- Latest tactic in opioid control: Take pain out of the mix in patient survey



Overdose Deaths
OxyContin pills.

Doctors have long complained about patients demanding inappropriate treatment, especially addictive opioid painkillers. Many say they feel forced to comply for fear they will be rated poorly by patients on the internet or even more official surveys.

Now the Obama administration, acknowledging the potential power of bad reviews, is proposing to remove pain management from a patient satisfaction survey that is mailed to hundreds of thousands of people after they are released from the hospital.

The goal: Reduce the toll of opioid addiction, which has killed more than 150,000 Americans over the last decade. Most of them, including a majority of those who overdosed on heroin, started with doctors' prescriptions for such painkillers as Vicodin and OxyContin.

Survey questions about pain have "undoubtedly fueled a massive increase in opioid prescribing," said David R. Gastfriend, former CEO of the Philadelphia-based Treatment Research Institute.

Responses to the federal survey play a role in future Medicare reimbursements. Hospitals, hoping to prevent costly penalties - and wanting to satisfy patients - hire consultants to advise doctors and nurses. Some clinicians say the survey data are used to demote or fire physicians whose treatment decisions, however legitimate, may not have been what the patient wanted.

Gastfriend, an addiction psychiatrist by training, traces the problem back decades, through a series of medical and cultural shifts that made pain a "fifth vital sign," in addition to the long-accepted checks for heart rate, blood pressure, temperature, and respiration.

Unlike the others, however, pain is a self-reported, subjective assessment. Asking patients to rate it on a scale of 1 to 10 - or, more vaguely, in a question about how your doctor addressed it - "conveys the implication that the proper amount of pain is zero," Gastfriend said.

Just as fever indicates a normal response to infection, "pain is the body's way of signaling the brain to take care of an injury or illness," he said.

The appropriate (and realistic) goal, Gastfriend said, is to reduce pain that is interfering with a patient's ability to function. That, he said, would be a better question.

Others say the problem with patient satisfaction surveys goes well beyond pain.

In a 2012 article titled "The Cost of Satisfaction," physicians in California reported tracking more than 80,000 respondents to two surveys for several years. "Higher patient satisfaction," they concluded in the Archives of Internal Medicine, was associated with "higher overall health care and prescription drug expenditures, and increased mortality."

Other studies have found a link between patient satisfaction and better health outcomes. A recent paper from Cooper University Health Care looking at data from more than 3,000 U.S. hospitals connected high marks on Medicare's five-star scale with lower rates of readmission within 30 days of discharge, as well as some surgical complications.

Medicare's patient satisfaction survey covers far more ground than just pain, which is featured in only three of 32 questions.

But, some doctors say that anger over pain management may come out in answers to other questions, such as one about whether they were treated with "courtesy and respect."

"Every single patient who comes to the ER has pain. Headache, smashed finger," concussions, chest pain, said emergency medicine physician Gerald O'Malley. "Our job is to sort out what it is that is causing the pain and address it," O'Malley, who has worked in emergency rooms around the region, said in an interview Friday.

"I can't tell you how many times a mother has come in insisting that her child get a CAT scan," he said. It is clear from the symptoms, he said, that a scan would show nothing while exposing the child to more radiation. But when he pushes back, O'Malley said, that mother "leaves angry and writes a scathing satisfaction survey" response.

O'Malley has been outspoken about the issue for several years, saying that hospitals, with a percentage of their future Medicare reimbursements on the line, apply pressure to doctors to favor survey results over what might be best for their patients, who often believe that more tests and additional drugs equal better care.

"I value my patients - their comfort and safety - more than anything else," said O'Malley, a professor of emergency medicine at Thomas Jefferson University's Sidney Kimmel Medical College.

After O'Malley challenged a consultant's statements at a lecture at Einstein Medical Center in 2014, he said, he was disciplined and stripped of his title as vice chair of research for the Department of Emergency Medicine.

He continued working as an attending physician through the end of his contract last month and will start a new job next month in South Carolina while continuing at Jefferson.

A spokesman for Einstein declined to answer questions on Friday, saying only that "Dr. O'Malley no longer works here."

The federal proposal to update the patient satisfaction survey still must go through a comment period in the fall. It was announced during a flurry of activity in Washington to address opioid addiction.

In a rare act of bipartisanship, the House approved, by a vote of 407-5, a sweeping bill intended to expand treatment and reduce access to the drugs. The compromise measure, which is expected to win Senate approval this week, was passed after Democrats gave in to Republicans' insistence that the $1.1 billion in funding requested by President Obama be dropped.

The legislation is separate from the administration's proposed change in the satisfaction survey overseen by Medicare. But Gastfriend, the addiction psychiatrist, saw a link.

Asked on Friday whether removing the pain questions from Medicare reimbursement calculations would make a difference, Gastfriend said that it would reduce physicians' prescriptions for opioids.

"But that is not going to fix the problem," he said, "because people who are truly addicted will turn to heroin." Stopping that, Gastfriend said, will require expanding treatment, which is the clear goal of the bill passed by the House last week.

"Whether the funding is there," he added, "is not so clear."