Michigan surgeons offered more money to limit opioids for pain

Jennie Elrod

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Money and pain first fed Michigan’s opioid crisis, but the state’s largest insurer hopes money might starve it, too.

Blue Cross Blue Shield of Michigan is offering a 35 percent boost in insurance reimbursement — hundreds of dollars per procedure — to doctors who follow tight, new prescribing guidelines that reduce the number of pills sent home with patients after surgery.

Instead of pills, doctors spend time explaining to patients the addictive nature of these drugs, the pain that can be expected after surgery and safer, alternative ways to manage it — by switching between ibuprofen and acetaminophen, for example.

Surgeons don’t want to “leave patients in pain,” said David Bye, Blue Cross’ health care manager of value partnerships programs. 

But overprescribing increases a patient's chance for addiction and risks allowing pills to fall into the wrong hands. “We’re trying to rightsize that,” he said, “to reduce the gap between what’s prescribed and what’s consumed.”

Recent research has spotlighted a lack of consensus on how often doctors should prescribe opioids and in what quantities. In a 2017 study published in Annals of Surgery, 642 patients who underwent five common surgeries — gallbladder removal or hernia repair, for example — reported using just 28 percent of the pills they were prescribed after surgery. 

And while the average number of pills prescribed was 20 or 30, depending on the surgery, some doctors prescribed 100 or more pills, depending on the procedure.

Other research suggests the United States is an outlier in its reliance on opioids compared to many countries. 

In September, research from the University of Pennsylvania’s Perelman School of Medicine found that U.S. patients were seven times more likely to likely to fill prescriptions for pain than patients in Sweden. According to the same study, published in the Journal of the American Medical Association (JAMA), U.S. doctors prescribed an average of 33 pills, while Swedes received an average of 26 pills, and Canadians 22 pills.

About 6 percent of U.S. surgery patients become chronic opioid users, according to a 2017 study by University of Michigan researchers, also published in JAMA. Surgery patients who have been smokers or diagnosed with alcohol or drug addictions, depression, anxiety or chronic pain conditions are particularly susceptible.

Indeed, misuse of opioids is now the top complicating factor in surgery in Michigan — more so than infection, blood clots, strokes or heart attacks, said Michael Englesbe, a University of Michigan transplant surgeon.

Many doctors are reluctant to change their prescription routines, a process that Englesbe and others say is made more difficult by inflexible medical record software, complex billing codes, and the daily pressures of seeing one patient after another.

Michael Englesbe

Michael Englesbe, a transplant surgeon, is part of a University of Michigan team of doctors and researchers trying to find a balance between overprescribing and leaving patients in pain. (Courtesy photo)

Englesbe is co-director of Michigan Opioid Prescribing Engagement Network (M-OPEN), which launched in 2016 to establish guidelines for prescribing opioids after medical procedures. He and other doctors are increasingly acknowledging their part in a crisis that was linked to more than 5,200 deaths in Michigan between 2013 and 2017.

Englesbe noted the post-surgery addiction rate in May as he stood at a podium at an opioid summit hosted by U-M and Harvard University and attended by about 400 researchers, clinicians, advocates, law enforcement and policymakers.

“If I took out everyone’s gallbladder … 24 of you would then be left as a chronic opioid user, which is a devastating number,” Englesbe said. “That’s like those two tables over there,” he said, gesturing to one side of the room. 

Hard to change habits

Blue Cross helped fund the prescription network group, and funds the Michigan Surgical Quality Collaborative, a group of more than 70 Michigan hospitals  trying to improve quality and safety in surgery. 

Intrigued by the work at U-M, the Blues began offering a 35 percent boost in professional fee reimbursements to surgeons across the state who went even further than M-OPEN’s prescribing guidelines

Blue Cross asked M-OPEN to develop guidelines for surgeons performing six common surgeries (in addition to gallbladder and hernia, thyroidectomy, sinus surgery and septoplasty, prostatectomy, and bariatric surgery) to further reduce the recommended prescription.

