioners are requesting CMS to change the requirements for assessing patients' pain.

[Also: Multiple non-opioid treatments improve pain management outcomes, study finds]

They want CMS to issue a proposal for removing the pain questions within 90 days, and finalize the rule change within 180 days, after allowing a reasonable period for public comment.

"The current requirements for hospitals and other healthcare organizations to assess patients' pain encourage unnecessary, unhelpful and unsafe pain treatments that interfere with primary disease management," said Dr. Michael Carome, director of Public Citizen's Health Research Group.

CMS released no comment on the petition as of publication.

The Joint Commission pain management standards also foster the use of opioids, the groups said.

In 2001, The Joint Commission introduced pain management standards requiring healthcare organizations to ask every patient about pain, which led to the use of pain patient scales and hospital policies requiring aggressive pain management, according to the group's letter sent Wednesday.

[Also: Opioid prescribing guidelines set to change as Centers for Disease Controls probes practices]

In the letter to The Joint Commission President and CEO Mark Chassin, the organizations requested a reexamination of the pain management standards. Since they were introduced 15 years ago, more than 200,000 Americans have died from accidental overdoses involving prescription opioids, the groups said in the letter.

The Joint Commission shot back in a statement on Wednesday that the requirement for pain assessment for all patients was eliminated in 2009.

Commission standards require patients experiencing pain to be assessed and the pain managed, the agency said. This does not necessarily require the use of drugs, according to the commission.

The Joint Commission accredits healthcare organizations and therefore is influential as accreditation gives hospitals the ability to receive federal payments from Medicare and Medicaid.

Over the past 20 years, prescriptions for opioid painkillers have soared, leading to an epidemic of opioid addiction, rising heroin use and a record high rate of overdose deaths, said the groups writing to CMS and the Joint Commission.

Physicians prescribed opioids, often in high doses, in more than half of 1.14 million nonsurgical hospital admissions, they said, citing a  study in the U.S. National Library of Medicine, National Institutes of Health.

The number of opioid prescriptions increased after the standard became for pain to be treated as if it were a vital sign, the groups said.

[Also: FDA approves Narcan nasal spray for opioid overdoses, hopes for wider, safer use]

"The Joint Commission does not endorse pain as a vital sign, and this is not part of our standards," the commission countered. "It is likely that the increase in opioid prescriptions began in response to the growing concerns in the U.S. about undertreatment of pain and efforts by pain management experts to allay physicians' concerns about using opioids for non-malignant pain."

The number of opioid prescriptions filled at commercial pharmacies in the United States from 1991 to 2013 shows the rate had been steadily increasing for ten years prior to the standards' release in 2001, the Joint Commission said.

CMS acknowledges that the overprescribing of opioids has led to a severe epidemic of addiction and overdose deaths.

The agency is also under pressure from Congress to break the link between hospital reimbursements and patient satisfaction with pain management, according to the Associated Press. Recently introduced legislation called the PROP Act would end the use of pain management questions as a factor in Medicare reimbursement calculations.

The PROP Act has bipartisan support in both chambers of Congress and has been endorsed by the American Medical Association and other professional organizations, AP said.

Twitter: @SusanJMorse

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