As the opioid epidemic continues to dominate our national attention, states are enacting rules on opioids, on benzodiazepines, and other controlled substances.
The Challenges Facing Pain Management Clinicians
Managing pain patients can be a scary thing these days. It seems that every time I open the newspaper or check my email I read a story about a doctor getting into trouble of some sort or another related to prescribing opioids. There are cases of doctors being federally prosecuted and convicted of criminal charges, instances of physicians losing their medical licenses from state medical boards, and plenty of examples of providers getting dropped from insurance networks for having prescribing patterns that don’t line up well with the company’s metrics. As such, companies now examine claims data from insurance companies and measure the performance of healthcare providers relative to their peers or other set measures. These comparisons can then be used against those providers. In short, with constantly inscreasing regulations around prescribing and managing chronic pain, there is no shortage of ways to get into trouble when it comes to prescribing controlled substances.
Check out our state-by-state prescriber resource guide.
Balancing Good Bedside Care and Increasing Regulatory Oversight
Amidst this fear of regulatory action, most of us are simply trying to take care of our patients the best we can. For us, it keeps getting harder and harder to do the right thing and comply with an ever increasing regulatory burden. I feel like there is a new set of guidelines coming out every year that we must learn and follow. There are state prescribing guidelines, CDC guidelines, and multiple different insurance company policies. These guidelines range from very broad clinical recommendations to specific and quantifiable rules to follow. In addition, many states have passed laws related to opioid prescription practices. This is particularly scary for us, because none of us want to accidentally break the law by overlooking a detail that is now mandated by law.
It becomes an almost unmanageable task to keep up with all of the guidelines and laws. The documentation alone requires a mountain of paperwork. When we are already pushed to see more patients in less time, we certainly don’t have time to spend on extra paperwork. When I think back to my medical school application process, I didn’t aspire to be a physician so I could do paperwork. Some aspects of safe opioid prescribing require face to face time with the patient and there is never any substitute for that. Fortunately, there are ways to minimize the burden of paperwork associated with documenting good patient care.
Using Software Tools to Effectively Manage Regulatory and Documentation Requirements
It was once true that doctors could simply focus on patient care and everything else would just fall into place. Unfortunately, that time has passed. It is now imperative that we not only follow these guidelines and regulations but clearly document that we have done so. Like we have all heard before, “If you didn’t document it, you didn’t do it.” Failure to follow these rules can expose a healthcare provider to civil and criminal liability, insurance network exclusions, and licensure actions. There are many resources available for a practice to utilize to make sure that they are compliant. Some of these tools can be combined from multiple different sources such as patient advocacy groups and specialty societies. Trying to make sure that you have all of the appropriate measures, forms, and documentation in place on every patient every time is a daunting challenge. No one wants to get into trouble because they simply forgot to check all the boxes on one single patient. Fortunately, there is a digital health company, AffirmHealth, that uses technology to help effectively facilitate and manage compliance for practices like mine. Here's a link to a post outlining their value proposition and the customers they serve.
AffirmHealth has compiled these different tools into a complete compliance platform. The system translates multiple state controlled substance monitoring databases into an easy to translate format with graphics that measure daily dosing equivalents, percentages of long and short acting opioids, and changes in dosing over time. These reports are automatically generated based on your schedule of patients for the day. It also creates documentation that you checked the database as required. There are also tools for clinical staff to calculate pill counts with ease. It is also able to confirm whether you have the appropriate documentation in place for informed consent, functional measures, abuse and risk screening. Perhaps most importantly, the AffirmHealth solution provides an automated protocol to adjust the level of compliance monitoring based on the patient’s risk level. This gives clear reasoning for how many urine drug screens you order or how frequently you see the patient for follow up visits. All of these things are possible with paper documents and scanned forms, but this can be disorganized and require unnecessary time commitments from staff. With this platform you can relax knowing that your compliance protocol is in place and you can clearly document that. You can also minimize concerns about insurance or other audits. This assurance can give a provider the peace of mind to concentrate on taking care of the patient instead of worrying about paperwork. Here's a post on how the platform helps with determining risk and documentation to demonstrate medical necessity.