Jennie Elrod

Jennie Elrod, of Milan, said she is a responsible mother who understands the risks of opioid painkillers. In fact, she had leftovers from surgeries in past years. (Bridge photo by Robin Erb)

 

Clinicians also were to talk with patients before the procedure about the addictive risks of opioids and how to manage pain without them. Patients then were given four to 10 opioid pills, supplemented by acetaminophen and ibuprofen. 

For the extra effort, surgeons could be reimbursed $389 to $753 per operation.

A study published in the New England Journal of Medicine in August concluded that surgeons providing nine common operations at 43 Michigan hospitals were able to cut the number of opioid pain pills by one-third ‒ from an average of 26 pills to 18 ‒ without making patients feel more post-surgery pain. 

The study pulled prescribing data involving 11,716 patients. Just over half also filled out surveys sent to their homes after surgery, answering questions about their pain and how many opioids they used.

Even as prescription volumes shrank, patients reported taking just half of the pills prescribed, reinforcing earlier University of Michigan research that found surgery patients took just 1-in-4 opioid pain pills prescribed.

What about the pain?

The change, however, might not go down well with everyone. Ask Jennie Eldrod.

In January, she was in her living room near Ann Arbor caring for her newborn son, Oscar, when pain suddenly shot under her ribs in waves. Surgeons later would remove her gallbladder.

Elrod, 37, was stunned when, after surgery, she was prescribed just four Oxycodone tablets. She’d had had prior surgeries, including a C-section months earlier for her son. And she still had some of 50 oxycodone tablets left from a previous C-section in 2016.

Elrod said she knows post-surgery pain well and that she should take opioids only when necessary.

But she said getting a handful of pills for her gallbladder removal left her anxious and without a sense of control if the pain were to grow unbearable ‒ even with the extras left over from 2016. 

“I totally get this is a big issue,” the Milan woman said of the opioid crisis. “But I don’t want to suffer. I was frustrated.”

She decided to use the opioids only at night and, as it turns out, four pills were sufficient. “I think there’s an in-between,” she said of the overprescribing or limiting pills. 

“I had to tough it out. Why did I feel like I had to ration medication?”

Early results on the Blue Cross incentives for the half-dozen surgeries were reviewed first for surgeries performed at the University of Michigan over an eight-month period ending March 31, according to a research letter that appeared in September in JAMA.

The impact was promising. In a study of 1,459 medical procedures, roughly 70 percent of U-M surgeons followed the tighter prescription guidelines.  

Yet just half of these doctors claimed higher insurance reimbursements for those operations.

The reason? The “mire that is medical coding,” said U-M’s Englesbe, who quipped that “medical billing is slightly more complicated than putting a man or woman on the moon.”

Englesbe had just finished a surgery, himself, before talking with Bridge Magazine. 

“I just got out of the ER and it’s going to take me 15 minutes just to figure out the buttons to hit to do billing,” he said. “And then I’ll still get four emails about it.”

Lessening the financial incentive, the Blue Cross hikes can disappear into larger budgets for the hospital system or practice, so individual doctors are less likely to see all of the reimbursement. 

The results statewide were less encouraging — perhaps not a surprise given that surgeons at U-M, where the efforts were seeded by M-OPEN, are more likely to be early adopters of the guidelines.

Across the state, Blue Cross noticed an increase of about 60 to 70 cases each month believed to be driven by the change in opioid prescribing, according to Bye, of BCBS. That means U-M doctors represented the lion’s share of the change.

Given the thousands of surgeries performed each year in Michigan, that may not sound like much.

But that’s thousands of pills that a few surgeons may have kept off the streets by taking a little extra time to educate and properly dose surgery  patients, noted Chris Brede, a Grand Rapids urologist at Spectrum Health.

