The House recently passed 25 bills to combat the opioid epidemic. While these bills will undoubtedly help, they do little to tackle some of the systemic drivers that have facilitated and still facilitate opioid prescriptions and over-prescriptions.
One such factor emanates from the physician reimbursement system. Recent research that I authored in “Healthcare Transformation” magazine explores this relationship.
The physician reimbursement system emphasizes procedures and interventions as opposed to cognition. It also emphasizes quantity at the expense of quality.
This reimbursement system has created enormous time pressures on physicians, particularly amongst front-line providers and in non-procedural specialties like primary care.
Unfortunately, the time pressures of medical practice have been getting worse and are most pronounced for the most complicated patients with the most medical and societal needs.
Research in the “Journal of General Internal Medicine” determines the average primary care physician (PCP) addresses 7.1 clinical problems in an average 20.9-minute visit. According to the study, that allows just 3.8 minutes per clinical issue.
In reality, the actual time per problem is likely less, with more time being spent on electronic medical records, box-checking and paperwork, which results in less time spent on patient care.
A 2016 survey by the Physicians Foundation of over 17,000 physicians found that only 14 percent of physicians had enough time to always practice high-quality care.
This time crunch has produced a myriad of unintended consequences. It can impede the ability of patients to understand their disease, treatment plan and follow-up procedure.
Research in the “American Journal of Public Health” found that time is a barrier to health maintenance measures that could detect serious diseases earlier. Additionally, research in “Preventive Medicine” found that time pressures inhibit nutrition counseling that could prevent the development of illnesses like diabetes and heart disease.
These activities take time and the physician reimbursement system does not align with time-consuming interventions.
Chronic pain is incredibly complex and its treatment, too, takes time. It takes time to explain alternative therapies to a patient such as physical therapy and cognitive-behavioral therapy. It takes time to have a conversation with a patient why opioids are not indicated when a patient is asking for them or demanding them. It takes time to counsel a patient about the risks of opioids and warn a patient about behaviors that can increase their risk. It also takes time for clinicians to monitor the risk of opioids and implement risk-mitigation strategies into their medical practice.
Unfortunately, under the current reimbursement system, health care providers lack this time. Consequentially, in addition to other harmful effects, it is very likely the reimbursement system and the time constraints it has created have contributed to the overprescribing of opioids and the magnification of their risks.
Does anyone believe the aforementioned can be done in 3.8 minutes? Parenthetically speaking, one has to wonder what medical issues, if any, can be addressed in 3.8 minutes.
In many ways the challenges that doctors face when treating chronic pain — declining reimbursements, time constraints, inadequate resources, competing and conflicting mandates and priorities, a runaway malpractice system — best reflects the challenges physicians faces in general.
Doctors and patients need a system that works for doctors and patients, not the system. Despite the attention the opioid epidemic has received over the past year, the systemic drivers of opioid prescribing remain in place.
To tackle these challenges, there are several proposals that policymakers and regulators can enact.
One solution would be for the Centers for Medicare and Medicaid Services to develop a “pain visit” dedicated solely to the management of chronic pain in primary care.
This would afford providers more time and resources to help their patients with chronic pain. It would offer the opportunity to focus solely on the evaluation and management of their patient’s chronic pain and not crammed between a cohort of other complicated comorbidities that their patients may have such as diabetes, heart disease, liver disease, chronic kidney disease and high blood pressure.
While the ultimate medical decision-making should be left to the education, experience and training of the physician trying to best meet the individual needs of the patient, a “pain visit” could serve as a template and ensure consistency in efforts to educate patients about the risks of chronic opioids, counsel patients about behaviors that exacerbate their risks, monitor risk and implement risk mitigation strategies.
Focusing solely on pain would give physicians the time to address their patients’ chronic pain, emphasize alternative therapies, minimize the use of opioids and ensure the risk of opioids are mitigated when indicated.
Another solution would be for government payers to adopt a more flexible reimbursement system that better elevates the education, training and experience of physicians to meet the unique and complex medical conditions of patients.
This would better match the demand for medical services with the supply of healthcare professionals and be a broader solution to a broader problem.
Congress and the administration are right to have prioritized the opioid epidemic. Yet doctors in the trenches need a reimbursement system that better aligns with the treatment of chronic pain and those efforts.
Jason D Fodeman, MD, MBA is a practicing physician. He specializes in delivery systems and health policy.
The views and opinions expressed in this commentary are those of the author and do not reflect the official position of The Daily Caller.