Not long ago, we discussed the issue of chronic pain patients. Many non-addicted pain patients find themselves currently unable to acquire proper doses of medicine, largely due to the opioid epidemic and its effect on prescribing practices. Nonetheless, while overprescribing definitely occurs, many doctors perform their jobs with care. And while it’s easy to focus on patients suffering from debilitating pain, the opioid epidemic affects the white-coated men and women who help them as well. Not only that, but it may even have an impact on hospitals who treat emergency patients on a daily basis.
Hospitals answer to the government, particularly the Centers for Medicare and Medicaid Services (CMS). Many recognize this organization for its benefit programs, as well as its impact on insurance companies. But CMS, previously labeled the Health Care Financing Administration, also deals with certification and quality standards. And due to this federal agency’s numerous duties in regulating health care finance, hospitals sometimes rely on their cooperation to keep their funding in the black. This means that hospitals sometimes have a complex relationship with CMS. It becomes especially complex when looking at the current opioid epidemic in the United States.
We’ll explain this in further detail below. But to make a long story short, CMS issues patient satisfaction surveys that sometimes help dictate whether or not hospitals are reimbursed for treating patients. When patients enter a hospital for the express purpose of doctor shopping, this puts the doctors in a difficult position. As such, it seems clear that some changes in the way CMS conducts business might actually help hospitals fight the surge in opioid addiction. But before we get to necessary changes, let’s discuss these surveys in greater depth.
Patient Satisfaction Surveys
When CMS decided to mandate patient satisfaction surveys, they included questions about pain management. This created a problem. Not every patient who shows up to the hospital looking for painkillers does so honestly. Some patients might exhibit real symptoms, but this does not mean they actually need prescription opioids to handle them. In fact, many mild injuries can be treated with little more than prescription-strength ibuprofen. Nevertheless, many patients demand opioids for their problems. And if doctors refuse to prescribe them, they risk receiving a low satisfaction rating on their survey. This means that doctors at some hospitals feel pressured to fulfill the patient’s wishes, rather than the patient’s needs.
Dr. Gerald O’Malley, an osteopathic specialist with a quarter century of experience, expressed displeasure when speaking with The Fix. He does not believe that CMS made the right move in mandating these surveys. In his words:
“They made a mistake. They conflated quality with customer satisfaction. If you feel satisfied, that does not mean you’ve received high quality healthcare.”
He noted that some hospitals began deciding the doctors’ income in accordance with their survey results. Those who scored positively on patient satisfaction surveys would receive income boosts. In other words, some doctors saw themselves more as sellers than as healers. Their job became peddling medication rather than treating patients with discipline.
In some cases, O’Malley notes that writing a prescription may be the only way to avoid a confrontation with a patient:
“When I worked at Albert Einstein Medical Center in North Philadelphia, folks came back time and time again—for back pain, headaches, sickle cell pain. They’d walk in and say, ‘I need two milligrams of Dilaudid 4 with 25 milligrams of Phenergan,’ and, ‘Come on, chop chop, let’s go. Snap to it.’ Or they’d say, ‘I’m going home now so I need a prescription for 50 tablets of oxycodone.’ After looking up their records in the computer, I’d have to say, ‘Hang on, you just got a prescription for 50 tablets of oxycodone last week.’”
O’Malley knew that such patients likely suffered from addiction. In some cases, they may have been drug dealers. Either way, he could not give in to their demands without violating his oath. At the same time, denying them a prescription meant defending his negative satisfaction rating to his superiors. And in some cases, his superiors fail to understand his position.
Implications for Hospitals
The most telling story related by O’Malley demonstrates the tough position in which hospitals find themselves when forced to report patient satisfaction results.
