The latest survey showing a double-digit decline in prescription drug abuse is not enough to relieve pressure on the healthcare industry to step up efforts aimed at curbing the problem.
Late last month, the Substance Abuse and Mental Health Services Administration released figures showing that the use of prescription drugs for non-medical purposes was down 14% among people aged 18-25 between 2010-2011.
It was the first decline since 2003. But, gains made among young adults are offset by an increase in adults, aged 26 and older, who reported being hooked on pain relief medication. Plus, the Centers for Disease Control still considers prescription drug abuse an epidemic.
With healthcare industry buy-in, states have attempted to curb prescription drug abuse in various ways. Every state, except Missouri, has a prescription drug monitoring program.
Bob Twillman Ph.D, Director of Policy and Advocacy for the American Academy of Pain Management, helped Kansas develop its prescription drug monitoring system. He says the programs are very effective when used, but most are voluntary, and that reduces their effectiveness.
"The challenge we have is getting people to use them. In some states, only 30% of prescribers are signing into the program. It can be a tremendous time-suck at a physician's office. I've had physicians tell me that, for a busy private practice, it could take up two hours a day."
Twillman wants more physicians to be trained in pain management, a sentiment echoed by the American Society of Interventional Pain Physicians. Both ASIPP and AAPM are trumpeting training programs over a new proposal that changes labeling requirements on opioids.
PROP, Physicians for Responsible Opioid Prescribing, criticizes the labels for being too broad, and giving neither a time frame for use, nor a maximum dose for non-cancer pain. It wants opioid labels changed and has asked the FDA for three specific modifications:
Strike the term "moderate" from the indication for non-cancer pain
Add a maximum daily dose, equivalent to 100 milligrams of morphine for non-cancer pain
Add a maximum duration of 90-days for continuous (daily) use for non-cancer pain
Andrew Kolodny, President of PROP, says its aim is not to stop doctors from prescribing painkillers when necessary. It wants to stop drug companies from promoting the drugs aggressively.
"The label changes will prohibit advertising but will not limit clinical decision making. If a doctor believes that a patient might benefit from long-term opioids, they will be permitted to prescribe. Off-label use of medications is very common and is often considered to be perfectly appropriate," Kolodny says.
It's not the first time the industry has taken a hard line approach to curtailing prescription drug abuse. Mercy Medical Center in Des Moines, IA, has posted signs in its ED saying it would only prescribe pain medication for emergency medical conditions.
It's directed at patients who think they will get easy access to prescription painkillers in the ED. Ohio has adopted similar guidelines, but its ED pain plan asks that doctors to use the prescription monitoring database to see the presenting patient's prescription history, and, among other things, to refer the patient to a nearby pain management facility.
"As far as pain management in the ER goes, I think this is right on the money," says AAPM's Twillman. He worries that the patients who genuinely have chronic pain are forgotten about.
"I think some primary care doctors are looking at not prescribing anything, and that's a problem. Then the patient is left with no care and they end up in the emergency room," he says.
A turning point in painkiller abuse could be mandatory pain management training for physicians. ASIPP's David Kloth, MD, says the group lobbied hard for a mandatory 8-hour training course for all primary care physicians last year, but the legislative proposal failed.
"We teach this course all the time. We can divide it up into one-hour lectures on the web. There is a way to educate physicians on the use of these controlled substances."
CME is, for now, the closest thing to mandatory requirements for physicians, and even those vary widely. For example, in Massachusetts, doctors who prescribe controlled substances are required to complete at least three hours in opioid education before renewing their license.
Tennessee, which AAPM's Twillman says comes closest to ideal, requires healthcare providers, including MDs, DOs, ARNPs, and PAs to complete 10 hours of CE during each license renewal period.
The White House's Office of National Drug Control Policy supports more provider education as well. Last week, it unveiled two online training videos. Doctors who watch them can receive 1.25 CME credits.
"These CME courses provide practical guidance for clinicians in screening their pain patients for risk factors before prescribing. They also help medical professionals identify when patients are abusing their medications, using videos that model effective communication about sensitive issues, without losing sight of addressing pain," says Gil Kerlikowske, Director of National Drug Control Policy.
A plan released by the White House last year aims to decrease prescription drug abuse by 15% by 2015.
Should health policy be a bigger part of medical students' education?
While most medical students feel obligated to put the Patient Protection and Affordable Care Act into practice, they don't understand much about it, a study shows.
