“The creatures cause pain by being born, and live by inflicting pain, and in pain they mostly die.”–C. S. Lewis
The problem of pain, from the viewpoint of British novelist and theologian C. S. Lewis, is how to reconcile the reality of suffering with belief in a just and benevolent God.
The American physician’s problem with pain is less cosmic and more concrete. For physicians today in nearly every specialty, the problem of pain is how to treat it responsibly, stay on the good side of the Drug Enforcement Administration (DEA), and still score high marks in patient satisfaction surveys.
If a physician recommends conservative treatment measures for pain–such as ibuprofen and physical therapy–the patient may be unhappy with the treatment plan. If the physician prescribes controlled drugs too readily, he or she may come under fire for irresponsible prescription practices that addict patients to powerful pain medications such as Vicodin and OxyContin.
Consider this recent article in The New Republic: “Drug Dealers Aren’t to Blame for the Heroin Boom. Doctors Are.” The writer, Graeme Wood, faults his dentist for prescribing hydrocodone to relieve pain after his wisdom tooth extraction. As further evidence of her misdeeds, he says, first she “knocked me out with propofol–the same drug that killed Michael Jackson.” Wood uses his experience–which sounds as though it went smoothly, controlled his pain, and fixed his problem–to bolster his argument that doctors indiscriminately hand out pain medications and are entirely to blame for patient addiction.
But what happens to doctors who try not to prescribe narcotics for every complaint of pain, or antibiotics for every viral upper respiratory infection? They’re likely to run afoul of patient satisfaction surveys. Many hospitals and clinics now send a satisfaction questionnaire to every patient who sees a doctor, visits an emergency room, or is admitted to a hospital. The results are often referred to as Press Ganey scores, named for the company that is the leading purveyor of patient satisfaction surveys. Today these scores wield alarming power over physician incentive pay, promotion, and contract renewal.
Now hospital payments are at risk too. Beginning in 2002, the Centers for Medicare & Medicaid Services (CMS) began work with the Agency for Healthcare Research and Quality (AHRQ) to develop a standardized survey of patients’ perceptions of hospital care, now known as the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. Press Ganey submits HCAHPS data to the government on behalf of its many clients. At first, the HCAHPS survey was intended as a tool to allow objective comparisons of hospitals on topics important to consumers, including:
How well doctors and nurses communicate with patients
How responsive hospital staff are to patients’ needs
How well hospital staff manage patients’ pain
Whether key information is provided at discharge.
But since 2007, hospitals that fail to report “required quality measures”, which include HCAHPS results, receive less payment from CMS. The government’s “Value-Based Purchasing” program bases only 70% of hospital performance scores on actual clinical care, and a full 30% on the HCAHPS survey’s report of the “patient experience of care”–including patient satisfaction with pain management.
“Never deny a request”
A patient who isn’t pleased with the experience of care may give bad marks overall, whether the problem was a long wait or a doctor who doesn’t heed requests for a medication or a test. But any physician who is associated with the low scores will earn the ill will of hospital administrators, who fear reduction of the hospital’s already slim Medicare/Medicaid payments, and of the CEO, whose salary incentive component may be at risk too. Never mind that Press Ganey scores are often based on small numbers of returned questionnaires, too small to be statistically significant.
Do these pressures affect how physicians deliver care? It would be surprising if they didn’t. A family physician, Dr. William Sonnenberg, wrote recently, “The mandate is simple: Never deny a request for an antibiotic, an opioid pain medication, a scan, or an admission.” He believes Press Ganey “has become a bigger threat to the practice of good medicine than trial lawyers.”
The Atlantic published a recent article: “When Physicians’ Careers Suffer Because They Refuse to Prescribe Narcotics.” The author, Richard Gunderman, highlighted the fallacy in satisfaction scores, noting that “patient perceptions may prove downright misleading.” Patients often visit multiple emergency rooms and physician offices asking for narcotics, Gunderman reported, and “the problem of prescription drug abuse and drug-seeking behavior is abetted by a robust and growing black market for prescription medications.” Still, physicians are at risk for being hired or fired on the basis of patient satisfaction data, without critical review of the source.
Do high patient satisfaction scores correlate with better health? Or higher quality care? So far, the answer is no. A recent study of hospitalized patients showed that many patients prefer “shared decision-making” with their physicians, but it results in longer inpatient hospital stays and 6 percent higher total hospitalization costs. A prospective study of over 50,000 clinic patients showed that the 25% who were most satisfied with their care had higher odds of inpatient admission, greater total expenditures, greater prescription drug expenditures, and–perhaps most surprising–higher mortality.
Forbes writer Kai Falkenberg, in her article “Why Rating Your Doctor Is Bad For Your Health,” concluded that “giving patients exactly what they want, versus what the doctor thinks is right, can be very bad medicine.”
Today, over 12% of primary care visits and over 32% of emergency department visits involve opioid or benzodiazepine prescriptions, according to the results of a study presented last month at the American Academy of Pain Medicine’s annual meeting, and these rates are steadily increasing. The study’s co-author, Dr. Ming-Chih Kao, said that between 1999 and 2006 there was a 250% increase in fatal overdoses in the US, and more than half involved more than one drug, usually opioids and benzodiazepines. Patients may lack resources to cover services like physical therapy and mental health treatment, and they urge physicians to prescribe opioids and benzodiazepines instead.
The recent history of opioid use and abuse in the US illustrates how well-intentioned actions so often have unintended consequences. There was a time when physicians hesitated to prescribe opioids even for cancer pain, let alone non-malignant pain, for fear of addiction. That philosophy started to change in 1986, when Dr. Russell Portenoy published a paper in the journal Pain concluding that “opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse.” Pharmaceutical companies began to promote new formulations including OxyContin for the treatment of pain.
A major upswing in the government’s interest in pain management followed in the 1990s, as the AHRQ issued guidelines advocating more aggressive treatment of pain. In 1998, the Veterans Health Administration premiered a national strategy intended to improve pain management for its patients, and defined “Pain as the 5th Vital Sign”. The new strategy required use of a numeric rating scale for pain in all clinical encounters. The Joint Commission quickly added the achievement of low pain scores to its measures of hospital quality, and issued a major monograph in 2003 called “Improving the Quality of Pain Management Through Measurement and Action.” CMS began to rate hospitals on the basis of patient satisfaction scores, and the rest is history.
Now political pressure in the opposite direction–against narcotic prescription–is escalating, as the Centers for Disease Control and Prevention is urging doctors to use opioids more sparingly. The state of Washington passed a law restricting opioid prescription, and other states are considering similar measures, while patients with chronic pain scramble to find treatment. In 2010, a new formulation of OxyContin was introduced in order to make it more difficult to dissolve or crush. The result, reported in the New England Journal of Medicine in 2012, was that the selection of OxyContin as a primary drug of abuse decreased, but the abuse of other opioids–including fentanyl, hydromorphone, and heroin–rose markedly.
Physicians are caught in the vise between patient satisfaction surveys and the epidemic of prescription drug abuse and overdose. Government and regulatory intervention, as well-intentioned as it may have been, has only led to worse problems and disastrous outcomes. Fed-up physicians are leaving clinical medicine for jobs in hospital administration, consulting, or industry wherever they can. Is anyone surprised?