Will Physicians Get Relief on Medicare's Pain Questions?

July 15, 2016

Medicare is proposing to give physicians pain relief on a patient satisfaction survey that gets some of the blame, rightly or wrongly, for the nation's opioid abuse epidemic.

The Centers for Medicare & Medicaid Services (CMS) says it wants to remove the survey's controversial questions on pain management from its calculations of hospital reimbursement. However, some physicians say the CMS simply should eliminate the questions from the survey, called the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).

The HCAHPS poses 32 questions to discharged patients about their stay, three of them on how well their pain was dealt with. The CMS factors the survey score into its calculations of how much a facility should be paid in its Hospital Value-Based Purchasing (VBP) program.

Many physicians say they feel pressured to overprescribe opioids to boost their hospital's survey scores and, in turn, their hospital's revenue. That issue is especially sensitive to physicians on a hospital's payroll, which can amount to a leash. The first survey question, the argument goes, wrongly equates pain management with prescribing a painkiller and skews the responses to the following two questions. The survey asks:

  • During this hospital stay, did you need medicine for pain?

  • During this hospital stay, how often was your pain well controlled?

  • During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?

The HCAHPS instructs patients that if they answer no to the first question, they should skip the following two questions.

In April, the CMS received a citizens' petition asking the agency to strike the three questions from the HCAHPS. The 58 signatories represented a "who's who" in the fight to prevent and treat substance abuse. They included medical school professors of anesthesiology, pain medicine, and clinical pharmacology; public health officials from four states; leaders of Physicians for Responsible Opioid Prescribing; medical directors of addiction treatment organizations, such as the Hazelden Betty Ford Foundation; R. Jeffrey Goldsmith, MD, president of the American Society of Addiction Medicine; Leslie Dye, MD, president of the American College of Toxicology; and Michael Carome, MD, director of the Health Research Group at Public Citizen.

"Medication is not the only way to manage pain and should not be overemphasized," the group said in its letter. They warned against setting unrealistic expectations for pain relief and equating aggressive management of pain with quality healthcare, "as it can result in unhelpful and unsafe treatment, the end point of which is often the inappropriate provision of opioids."

Pain-Medicine Societies Lobbied to Retain Questions

Taking a contrary stance, a coalition that included several pain-medicine societies lobbied the CMS to retain the three questions, at least until better ones are drafted. The groups said in a letter that there wasn't any evidence linking the questions to overprescribing of opioids. Eliminating the questions, they warned, would be a step backward to a time when pain was widely undertreated. It would "send the wrong message to clinicians and patients" and deprive researchers of data that could improve pain management.

Among the letter's signatories were the American Pain Society, the American Academy of Pain Medicine, and the American Academy of Hospice and Palliative Medicine.

In draft regulations issued earlier this month, the CMS staked out middle ground between the two sides of the HCAHPS debate. It said it was developing new pain management questions to "remove any potential ambiguity" about the survey. In the meantime, the current questions would stay put but would not figure into hospital VBP payments in 2018, all for the sake of eliminating any financial pressure that physicians may feel to overprescribe pain meds.

At the same time, the CMS cautioned hospitals not to misuse the survey. Some hospitals reportedly are using the HCAHPS to assess their emergency and outpatient departments and are disaggregating raw data to "compare, assess, and incentivize individual physicians, nurses, and other hospital staff," the agency said. "The HCAHPS survey was never intended to be used in these ways."

Andrew Kolodny, MD, executive director of Physicians for Responsible Opioid Prescribing, calls the CMS proposal a step in the right direction, but not ideal.

"They're acknowledging that the questions need to be changed," Dr Kolodny told Medscape Medical News. However, he said the CMS should immediately eliminate the three current questions while it's rewriting the survey.

"Even though the survey responses and reimbursement would be decoupled, prescribing pain medicine is still seen as a quality-of-care measure," he said. "There are other ways to address pain besides giving meds."

A policy expert at the American Hospital Association (AHA) said that the CMS proposal strikes the right balance on a "tricky issue."

"You want to make sure providers understand that when a person is in pain, it's important to address that pain," Nancy Foster, vice president of quality and patient safety policy at the AHA, told Medscape Medical News. "The other side is not putting so much pressure [on clinicians] to address pain that the only option is to give strong medicines that have potential [adverse] consequences."

The CMS will accept public feedback on its proposed regulations until September 6 and will then put them in final form. The proposed regulations explain how to submit comments.

Follow Robert Lowes on Twitter @LowesRobert

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