The study's survey results, published in the Archives of Internal Medicine, are from a January 2011 survey of all medical students in Minnesota, asking three things about the PPACA:
Did students understand the PPACA;
Did they support it;
Were they obligated to help implement it?
More than half, 69%, said they did feel obligated to help implement the ACA. But, only 48% said they understood the basic components of it.
Students were surveyed just nine months after the President signed healthcare reform into law. The study's author, Tyler Winkelman MD, of the University of Minnesota, says even now, a year and a half later, he doesn't think the results would change.
"When we surveyed those students, the ACA was all over the news. I obviously don't have any evidence, because there hasn't been another survey like ours, but I don't think the results would be much different."
Winkelman's results mirror a similar survey of medical school deans in the U.S. in 2010 who said that their schools didn't offer enough health policy education. In that study, published in the New England Journal of Medicine in March 2011, 52% of schools said they were increasing health policy courses.
One issue, says Barbara McNeil MD, PhD, founding head of the Department of Health Care Policy at Harvard Medical School, is time.
"During their first year, medical students are required to take a course in health policy. It's a good time to give them a general background. But, for most medical students, it's very hard to put something in that's a required course during the clinical years. It's just the nature of the way the curriculum works."
McNeil also says scrutinizing the details of healthcare policies doesn't serve medical students well.
"Our goal is not to get into the nitty gritty of every little regulatory aspect. That's not appropriate for medical students. They need to think bigger picture."
Students at Harvard did start thinking about the broader issue of healthcare policy nearly ten years ago. That's when they launched the website, improveyourhealth.org. It supplements the policy issues that they don't get covered in the classroom or in residency.
This year, Harvard medical students have added something called "journal clubs," a small gathering of about 20-50 students who get together to discuss case studies on health policy.
Joanne Conroy MD, Chief Health Care officer for the Association of American Medical Colleges, says it's time to step up healthcare policy education at medical schools.
"Everybody's doing things within their own institutions, and there's probably a place for a very thoughtful curriculum to help educate future health professionals."
The AAMC is looking into forming a working group to address the issue, and Conroy believes they're close to coming up with a formal proposal for curriculum that could work during residency.
Despite what has been a more than month-long string of bad press for HCA, Inc., the financial performance of the nation's largest for-profit hospital operator hasn't weakened.
The latest blow came from the U.S. Department of Justice on Wednesday detailing the terms of a $16.5 million whistleblower suit against the industry giant. Still, HCA's stock price closed up 8 cents at $32.75 a share and its profits are robust, according to the company's latest quarterly report.
Healthcare industry analyst Sheryl Skolnick, PhD, of CRT Capital Group, says the hospital chain is weathering a tough investigative environment because of its size.
"To say that there's no financial impact? Sure, there is, but the company is so large and well capitalized that you don't see it. A smaller company might be more obvious," says Skolnick.
The DOJ agreement announced Wednesday says HCA agreed to settle allegations that two of its subsidiaries paid remuneration and other financial benefits to a doctors group in exchange for patient referrals.
In 2007, the DOJ alleges, HCA Physician Services (HCAPS) in Nashville leased space from Diagnostic Associates of Chattanooga, a physician's group, above fair market value, as an incentive to generate patient referrals to its Nashville location and to Parkridge Medical Center in Chattanooga, also a subsidiary of HCA.
Bill Killian, the U.S. Attorney for the Eastern District of Tennessee said in a statement, "Physicians should make decisions regarding referrals to health care facilities based on what is in the best interest of patients without being induced by payments from hospitals competing for their business."
HCA's Parkridge Medical Center is the third Chattanooga-area hospital since 2005 to get caught up in the DOJ's crackdown on healthcare fraud. In August, Memorial Health Care System agreed to a $1.3 million settlement for alleged kickbacks. In 2005, Erlanger Health System settled with the DOJ for $40 million.
As with most healthcare settlements, HCA's Parkridge facility will be subject to a corporate integrity agreement; it will last five years. In an e-mailed statement, Kathy Winn, Director of Marketing for Parkridge, said, "We are pleased the matter is concluded, and we will diligently fulfill the terms of the corporate integrity agreement."
HCA's latest settlement with the DOJ is the latest hit to the for-profit hospital chain, which, just a month ago, disclosed to investors on a second quarter earnings call that it was under a federal investigation by the DOJ for cardiac procedures performed at hospitals in Florida.
On the call, HCA pre-empted a New York Times investigation into its care of the indigent population and payment of ER doctors. That federal probe is ongoing and is unrelated to Wednesday's settlement. HCA stock closed down the day after the August 6th second quarter earnings call, but since then its stock price has risen by $6.96 per share.