“I had a guy show up at three in the morning with a herpes outbreak. He said, ‘I need Acyclovir and Zovirax cream.’ Okay, that made sense. But then he said, ‘I need something for the pain—Percocet or Vicodin or Dilaudid.’ I go, ‘Dude, you’ve got herpes. It’s not like a broken leg.’ He started yelling, ‘I paid a $200 copay so give me my six-month prescription.’ When I say no, then I’m the bad guy. He complains to the administration, then they come to me and say, ‘Why didn’t you just give him the prescription?’”
It may sound like O’Malley’s administrators advised him to enable this patient. On some level, they did. But it wasn’t out of lack of care for the patient’s health. If anything, they were simply trying to keep the doors open for the rest of their patients. Because CMS doesn’t simply require surveys in general; they also require hospitals to make decent scores. When a patient complains because they didn’t get what they wanted, CMS may not reimburse the hospital for that patient’s care. This means that hospitals risk losing money when they attempt to do the right thing by not contributing to the opioid epidemic.
The opioid epidemic also puts hospitals at risk of losing patients. While Narcan is a highly effective overdose reversal drug, patients require further medical care after its use. According to O’Malley, however, they do not always stick around to receive it:
“After you revive someone, they often get pissed off and start screaming at you. They jump off the bed, and run out of the ER. That is terrifying. Narcan is only going to last 20 to 30 minutes. If they overdosed on opioids like methadone or oxycodone they’re going to go back into respiratory arrest, or pass out at the top of a staircase, or get behind the wheel of a car.”
O’Malley still believes Narcan to be an important medication. But it cannot stem the opioid epidemic on its own. And hospitals that lose patients, in addition to returning unsatisfactory survey scores, risk losing both reputation and resources as they struggle against the growing drug threat. O’Malley doesn’t have a one-size-fits-all answer for halting the opioid epidemic. He does, however, have a few ideas regarding what doctors and hospitals can do to improve the situation from their end.
What Needs to Change
First, O’Malley feels that CMS should do their part by putting less emphasis on patient satisfaction surveys. His main problem with them revolves around the way they affect the manner in which doctors and hospitals receive income. Neither hospitals nor their staff should feel punished for following safe prescription guidelines. Eliminate the financial motive to write prescriptions without thinking it through, and hospitals can stop contributing to the opioid epidemic without fear of losing money. This won’t halt black market sales, but at least it will deny addicts and drug dealers one potential source of product.
O’Malley also feels that doctors and first responders should continue stocking Narcan in case of emergencies. While hospitals sometimes lose these patients if they choose to leave against medical advice, they still save the lives of those who remain. O’Malley believes that each overdose reversal gives the patient a second chance at life. As far as those who say that Narcan contributes to the epidemic, O’Malley voices no opinion one way or the other. He cannot wholly deny this claim, but he feels it draws focus from the life-saving aspects of the drug.
In truth, Narcan largely saves lives by giving patients the opportunity to question their near-death experience. Looking back, some may choose to seek treatment and prevent future overdoses. O’Malley does his best to remind his patients of this.
“I’ll always wonder how they got so broken that they ended up in my ER after a near-death experience. I talk to them probably more than most. I’m interested in their stories. I want to know what happened to them. Many don’t feel like sharing… They don’t want to listen to me, but I have had some meaningful conversations. I learn they were abandoned, or sexually abused, or a romantic interest convinced them to try a drug and they became addicted. It’s a fascinating behind-the-curtain look at the human condition.”
Doctors like O’Malley fight the opioid epidemic one patient at a time. If CMS were to lift restrictive policies, perhaps all physicians could attempt healing on this level, getting to know their patients and recommending treatment to those who overdose or who simply enter the hospital looking for a fix. At the very least, they could do their best to use sound judgment before writing a prescription. Hospitals and their staff need to be able to conduct themselves without fear of inadvertently contributing to the opioid epidemic.
Fortunately, O’Malley shows that some doctors continue fighting against the drug problem, even at the risk of losing money. Because at the end of the day, saving lives is more important to him than lining his pocketbook. Many other doctors feel the same way. It’s time to lift restrictions on hospitals that keep such men and women from performing their jobs properly.