Dr. Joceline Vu

The key to pain management is as much about educating and empowering patients as it is what is in a bottle, said Dr. Joceline Vu, a surgery resident and research fellow at the Opioid Prescribing Engagement Network at the University of Michigan. (Courtesy photo)

Brede said he routinely prescribes just six pills after surgery, down from the 15 he once prescribed. By back-of-the-napkin math, that’s about 350 fewer pills that he’s prescribed in just six months, he said.

The change has been well received, Brede said: “More and more patients are becoming more aware of the opioid epidemic… It’s like everyone wants to be part of the solution.”

Blue Cross now has added another 11 procedures to the list for a total of 17 procedures now eligible for the expanded reimbursement.

A key to patient buy-in is taking time to talk to patients before surgery, said Joceline Vu, a U-M surgical resident and research fellow at M-OPEN and lead author of the New England Journal of Medicine research letter.

While some patients still may consume every opioid they're prescribed, others find the conversation both comforting and empowering in not only managing pain but also in avoiding a possible route to addiction, she said.

"We're not trying to take opioids away from people who need them for pain control," Vu said. "We want patients to be healthy for years and years instead of just the week after surgery."

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Comments

Paul Jordan
Tue, 10/15/2019 - 11:26am

While it is undoubtedly a good thing to limit the prescription of opioids to those who really need them (and for only the time that they need it), this situation came about because physicians were offered financial incentives to over prescribe them in the first place!
Paying them NOT to prescribe opioids seems to address them problem through the means that caused it in the first place!
Let's face it: For-profit medicine is a bad idea, on whatever level it occurs. We need a single payer system that pays doctors fairly (and frees them from school debt!) without providing financial incentives for their medical judgments.

DJ
Tue, 10/15/2019 - 12:06pm

As a sufferer from chronic pain caused by botched surgery the whole debate sickens me. Any competent doctor will agree that pain is an inhibitor for healing as well as getting the rest you need to lead a normal life. And where does this leave people like me who have an allergy to both ibuprofen and tylenol? Or have paid for the 6 extra hospital days following a surgery not from the surgery itself but from the deathly allergy to those drugs?
I sympathize with anyone who has an addiction but don't then subject the rest of us who are responsible pain managers to excruciating life altering perpetual pain?
This has more to do with a total lack of accountability and responsibility on behalf of the fly by surgeons. And a total lack of caring for patients post surgery. Mine said if you're still in pain then go to the pain clinic - not my problem any more! And if one more individual suggest I tough it out, or practice 'mindfullnes' I'd ask then to stick a screwdriver in the side of their leg and leave it there for years and see how quickly they'd be screaming for help?

Bones
Wed, 10/16/2019 - 9:47am

May I suggest you try cannabis or kratom as an alternative pain management strategy?

Stephanie Siller
Fri, 10/18/2019 - 9:56am

I love how people suggest these things like people living in chronic pain are just waiting around for them. Trust me they've tried everything. Many people in severe chronic pain find that their pain isn't helped by cbd, marijuana, or kratom.

Steve
Fri, 11/08/2019 - 3:39pm

Neither is NEARLY as effective on pain as opioid prescriptions.
Our brains were designed to make use of things in nature for energy (caffeine), sleep (chamomile), fever and mild pain (willow bark), and severe pain (opium).
THC and kratom are alkaloids and do more in the way of affecting attitude (buzz, and YES, kratom causes buzzes) rather than relieving pain.

Veronica
Sat, 11/09/2019 - 5:41pm

Who can afford it now? And it simply isn't strong enough after a surgery.

Jeffrey Smith
Tue, 10/15/2019 - 8:11pm

Paul, you are so misinformed. You dont have a clue what the real problem is, your just buying into what the media tells you which is completely false.

Bones
Wed, 10/16/2019 - 9:46am

So which part of Purdue Pharmaceutical's two decade crusade of paying off doctors to prescribe opioids for every possible condition, suppressing information about the habit-forming nature of oxy, and looking the other way as massive orders from obvious pill mills brought in millions *wasn't* based on our inhumane healthcare system that places profits over people?

