Advancing Sound Policy
As the Academy engages with policymakers, our leaders have considered both the growing challenges related to managing pain with opioids and the need for ready access to these medications by patients with serious illness or at the end of life-patients for whom high-dose opioids may be medically indicated. Acknowledging the indisputable public health imperative to curb the opioid epidemic, AAHPM points to an equally important public health imperative: ensuring our sickest, most vulnerable patients receive appropriate treatment of their pain and suffering.
AAHPM has cautioned legislators and regulators against a “one-size-fits-all” approach to policymaking that assumes all pain is the same and that high prescribing must be inappropriate prescribing. The Academy has routinely opposed policies that would limit dosage or duration of opioid prescriptions-such as those being enacted in many states and more recently proposed by the Centers for Medicare & Medicaid Services (CMS)-as they would unduly burden patients with serious illness.
“In the wake of the opioid crisis, AAHPM has been a strong voice advocating for balanced public policy,” said Public Policy Committee Co-Chair Kyle P. Edmonds, MD FAAHPM. “We’re working with other stakeholders to promote solutions that maximize individual and public safety. At the same time, we must push back when there are efforts to essentially legislate the practice of medicine and fight to maintain the ability to individualize treatment to patients’ needs.”
Emerging Proposals
In 2017, the Academy of Integrative Pain Management reported tracking more than 1300 bills and nearly 500 regulations related to pain management at the state and federal levels. Policies focused on a myriad of issues, including prescribing guidelines, mandatory CME/CE, prior authorization, pain clinic regulation, availability of treatment for substance use disorder, naloxone distribution/administration and Good Samaritan protections, safe disposal, coverage of non-pharmacological treatment, abuse-deterrent opioids, and more.
In 2018, it’s been just as challenging to keep up with emerging policy. In Congress, more than 100 bills have been the subject of congressional hearings on the opioid crisis. At the end of April, the Senate Health, Education, Labor, and Pensions (HELP) Committee unanimously advanced S. 2680, the Opioid Crisis Response Act of 2018, which includes more than 40 bipartisan proposals from 38 senators. In the House of Representatives, the Energy and Commerce Committee in early May advanced more than 20 opioid-related bills, while the Ways and Means Committee had plans to consider four thematic packages of opioid-related legislation based on bills introduced by members from both parties.
AAHPM has been working to monitor these congressional proposals and recommend changes that would support patients with serious illness. The Academy also responded to a Senate Finance Committee request for stakeholder input on how to improve Medicare, Medicaid, and human services programs’ responses to the opioid epidemic. “It is important for AAHPM and its partners to weigh in to ensure that the pendulum does not swing too far, to maintain access to opioids for those receiving hospice or palliative care,” explained Sue Ramthun, AAHPM’s lobbyist with Hart Health Strategies. “As part of that process, it’s clear that more education is required with respect to palliative care-what it means, how it is used, and how patients benefit. As the experts, it is critical for AAHPM and its members to continue to serve as a resource to Congress on these important issues.”
AAHPM has also promoted the Palliative Care and Hospice Education and Training Act (PCHETA)-a bill developed by the Academy-in the context of the opioid crisis. This bipartisan legislation would increase research in pain, palliative care, and symptom management; expand palliative care education and training, elevating the knowledge of appropriate prescribing of controlled substances across providers and specialties; and offer career awards and incentives to ensure there are palliative care-trained faculty in medical, nursing, and other health professions schools who can incorporate appropriate pain management education into their teaching. U.S. Senator Tammy Baldwin (D-WI), who introduced PCHETA in the Senate, filed the bill as an amendment to the Opioid Crisis Response Act when it was in committee.
AAHPM has also promoted the Palliative Care and Hospice Education and Training Act (PCHETA)-a bill developed by the Academy-in the context of the opioid crisis. This bipartisan legislation would increase research in pain, palliative care, and symptom management; expand palliative care education and training, elevating the knowledge of appropriate prescribing of controlled substances across providers and specialties; and offer career awards and incentives to ensure there are palliative care-trained faculty in medical, nursing, and other health professions schools who can incorporate appropriate pain management education into their teaching. U.S. Senator Tammy Baldwin (D-WI), who introduced PCHETA in the Senate, filed the bill as an amendment to the Opioid Crisis Response Act when it was in committee.
AAHPM recently relayed concerns regarding the 2019 update of policies for Medicare Advantage and Part D plan sponsors, which proposed new strategies to address opioid overutilization, including a days supply limit for opioid-naive patients, enhanced use of the Overutilization Management System, real-time care coordination safety edits, and use of quality measures. Reflecting input from the Academy and other stakeholders, CMS’s final rule for opioid coverage under Part D recommends that “beneficiaries who are residents of a long-term care facility, in hospice care, or receiving palliative or end-of-life care, or being treated for active cancer-related pain be excluded” from particular interventions.
AAHPM has been working with partners in the PQLC to develop guidance the Department of Health and Human Services might use when implementing exclusions for palliative care, acknowledging the limitations in doing so. “We don’t already have a consensus in our field on how to identify patients-or clinicians-for a palliative care exemption, nor do we have time to develop one before opioid policies are implemented,” said AAHPM Chief Medical Officer Joe Rotella, MD MBA HMDC FAAHPM. “The rush to find solutions to the opioid crisis won’t wait for us to take a scientific approach. Whatever we propose will be flawed, so it is important that we stay engaged with regulators at all levels on an ongoing basis.”
Collaborating for Success
For a smaller medical society like AAHPM, working in collaboration with other stakeholders-such as the PQLC, the National Coalition for Hospice and Palliative Care, and the American Medical Association Opioid Task Force, where AAHPM is an active member-is key to advancing our priorities. Last fall, AAHPM Advocacy and Awareness Strategic Coordinating Committee Chair Gregg VandeKieft, MD MA FAAHPM, represented the Academy at the inaugural Integrative Pain Care Policy Congress. Attendees from more than 50 organizations considered joint strategies for promoting individualized care for people with pain.
AAHPM staff also connect with counterparts at the State Pain Policy Action Network and member organizations of the State Hospice Organizations Executive Roundtable. Such collaboration has allowed the Academy to alert members to action by state medical boards and opportunities to respond.
Some states have sought to address the opioid epidemic by setting requirements for establishing a physician-patient relationship by direct physical exam as a prerequisite for prescribing. Given the realities of hospice practice, policies that are overly restrictive in this regard will be untenable for hospice physicians and threaten patient care. Public Policy Committee Co-Chair Phil Peterson, MD CMD FAAHPM, expressed concerns about such efforts. “More of my colleagues are feeling pressured and scrutinized by reactive policies at the state level making it more difficult to prescribe opiates even in the hospice setting. Some providers are now reluctant to prescribe, while others consider leaving hospice practice to avoid the issue.”
To help guide emerging policy, Peterson is leading an AAHPM workgroup tasked with developing an Academy statement on establishing the physician-patient relationship for the purpose of prescribing controlled substances in the hospice setting. The goal is to help define a safe standard for prescribing in the context of high-quality hospice care and address safeguards against inappropriate prescribing and diversion. The workgroup includes representatives from the Board, Hospice Medical Directors Council, Public Policy Committee, Substance Abuse and Diversion SIG, and an AAHPM past president.
In the meantime, Peterson encourages Academy peers to join the State Healthy Policy Discussion Community on AAHPM Connect to communicate with colleagues about issues facing your state, ask advice, and share resources and best practices for advocacy.
Jackie Kocinski is AAHPM’s director of health policy and government relations. For more information or questions about the Academy’s policy efforts, e-mail [email protected].