The AffirmHealth solution has greatly improved my practice's ability to efficiently manage regulatory and documentation requirements. If you have been looking for a software solution to help with the management of regulatory compliance, I highly recommend reaching out to the AffirmHealth team. If you're interested in learning more, click the link below:
About the Author: Dr. Blake is a practicing pain physician in Chattanooga, TN. He is the medical director of Specialists in Pain Management and has been practicing there since 2009. His practice is a multi-disciplinary pain program that includes physical therapy, psychology, medication management, and multiple different injection therapy options. Dr. Blake graduated from University of Alabama Medical School where he completed his residency in Anesthesiology. He went on to complete a fellowship in Pain Medicine at UAB. Dr. Blake served as the chairman of the Tennessee Medical Association’s Chronic Opioid Guidelines Committee and was a member of the Tennessee Department of Health’s committee that developed the Tennessee Chronic Pain Guidelines. He is the immediate past president of the Tennessee Pain Society , serves on the board of the Tennessee Society of Interventional Pain Physicians, and is the chairman of the Neurospine Committee. Dr. Blake is also a member of the Governor’s task force on opioid abuse.
Defining Patient Risk and the Challenges of EHR Integration
How does your practice define patient risk to decide the services you may provide, the laboratory tests you may order and/or the prescriptions you may write? Another important question in today’s environment--How do you document these multi-layered facets within your EHR system?
Treating chronic pain in 2018?
One of the questions we get most frequently when we discuss AffirmHealth is, “who are your customers?” It’s a fair question and broadly speaking, our customers are two-fold: clinical providers and the patients they serve. The second follow on question that occasionally comes up is, “do you want to get rid of all opioids?” To be clear, our goal is not to eliminate opioids. In fact, we firmly believe in the viable role that opioids have in pain management. But we also believe that responsible opioid prescribing must be practiced within the boundaries of a relationship founded on trust between the physician and the patient. Our products are designed to help develop that relationship so that both providers and patients can manage these prescriptions as safely as possible. Recognizing that different medical specialties have different regulatory demands, we offer solutions in three practice areas:
When we first founded AffirmHealth in April 2016, we had one goal: to make opioid prescribing safer for patients and providers. We did that by automating state opioid database queries so that they integrated with clinicians’ workflow and improved patient safety, maximized provider efficiency, and fixed a headache for both patients and providers. In 2018, we are going to be dramatically expanding that offering and I wanted to spend some time explaining our value proposition and how we support practices that use our services. Our focus is still the same: we recognize that opioids have a critical role in the management of pain. But even one overdose is too many. Our goal is to make sure we help drive that number to zero.
This past week, several of our nation’s public health experts testified on Capitol Hill before the Senate Health, Education, Labor, and Pensions Committee. They made the concerning argument that despite all of the effort and attention being cast on the national opioid epidemic, we are failing to make significant progress. In fact, we are continuing to lose ground and opioid related deaths continue to accelerate across the country.
With all of the recent attention cast on the national opioid epidemic and the increase in overdose deaths, one issue that seems to have fallen out of focus is the need for increased scrutiny on concomitant drug prescriptions, particularly benzodiazepines. The combination of opioids and benzodiazepines was found to be dangerous enough that dual prescribing of the two medications caused the FDA to issue black box warnings when prescribing each of these medications in 2016. An article originally published in Clinical Advisor (March 2017) makes two important points:
At AffirmHealth, we're passionate about improving the processes needed to manage chronic pain safely. In the past, I've written several times about the patient-physician relationship and the complex parts of managing those relationships in the setting of our national opioid epidemic. This morning, CNN published an interesting article that highlights another side of the problem: the increasing legal issues that physicians are facing as they navigate the pain management landscape. I share it here not so much to give a direct opinion on the issue, but because I feel that it's important that we all engage in a discussion informed by everyone's viewpoint. This article goes a long way to sharing the evolving physician and law enforcement perspective. The following is directly reprinted from CNN:
A few days ago, Mark Jarrett penned a provocative online op-ed on The Hill website, “Congress, take an Ebola inspired approach to the opioid epidemic.” He made several interesting points including the following: in 2015, the opioid epidemic claimed 33,000 American lives compared to 11,000 worldwide from Ebola from 2013 to 2016. During a period from 2014-2015, I was fortunate to serve as a White House Fellow and Acting Director for Pandemic and Emerging Threats at the U.S. Department of Health and Human Services and was intimately involved with the domestic and international Ebola response so I found this point particularly remarkable. Without question, the Ebola outbreak was a full blown international crisis, so it’s quite striking that our own domestic health crisis around opioid abuse is only now beginning to get the full attention it deserves even though the scale of magnitude is three times greater than the Ebola epidemic. I believe there are many reasons for this including the particularly heinous way that Ebola causes disease and its portrayal in popular media. At the same time, I suspect that the relatively insidious onset of the opioid epidemic and the fact that these medications are often prescribed legally by medical professionals allowed us to look the other way while it took its full hold. Either way, we now find ourselves in the midst of a national crisis that is claiming close to 100 American lives every day.