Jeffrey Smith
Tue, 10/15/2019 - 8:06pm

This opioid crisis has nothing to do with prescriptions being given to chronic pain patients yet they are the ones suffering the most from them being reduced or taken away. What they're doing is inhumane and barbaric. The real problem is illegal fentanyl and other opioids( heroin) on the street.

Robin Stitt
Wed, 10/16/2019 - 11:28am

Having lived through several surgeries, plus injuries in life, it concerns me a lot to think I will have untreated pain if I have to go through another painful incident. The pain meds given were not excessive, and sometimes needed a second prescription to survive, but have never felt a need to continue the drugs once healing took place...
Everyone experiences pain differently. My pain threshold is low but I am positive I won't become addicted, and should receive individualized care, my experience has shown that.

Doug L
Wed, 10/16/2019 - 5:03pm

I do understand that there is a serious problem with opioid abuse, and related deaths. However, those who suffer with chronic pain are the innocent ones who suffer because of this. Tylenol and Ibuprofen do not scratch the surface for those who suffer chronic pain, but there does not seem to be any strong painkillers that are not opioids. It has been common for a long time to supply chronic pain sufferers with a regular, limited supply of opioids, such as acetaminophen with codeine. Now doctors are afraid to prescribe the needed painkillers to the patients that need them. Those who need strong painkillers, and use them responsibly, should not suffer because of those who abuse painkillers.

Nicole Armand
Thu, 10/17/2019 - 5:28pm

"We're not trying to take opioids away from people who need them for pain control," Vu said. "
But you are! All across this country opioids are being taken away from chronic pain patients!!

Dr. Josef Mengele
Thu, 10/17/2019 - 7:47pm

Excellent. I especially like that you recommend children be totally deprived of pain relief (0) for certain procedures. The little ones can't complain or, if they do, won't be believed. It's like how people used to be told that animals felt no pain. Very nice work. Seems totally ok!

David Acevedo
Fri, 10/18/2019 - 1:18pm

"...instead of pills" Pills? YOU think severe pain medicines prescribed by Doctors of Medicine for severely painful diseases and conditions cause "opioid crisis"??? You could not be more confused. And now the WHOLE NATION is open to un-treated severe pain for the DOJ/AG money grab of which media is STILL a satellite investor. I do not envy you...

Lauri
Sat, 10/19/2019 - 1:04pm

I cannot believe that horrible chart!!!! You recommend treating pain for an adult appendectomy, but ZERO pain treatment for a pediatric appendectomy??? You vicious, violent, brutal, torturers!!!! You should be jailed for abusing helpless children!!!

Peggy Hillman
Sat, 10/19/2019 - 7:56pm

This is disgusting. Let's just put aside the fact that the overdose crisis was proven by CDC's own data to be mostly due to illicit drugs, NOT prescribed drugs, that only .6 percent go on after surgery to develop dependence, abuse, or misuse according to a 2018 article in the BMJ, that the majority of those who become addicted NEVER had a prescription, and that Tylenol and NSAIDS impair and kill as many if not more people each year than prescribed opioids. Yeah, we'll just set all that aside.

Proper pain control is essential to healing and wellness. While I concede prescribing should be done responsibly, providing a financial incentive to deprive patients of proper pain control, causing them anxiety and forcing them to ration their meds due to fear of addiction or not having enough medication, as was admitted by patients in the article, is completely unacceptable medical practice. Proper pain control is essential for psychological and physiological healing and rehabilitation. Improper pain control means that for each future medical procedure that is needed, that patient's anxiety will build from fear that their pain will not be adequately treated. This is unhealthy and damages the patient not only while recovering but can have lasting effects long term. This will likely cause avoidance, delaying necessary treatment, and will set the patient up for PTSD. This policy creates irrational fear of addiction in patients and practitioners which further perpetuates the stigma that surrounds opioid use. We currently have an ongoing campaign to eliminate the stigma surrounding opioid use, yet at every turn, policies and the dialogue that surrounds them only serve to emphasize and magnify the very stigma we are trying to eliminate.

