Letter to Mr. Andrew Slavitt, Acting Administrator of the Centers for Medicare and Medicaid Services - Finalize Rule Combating Opioid Epidemic, Implement PROP Act

Letter

Dear Acting Administrator Slavitt:

I write regarding a proposed rule by the Centers for Medicare and Medicaid Services (CMS) to remove the pain management dimension from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey for the hospital Value-Based Purchasing Program beginning in Fiscal Year (FY) 2018. I support this proposal, and I write to highlight the numerous other comments that were filed in this proceeding also supporting such an approach. I also write to request regular briefings on CMS's progress in evaluating the comments and implementing the rule change.

The National Institute on Drug Abuse (NIDA) reports that "[o]ver 2 million people in the United States suffer from substance use disorders related to prescription opioid pain relievers," and that while the "causes are complex . . . they include overprescription of pain medications." This is particularly alarming, as the current drug czar recently testified to my Committee that "four out of five newer users to heroin started by misusing prescription pain medication." Thus, the overprescription of pain medication has led to an opioid epidemic in this country.

As a result of this epidemic, my home state of Wisconsin has seen a spike in overdose deaths. According to a witness at a Committee field hearing convened in Wisconsin, in 2015 "Milwaukee County alone reported 109 heroin-related overdose deaths," up from 31 in 2008. Fentanyl, a stronger opioid than heroin, has already been responsible for 30 deaths in Milwaukee County, Wisconsin, in the first three months of 2016. To address this epidemic, on April 7, 2016, I, along with Senators Manchin, Barrasso, and Blumenthal, introduced S. 2758, the Promoting Responsible Opioid Prescribing (PROP) Act to reduce the pressure doctors currently face that may lead to overprescribing. Specifically, the PROP Act prohibits pain management questions on patient surveys from being factored into Medicare reimbursement calculations. In July 2016, CMS recognized the importance of this proposal and proposed to remove pain management questions from hospital payment calculations.

CMS suggested that this change was proposed "in an abundance of caution" to remove any potential incentive for health professional to over-prescribe pain medication in order to receive a higher score from patients. CMS's reluctance to recognize this as a problem has motivated me, and others, to emphasize the facts in this proceeding. As one commenter wrote, "I would disagree with the assertion that there is no published data regarding the correlation between patient satisfaction metrics and provider behavior." He went on to explain: "there is most definitely a perception in the practicing community that withholding opiate prescriptions when demanded by the patient will lead to consequences on patient satisfaction metrics."

Comments to CMS's proposed rule were due on September 6, 2016. Upon review of these comments, there appears to be overwhelming support at every level of the healthcare profession for CMS to move forward in eliminating pain management questions from the HCAHPS survey. As one pain management physician pointed out, these questions "ABSOLUTELY result[] in increased narcotic prescribing in the inpatient and outpatient setting, and also contributes to higher rates of adverse patient events due to narcotics." A nurse of 21 years elaborated: "Physicians will give pain meds to patients so they don't receive negative patient satisfaction scores. Their pay is often directly related to that scoring system. Our nation has raised a whole new generation of people who expect a pill to fix them." Similarly, a neurosurgeon wrote "we need to treat our patients' pain, but within reason." Finally, a hospitalist explained that these questions, "led to increased opiate prescribing at our facility and inappropriate prescribing at that." This commenter went on to explain: "The number of times I have heard from physicians at not just our facility but other facilities throughout the city, that they feel forced into prescribing opiates in spite of their better judgment due to patient satisfaction surveys is astounding."

Not only did the medical community weigh in with your proposal, but concerned parents did as well. A commenter from North Carolina explained how his daughter was prescribed opioids after she had to have eight teeth pulled in preparation for braces. The parent asked the doctor why an opioid was prescribed over ibuprofen. The doctor responded that "he prescribed the opioids not because it was the right choice for the patient but rather because he was concerned about dissatisfaction among patients and their parents if opioids were not prescribed." As this commenter concluded "Perception by the patients of what was best, not what the research found most effective ruled the day."

Beyond individual testimonials, a host of hospitals and associations across the country also weighed in in support of the CMS proposal. The American Academy of Physician Assistants noted such a reform "helps mitigate the country's severe opioid addiction problem by reducing over-prescribing." The Emergency Nurses Association, American Association of Orthopedic Surgeons, Association of American Medical Colleges, American College of Physicians, PhRMA, American College of Surgeons, American Hospital Association, National Rural Health Association, and the American Medical Association also filed comments supporting the proposed rule.

Finally, at a state and local level there is also broad support for this approach. For example, the Rural Wisconsin Health Cooperative wrote: "By removing this metric from VBP calculations, the providers can implement their best judgment about managing the patient's pain . . . . Our goal is that over time we will see a reduction in opiate use in the rural population while simultaneously improving pain management." This sentiment was echoed by the Hospital and Healthsystem Association of Pennsylvania, California Medical Association, Healthcare Association of New York State, New Hampshire Hospital Association, New Jersey Hospital Association, and Missouri Hospital Association.

One commenter eloquently concluded, "Removing this sword of Damocles will help to alleviate the perverse incentive created by regulatory bodies to over-prescribe." I agree with this assessment. Based on the record described above, I urge CMS to quickly move forward to adopt a final rule in this proceeding that pursues the same goals as my bill, the PROP Act.

During the Committee's field hearing in Wisconsin, Dr. Timothy Westlake, the Vice Chairman of the State of Wisconsin Medical Examining Board, testified that the PROP Act is "the single-most important piece of legislation reform that [policymakers] could do." I will continue to work in Congress to advance this bill. Given the importance of this rule in stemming the tide of opioid abuse in Wisconsin and across the country and the overwhelming support for the change among doctors, administrators, and patients, I respectfully urge you to implement the rule as soon as possible and provide the Committee with regular briefings on your progress.

Thank you for your prompt attention to this matter. If you have any questions about this request, please contact Brooke Ericson of the Committee staff at (202) 224-4751.

Sincerely,

Ron Johnson

Chairman

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