Comments on Draft Report on Pain Management Best Practices

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To: Vanila M. Singh, MD, MACM Chief Medical Officer
Office of the Assistant Secretary for Health
U.S. Department of Health and Human Services.

Dear Dr. Singh and Members of the Pain Management Best Practices Inter-Agency Task Force

Thank you for undertaking the challenge of searching for solutions “to improve care for those suffering from acute and chronic pain in an era challenged by the opioid crisis.”

We appreciate this opportunity to comment on the “Draft Report on Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations.”

As the report recognizes, too often the unintended consequences created by past robotic, top-down policies resulted in harm to patients. Past policies incentivized the use of opioids even when they might not be in the best interest of patients. Now, the current shift to deterrence is improperly punishing pain patients and those trying to care for them.

That is why we strongly support the draft report’s conclusion that “individualized, patient-centered care is vital to addressing the public health pain crisis.” Sacrificing the needs of individual patients to “population health” is perhaps one of the most under-appreciated factors precipitating the current crisis. Restoring the primacy of individual patient’s interests is key to solving the issues the task force is addressing. The Association of American Physicians and Surgeons (AAPS) thanks the members for recognizing this crucial point.

The report also makes another important observation that agrees with original analysis of NIDA and CDC data that AAPS published in early 2018: “illicit fentanyl-related overdoses are now a leading cause of overdose deaths in the United States.” Blaming doctors and pain patients for the surge in opioid deaths is misplaced and diverts resources from addressing the true culprits complicit in the increased deaths. It is encouraging to see that the task force is acknowledging these facts.

The report’s helpful review of non-opioid medications for pain management perhaps could be improved by mentioning the role insurers, Pharmacy Benefits Managers, and sometimes Group Purchasing Organizations play in determining which drugs are available to patients. We are aware of situations where patients requested non-opioid medications, e.g. IV acetaminophen, but the drugs were either not on the insurers’ formulary, were priced in a way intended to steer patients to a more profitable drug, or were unavailable due to a shortage.

Innovative procedures or therapies similarly are subject to discriminatory reimbursement practices by payers. One payer we particularly hear complaints about in this regard is Medicare. Medicare Administrative Contractors give conflicting answers to physicians seeking reimbursement for innovative procedures or therapies that are helping patients. Physicians who have treated patients with the understanding that Medicare would pay for the care later find the payment denied or receive demands that payments be returned, not to mention related fines, expensive appeals, and even jail time. The report correctly admits to “barriers, such as lack of coverage and reimbursement” but we would hope that identifiable action steps will result, particularly with Medicare, since it is administered by HHS.  For instance, steps could include granting Medicare beneficiaries more control over the funds used for their care, aligning with Sec. Azar’s aspiration for a Medicare system that “puts patients in charge of their care” and his observation that, “value is best determined by markets and consumers, not arbitrary rules and central planners.”

We would also like to see the task force report address the manner in which Medicaid patients are sometimes blocked from obtaining Medication Assisted Therapies, like buprenorphine, from physicians who are working with them outside of the Medicaid system, due to provisions of the Affordable Care Act that are being implemented in an overly inflexible manner, especially in certain states.

A final area of concern with the report we’d like to raise is the encouragement for expanding reliance on Prescription Drug Monitoring Programs (PDMPs). A July 2018 report in the Annals of Internal Medicine finds, “evidence that PDMP implementation either increases or decreases nonfatal or fatal overdoses is largely insufficient. … Some evidence showed unintended consequences.” While the PDMP concept may seem like a helpful tool, extreme caution should be taken when infringing on patient privacy and the patient-physician relationship in this way, especially in light of abuse of the data. For instance the California Medical Board is mining the data and cross-referencing with death certificates (the “Death Certificate Project”) to improperly initiate discipline against physicians who are doing their best to care for complex patients. Bureaucrats should not be second guessing patient care decisions in this manner, or in any manner.

In conclusion, we would like to reiterate our support for the report’s emphasis that the needs of individual patients need to remain at the center of patient care decisions and that actions by third parties interfering in the patient-physician relationship need to be minimized and even eliminated.

We are grateful to Dr. Singh and the task force for taking on this challenging work. Please do not hesitate to reach out to us for further discussion.

Sincerely,

Marilyn Singleton, MD, JD
AAPS President

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