Policies should be designed in the best interest of the patient's physiological and psychological well being. This policy is clearly based on myths that create unnecessary paranoia and stigma surrounding opioid use rather than knowledge based on fact and, like most things wrong in our society, it is driven by politics and corporate greed rather than the best interests of the patient. You can't tell me the physicians won't see any financial benefit from that but even if they don't, the hospital will and will insist that surgeons use these inhumane practices to increase their bottom line.

We have already been here. Remember? This is the way it used to be. It's what caused much of the chronic pain and anxiety in patients to begin with and is what continues to cause escalating anxiety in current chronic pain patients. When will we learn from our mistakes? The studies prove medical use of opioids has little to do with the rate of addiction or ODs. We have the evidence. When will policy makers acknowledge it?

In short, this policy causes unnecessary pain, psychological trauma, and perpetuates the myths creating the stigma surrounding opioid use. This is a disaster in the making. We can do better. Is anyone willing to try or or must we sink deeper into the abyss? How much lower must we sink before providers and patients stand together to fight this insane assault on humanity and common sense? People, stand up for your rights! If you think someone else will do it for you, think again. Docs, you are losing everything, being wrongly suspended and prosecuted. Your practice and your freedom are in jeopardy. Patients, you are suffering, many dying from medical collapse or suicide. Those who think they are immune, I promise you are not. You are just one accident or serious disease away from being denied appropriate pain management. We must UNITE and FIGHT.

Website: dontpunishpainrally.com
Fb: https://dontpunishpainrally.com/state-fb-groups/

Sources:
https://thewaronchronicpainpatients.com/2019/01/30/example-of-what-happe...

https://reason.com/2019/08/21/new-survey-data-confirm-that-opioid-deaths...

https://www.ncbi.nlm.nih.gov/pubmed/15239078

https://www.acsh.org/news/2017/09/11/tylenol-far-most-dangerous-drug-eve...

https://www.sciencedaily.com/releases/2005/01/050111123706.htm

https://www.statnews.com/2019/06/28/stop-persecuting-doctors-legitimatel...

https://www.painnewsnetwork.org/stories/2019/10/18/study-finds-only-13-o...

https://journals.sagepub.com/doi/abs/10.1177/0033354919878429#articleSha...

https://www.bmj.com/content/360/bmj.j5790.long

https://www.acsh.org/news/2019/10/07/analyzing-opioid-crisis-65-articles...

Tammy
Sat, 10/26/2019 - 2:02pm

How is it even legal to bribe doctors to torture patients? Are we back in Nazi Germany. What is wrong with this country now

KathleenEdsMom
Mon, 11/04/2019 - 9:56pm

REDICULOUS!!! The problem IS and always will be illegal drugs!!!! Where have these people been? This whole insane epedemic started on the local news showing junkies nodded off with their little kids in the car at a stop light!!! And since junkiues and abusers don't register anywhere chronic pain patients have been targeted! We can be found with a click of the mouse. Wake the hell up! This country is catering to those that abuse with offers of repeated rehab and other drugs to be addicted to! The addicts, who are the opioid epedemic, have all the drugs they need. Even TV shows about entire cities plagued with heroin like it just happened. Insane. And all the money that they are making with shows like Intervention by exploiting the abusers and pressureing them into rehab, which they will fail. They return home to the same old crap and drug dealers. You mean to tell me that law enforcement has no idea where the dealers are? Bull. Time that they and the DEA do their jobs instead of ruining the quality of life for millions who did nothing wrong but follow the rules concerning their medications. For crying out loud, we have troops guarding poppy fields in Afghanistan for 10+ years so they can harvest the raw opium!! Google it. Research it, investigate this 'crisis'. People just believe everything they hear. The medical profession let the DEA do the damage and threatened them with closing their doors and pulling their medical license unless they stopped prescribing opioids to chronic pain patients. THEY should have stood up but they didn't. There is too much money being made and greed has taken over. This country sucks. Insurance companies, rehab centers, big pharma are making millions at the expence of people who have chronic pain they never asked for. My life is gone and filled with suffering needlessly in untreated pain. No one cares. Thousands have ended their lives because the pain was too much to live with. I lost my job, car, friends, family and no one gives a rats ass. Now insurance is the dictator of what drugs, IF any, a person can have. Their greedy hands are in this and it will never change. I might as well load my gun. I worked, while my pain was controlled and raised 3 boys and should be enjoying my retirement. Ha, right. The damage is done. I can only pray that those that had a hand in getting my meds taken away suffer in pain and are told to just take an aspirin and suck it up. Suffer. We don't ket animals suffer we have undying compassion for them. If only I had fur and a tail, my pain would be controlled or they would put me to sleep. I could go on but why should I, no one is listening.

