Hospitals get reimbursed from the federal government based, in part, on the quality of care they deliver. But U.S. Sen. Susan Collins of Maine says one measure of quality — pain — should be reconsidered.
In a letter to the U.S. Department of Health and Human Services this week, Collins and 25 other lawmakers say tying reimbursement to a hospital’s ability to manage patient pain could encourage physicians to overprescribe opioids, and inadvertently help fuel the nationwide opioid abuse epidemic.
When patients are discharged from hospitals, they sometimes receive a national, standardized survey about their stays. Among other questions, the survey asks patients whether they were treated with courtesy and respect, whether the bathrooms were clean, and Collins says they also get questions about pain.
“During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?” she says, for example.
It’s a well-intentioned question, says Collins, that may have unintended consequences.
“It could put pressure on physicians to prescribe more opiate pain relievers in order to improve the hospital’s performance on these quality measures, which directly affects the reimbursement rate,” she says.
And those opioid pain relievers can be addictive and lead to abuse. According to the National Institute on Drug Abuse, from 2001 to 2014, the rate of prescription opioid overdose deaths increased more than threefold.
That has coincided with a stark increase in the overall number of prescriptions, Collins says.
“Americans consume these powerful painkillers at a greater rate than any other nation, including twice as many opiates per capita as Canada,” she says.
Ten years ago, Collins says, pain was undertreated. But now the pendulum has swung the other way.
It has prompted the Republican senator, along with 25 bipartisan colleagues including U.S. Sen. Angus King of Maine, to write a letter to U.S. Department of Health and Human Services Secretary Sylvia Burwell.
The senators are urging the department to examine whether there’s a connection between survey questions about pain and potentially inappropriate prescriptions of opioids.
“I think it’s a very valid question to ask,” says Lisa Letourneau, executive director of Maine Quality Counts.
Letourneau says one problem with the hospital patient survey is that it doesn’t differentiate between acute and chronic pain, and opioids are not effective for chronic pain.
“So there’s absolutely no way to tell from the survey results whether you did a great job at the hospital adequately controlling pain for acute injury, or whether you appropriately said ‘no’ to somebody with chronic pain who is asking for opioids,” she says.
Jeff Austin of the Maine Hospital Association says another flaw in the survey is that it emphasizes whether a patient’s pain needs were “always” met. That’s a difficult bar to meet, he says, when dealing with a subjective issue like pain.
“If the feds are saying you need to always address the patient perception of pain, and anything less than that is not good enough, you respond,” he says.
Austin supports the senators’ letter to HHS. He says survey questions should be modified to strike the right balance between managing patient pain and not putting unnecessary medications out in the community.
Collins says she hasn’t received a response from Burwell yet. But in a January webinar from the Centers for Medicare and Medicaid Services about the hospital survey and pain management, a CMS medical officer said the survey’s pain questions represent one-eighth of the survey, and that the survey does not promote inappropriate prescribing of opioids.
