Why CMS Should Not Remove Pain Questions

Why CMS Should Not Remove Pain Questions From Payment Calculations – Pain Medicine News – Oct 13, 2016

The Centers for Medicare & Medicaid Services recently recommended removing pain questions from the Hospital Consumer Assessment of Healthcare Providers and Systems survey, which would remove pain questions from payment calculations. This is an alarming development for many reasons.

The Affordable Care Act promotes a new paradigm of patient-centric health care and seeks to empower patients. Removing pain questions from the survey essentially removes pain control from their power:

Patients will suffer pain to the extent that their health care providers permit it, and they can do very little about it.

This is the very antithesis of the patient-centered model. We need to give a voice to our patients, not silence them.  

The obvious motive behind this action is an attempt to reduce opioid abuse.

This is based on the false and ridiculous notion that pain control is achieved solely through opioid therapy, and that opioid therapy is being administered carelessly and without appropriate safeguards.

This monolithic view of opioids as the one and only source of pain control is not true in most clinical practices. Patients in pain may be treated in any number of ways.

We cannot stop treating pain simply because one type of pain therapy has become the subject of abuse.

Uncontrolled pain is dangerous. It not only causes unnecessary suffering for patients; it can delay or inhibit rehabilitation and prolong hospital stays.

Untreated acute pain can transition into maladaptive chronic pain, which can be a lifelong problem that is challenging to treat and is associated with disability.

Pain specialists in particular are well trained in the nuances of opioid therapy, and can identify appropriate patients and supervise them properly.

Denying opioid therapy to a patient who truly needs it to reduce suffering and ensure a safe, speedy recovery is akin to not allowing anyone to drive a car because some people drive recklessly.

With proper clinical education and pain specialists at the vanguard, opioid therapy can be prescribed safely and appropriately.

However, this does not mean that opioid therapy will be prescribed to all pain patients—that is not the case now, and it is unlikely to be the case in the future. Opioids are but one tool in the toolbox.

Most pain specialists can and do prescribe opioids—but not to all patients and not in all situations. The notion that a physician hears the word “pain” and instantly writes a prescription for opioids in a knee-jerk reaction is simply not accurate.

Pain control has been recognized internationally as a “fundamental human right.”

If we stop measuring pain control,
we essentially dehumanize
the patients we are under oath to serve.

This is absolutely right. By muzzling patients, the medical model is effectively removing the patient from their own care and giving the doctor absolute authority, constrained only by the DEA.

patients who are burdensome to the system. These so-called “difficult patients” include heroin addicts, high-dose opioid-dependent patients, and patients who enter the system with unrealistic demands and expectations about how they will be medicated.

Not all pain patients fall into this category, and it is important not to penalize the majority of patients for the behaviors of these “difficult patients” who are fueling the opioid epidemic

Questions on the survey ask how well a patient’s pain was managed and not whether that pain was completely eradicated.

As clinicians, we can perhaps do a better job to promote realistic expectations in our patients. Patients must understand that while pain can be effectively managed, it may not be possible to entirely eliminate it.

The opioid abuse epidemic cannot be stopped by simply pretending that pain does not exist.

Our patients deserve pain control—it is their right—and as physicians, we must continue to talk to our patients frankly and fearlessly about pain.

Author: Melanie Rosenblatt, MD, has managed an inpatient pain service at a Level II trauma center, which exceeds the 90th percentile in pain scores nationally without “encouraging the overuse of opioids.”

Indeed, the hospital setting is an ideal place to treat patients with complicated painful conditions and substance abuse.

While these patients must not be denied pain treatment, it is not appropriate to overprescribe opioids to them, or anyone else. The answer resides in a balanced but compassionate solution that treats pain while recognizing and addressing the mechanisms of abuse and addiction.  


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