SHM Submits Comments to CMS on OPPS Proposed Rule

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attn: CMS-1656-P
Baltimore, MD 21244

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Dear Acting Administrator Slavitt:

As the representative organization for the nation’s nearly 52,000 practicing hospitalists, the Society of Hospital Medicine (SHM) is pleased to see the proposed removal of the Pain Management dimension of the HCAHPS Survey in the Patient- and Caregiver-Centered Experience of Care/Care Coordination domain of the FY 2018 and 2019 Hospital Value-Based Purchasing (VBP) Program, as outlined in the proposed rule entitled Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Organ Procurement Organization Reporting and Communication; Transplant Outcome Measures and Documentation Requirements; Electronic Health Record (EHR) Incentive Programs; Payment to Certain Off-Campus Outpatient Departments of a Provider; Hospital Value-Based Purchasing (VBP) Program.

Hospitalists play a critical role in hospitalized patients’ pain management, and we recognize this as an important aspect of improving patient experience. Yet, recent nationwide attention has focused on the dramatic and increasing rate of opioid prescribing and prescription opioid overdose-related deaths in the United States. According to the Centers for Disease Control and Prevention (CDC), over 18,000 Americans died of a prescription opioid drug overdose in 2014, more than any year on record.¹ Emergency Departments across the country now treat more than 1,000 people every day for misusing prescription opioids.² With nearly 2 million Americans abusing or dependent on prescription opioids, the situation is clearly at epidemic proportions.

Factors driving increased prescribing and use of opioid pain medications are multifactorial and nuanced. However, in principle, prescription opioid use is targeted at the relief of pain and suffering associated with physically painful conditions. Indeed, pain is a frequent symptom encountered in the hospital setting and one of the most common reasons for hospital admission. Consequently, hospitalization has been found to be a time of increased usage of opioid analgesics to control pain. Unfortunately, inpatient opioid use has been linked to in-hospital complications and subsequent outpatient use and addiction. Severe opioid-related adverse events also occur more frequently at hospitals with higher opioid-prescribing rates.³

Given the frequency with which it is encountered and the impact on patient experience, it is clear that optimization of pain control must be balanced with the risks of the medications used to treat pain in order to avoid the unintended consequences of opioid-related adverse events and death. Complicating effective inpatient pain management is the absence of evidence-based guidelines or uniformly used scales by which to measure and treat pain, highlighting the subjective nature of pain and its impact on an individual’s experience of care. As physicians who care for patients in the hospital, hospitalists must therefore work to construct a careful and individualized approach to pain management for each of their patients. Ideally, these plans should help alleviate pain and minimize risks of dependence and overdose.

Although designed to evaluate patients’ hospital experience, the HCAHPS survey pain assessment questions (i.e. During this hospital stay, did you need medicine for pain? How often was your pain well controlled? How often did the hospital staff do everything they could to help with your pain?) are providing a perverse incentive for the overprescribing of opioid medications as a component of “everything” available to physicians to treat pain. Thus, we strongly support CMS’ decision to suspend the questions around pain management within the Hospital Value-Based Purchasing (HVBP) program.

Linking a patient’s experience of pain management into the hospital value based purchasing program, as the HCAHPS survey has done, is misguided and potentially dangerous. The current questions in the HCAHPS survey regarding pain do not recognize the difficulties and subtleties impacting decisions around acute (and chronic) pain management in the hospital, which often requires multiple assessments and discussions to achieve adequate yet safe pain control. Additionally, many hospitals link HCAHPS scores with individual or group physician incentives, despite this not being its intended use. Due to fear of patient dissatisfaction and poor HCAHPS score performance, these questions may either directly or indirectly influence practice, risking dangerous prescribing on the part of hospital medicine physicians, as well as potentiate ongoing addiction in certain individuals. Thus, we support and look forward to the Department of Health and Human Services (HHS) study of the unintended consequences of the Pain Management dimension of HCAHPS and adverse opioid prescribing patterns.

We take keen interest in CMS’ development of alternative questions for the Pain Management dimension to help remove the uncertainty and the intimation that opioids are a requirement for “everything” to be done for pain management. An example of a positive shift in verbiage is question 15 of the Outpatient and Ambulatory Surgery (OAS) CAHPS which asks: “Some ways to control pain include prescription medicine, over-the-counter pain relievers or ice packs. Did your doctor or anyone from the facility give you information about what to do if you had pain as a result of your procedure?” Other potential replacement questions that evaluate a patient’s hospital stay should focus on:

• Assessing the patients’ pain versus treating it, particularly focusing on pain functions over symptoms, as they are more readily measureable.
• Whether a pain control plan was discussed with the patient, including discussion of risk and benefits of opioid medication when prescribed and the potential for use of alternative, non-opioid therapies and should include specific examples of non-narcotic options available for patients.

SHM is very interested in being involved in future developments and would welcome the opportunity to work with CMS on refining these questions. These are important steps to keep patients safe while also working to improve patient experience – principles we share. We appreciate CMS’ responsiveness to stakeholders’ concerns on this matter. We feel there is much more work to be done, and we would appreciate the opportunity to continue to partner with CMS in efforts to reform and advance the safe, effective, and quality care of our patients.

Sincerely,

Brian Harte, MD, SFHM
President, Society of Hospital Medicine

¹ Opioid Data Analysis. (2016). Retrieved June 22, 2016, from http://www.cdc.gov/drugoverdose/data/analysis.html
² Prescription Opioid Overdose Data. (2016). Retrieved June 22, 2016, from http://www.cdc.gov/drugoverdose/data/overdose.html
³ Herzig, S. J., Rothberg, M. B., Cheung, M., Ngo, L. H., & Marcantonio, E. R. (2014). Opioid Utilization and Opioid-Related Adverse Events in Non-Surgical Patients in U.S. Hospitals. J Hosp Med. 2014;9(2):73-81.