Vickie Tway
Thu, 11/07/2019 - 7:18pm

It is absolutely stunning how ignorant doctors can be. You guys would allow a patient to go without proper pain control so you can make a few extra bucks!?! Any doctor who follows this asinine reward for pain system should be ashamed of yourselves. You should all be standing up, en masse and shut down this stupidity. And if you think this "saving" of a few pills here, and a few pills there is going to rid us of the so-called "opiate crisis," I really have to wonder how you ever finished college in the first place. This is very easy to understand. You won't need to take notes. The current opioid crisis in our country is caused by ILLICIT fentanyl, heroin, and a resurgence of meth on the scene. Our jack-booted thug DEA officers would rather storm a doctor's office searching for infractions to take away his livelihood while leaving hundreds of patients with no doctor as opposed to doing the "hard" work of putting a stop to the illicit fentanyl sent from China by the bargeload or catching it as it comes in by plane or through the U.S. mail. Everything about this country is on the skids. The government has turned into a poorly made-for-tv movie of some sort. All this attention spent on taking pain pills from people in pain is so misguided as to be laughable. Come on, Doctors....if you won't stand up for your patients at least stand up for yourself by simply doing the right thing. Oh, and never forget, it could be you who needs that unplanned surgery or has an accident leaving you with a lifetime of runaway pain. Lets see how you feel about the doctor who treats YOU and makes a couple of bucks off your misery.

Steve
Fri, 11/08/2019 - 3:31pm

When will this OVERREACTION to a minuscule problem END?
A great many of us get no relief from our excruciating pain, and no matter how the asshole reporters, doctors, insurors, DEA agents, medical officers, and pharmacy heads cry to the contrary, THEIR INTEREST IS NOT IN COMPASSIONATE MEDICINE.
All the above who knee-jerk cut, taper, or refuse nature's BEST painkiller to patients in need are NAZIS whose ONLY interest is in their own lily white asses.
I am a chronic pain sufferer who gets NO PAIN RELIEF OF ANY KIND.
"Alternate between one ineffective, gut-killing med and an ineffective, liver-killing one" for GOD'S sake. I cannot take ONE dose of ANY NSAID because I KILLED MY GUTS TAKING THAT SHIT. As I write this, I am sitting in my hotel room in Nashville, having just returned from Vanderbilt University Medical Center for my FIFTH colonoscopy in 3 years because all the glorious perfect heavenly sublime substitutes for the opioids I MEED FOR PAIN CONTROL are fucking killing me.
Good job, media and CDC...you have fucking RUINED compassionate health care in this once-greatest medical system on earth.

Veronica
Sat, 11/09/2019 - 5:50pm

Since when are insurers, or the government of Michigan doctors? Payment to stay in pain. Really? And no, you just can't always drive to get a refill if 1) because of your surgery you can't drive and 2) you may be in a rural area over an hour or more from your doctor and 3) if you are poor you might not even have a car or money for gas. And what is the unintended consequence? A rise in heroin and fentanyl deaths. About 5000 people in 4 years died in Michigan which has a population of almost 10 MILLION. Is that really a crisis? Do the math. This is just a way for BCBS to make money.