There are multiple claimants to responsibility for the opioid epidemic. The usual suspects are well examined, each sharing culpability. Perhaps less well examined is the role that insurance companies play in creating incentives by setting reimbursement rates to medical providers.
Insurance companies tie reimbursement rates to “Patient Satisfaction” scores. To understand why, look no further than the Hospital Consumer Assessment of Healthcare Providers and Systems (or H-Caps) patient satisfaction survey required by the Centers for Medicare and Medicaid Services (CMS) for all hospitals in the US. H-Caps was adopted in 2014 as a part of the Affordable Care Act. Unsurprisingly, pain management is a leading predictor of patient satisfaction. Viewed as “low hanging fruit” among the many elements to providing quality care, providers work to ensure that the pain management element is well-scored. This can create incentives to provide seriously effective pain medication, warranted or otherwise. A quick Google search on “HCAHPS Reimbursement” returns a bevy of hits about “protecting hospital revenue streams.” It is hardly surprising that hospitals quickly learned how to control and protect revenue streams in a competitive environment.
Patients deserve proper pain management. Providers deserve a wide degree of discretion on how to best treat patients, and they deserve a reimbursement policy that compensates for their expertise. Insurance companies deserve a role in how those rates are set as they grapple with dynamic markets and regulatory environments. But there are areas to address from both the demand and supply side of the pain management “market.”
First, patient experience expectations need to be managed and that pain will necessarily accommodate most regimens: It should be managed but not eliminated. Pain is medically valuable as an indicator of treatment, diagnosis, and other issues. By setting the expectation that patients should be pain free, we are inadvertently forcing some patients to seek out alternatives, including heroin and fentanyl when the prescription expires.
Crucially, pain management—a central element of the H-Caps rating system—is too broad and easily manipulated by both patients and providers. While the consumer-driven transparency of H-Caps is well intended, the consequence of its administration has contributed to the perverse overuse of powerful opioids. State and federal legislators need to reconsider the H-Caps regulation to encourage other metrics, including outcome-based reimbursement. Placing pain management in the hands of the patient and in the way of hospital revenue streams creates a dangerous intersection ripe for disincentives and unintended consequences.
While the debate for more or less regulation is unsettled, one thing is clear: Current solutions—increased law enforcement, increased access to Narcan, focus on treatment and rehabilitation, and enhanced awareness—are all important tools for handling problems that already exist, but alone they fail to address origins of abuse. We have a responsibility to stem the epidemic and legislators have an opportunity to examine the connection between reimbursement policy and the over-prescription of powerful drugs. Too many lives are being ruined to leave this stone unturned.
Maureen Morse is a registered nurse. Jeff Morse is Managing Director, Investment Banking for Brighton Securities.
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