"They're in very strong position, financially," says CRT's Skolnick. Perhaps because the company was only released from its eight-year CIA in 2009, she says she doesn't see evidence of a widespread problem at HCA. "The behaviors you learn while someone is watching your every move are hard to shake off," says Skolnick.
In fact, Skolnick says she was surprised last year when, at one of HCA's hospitals in Georgia, she had to pay for parking. "I had to pay because their view, under the rules, is you're not even allowed to give a patient or a doctor a gift of parking without it being considered an inducement. It was very interesting to see."
Skolnick says the healthcare industry, particularly at the hospital level, is under tremendous pressure to be in compliance with the Patient Protection and Affordable Care Act, which gives whistleblowers and federal agencies such as the Centers for Medicare & Medicaid Services, the Office of Inspector General, and the DOJ more tools to go after healthcare fraud.
"What energized the effort is a provision in the healthcare reform act that can very quickly turn what is an error in billing into a false claims act. So you have a lot more self-reporting. Whether it be Tenet, or HCA, or even specialty hospitals like HealthSouth, everybody knows it's a very hospital-investigative environment. It's tough, and the authorities are using that as their ammunition in already well-armored fight," Skolnick said.
The healthcare industry's opposition to federally required sequestration cuts will likely grow stronger this week following Friday's report from the Office of Management and Budget that shows $11 billion in annual cuts to Medicare over the next decade.
The OMB released its report under pressure from Congress to detail how sequestration would affect federal programs. The 394-page report shows an overall federal budget reduction of $109 billion annually through 2021.
More than half of the cuts come from a $5.8 billion reduction to the Hospital Insurance Trust Fund. Prescription drug funding is slated to be cut by $591 million. The National Institutes of Health's 8% budget reduction results in a $2.5 billion drop in funding which, according to the OMB, means less "scientific research, including needed research into cancer and childhood diseases."
Some federal programs are exempt by law. For example, defense spending on war and military readiness would not be subject to sequestration. Medicare also has some protection with $1.7 billion in Health Information Technology Incentive Payments and $84 million for the program's Hearings and Appeals process will remaining funded at 2012 levels.
At issue is whether or not Congress will truly let the sequester stand. The cuts will go into effect Jan. 3, 2013, unless members agree to either a budget that trims $ 1.2 trillion from the federal deficit or a short-term solution that delays sequestration. The general consensus is that nothing will be decided before November's elections.
"First, we only have three more days of Congress scheduled. How are you going to get a compromise in three days? Second, barring an act of war or terrorism I don't think you're going to see either the House or the Senate meeting between now and the election." says Congressman Jim Cooper (D-TN.).
Cooper has served in the U.S. House for over two decades and teaches health policy at Vanderbilt's Owen School of Management. He says hospitals might want to rethink their lobbying strategy.
"Medicare gets off light in sequestration. Cuts against other programs are four to five times larger. You know, healthcare is probably getting off light with sequestration given the gravity of nation's economic problems. This is the lightest cut they're likely to get," Cooper says.
While the overall cut to Medicare is a relatively small percentage cut, just 2%, the double-digit dollar figure will put hospitals in a tough spot.
"Hospitals will have to make tough choices about which services to maintain because of potential cuts since hospitals will maintain the highest quality for whatever services they provide," says Marie Watteau of the American Hospital Association.
The AHA already knew a 2% cut to Medicare would heavily impact hospitals. It, along with the AMA and ANA issued its own report, also last week, stating 766,000 healthcare and related jobs would disappear by 2021 if the sequester went into effect.
In a state-by-state comparison, California is shown to be hit the hardest with more than 50,000 job losses forecast for next year alone. The California Hospital Association says the Medicare sequester adds pressure to an already tense budget environment.
"We already are underpaid, and then you're looking at the cuts that are built into the Affordable Care Act, which are going to be $17 billion here in California between now and 2020, and then you add these additional cuts, hospitals can't sustain that. Sequestration makes an already very difficult situation worse," says CHA spokeswoman Jan Emerson-Shea.
Hospitals are also facing a cap on payments for outpatient services in hospitals. Those limits, proposed by the Medicare Payment Advisory Commission could save the federal government about $1 billion. The AHA and three other hospital associations are urging Congress to oppose the move.
The sequester has been on the table since last year when first, Congress, then, a joint committee of Congress, could not agree to a budget that included massive federal deficit reductions. With just three months remaining before the sequester goes into effect, both sides are under pressure to resolve their partisan stalemate.
