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Another Voice: Health care risks and incentives don't match up

By Philip L. Glick, M.D.

Our nation is going through an unprecedented incidence of our citizens dying from prescription and illicit opioid overdoses. Several reports have suggested that many of these deaths can be traced to prescription drugs that were overprescribed by usually well-meaning physicians for patients with acute or chronic pain problems.

These prescribed drugs are then used either by the original patients or somehow make their way onto an illicit street aftermarket that can lead to addiction, overdosing and death.

New York State and the Drug Enforcement Administration have weighed in, trying to regulate the opioid prescribing behavior of physicians, i.e., limiting prescriptions to seven days or less and without any automatic renewals; requiring physicians to check their patients’ recent opioid prescriptions to avoid doctor-shopping; and mandatory opioid continuing medical education.

Our professional societies have also offered training on alternative therapies for acute and chronic pain problems.

As a pediatric physician, I am sensitive to the comfort of my patients; children are not just small adults, especially in pain management. And particularly as a pediatric surgeon, I want my post-op patients to have the exact therapeutic balance between adequate pain control and safety. As a pediatric specialist, I always dose my patients’ medications on a per-patient weight basis to assure therapeutic efficacy and safety.

With our heightened sensitivity to trying to limit opioid prescriptions and the availability of local pain blocks that can last for days, our management patterns have changed. Whenever possible, we try to use post-op pain management limiting or eliminating all opioids.

But here is the problem. Although some of the non-opioid pain meds are quite affordable to the patients, others are quite expensive. When the injectable locals are used in hospitals or an outpatient surgicenter, they are not charged directly to the patient, but added to their account. If the family is insured, the insurance company pays only a pre-agreed upon amount regardless of the supplies and medications used.

The extra cost (risk) for these “wonder drugs” eats into the hospital’s and surgicenter’s profit margin. They don’t like this because it affects their profitability and they get no “credit” for their effort for optimizing the comfort of that patient and lessening the amount of opioids on the street. Hospital formularies are trying to limit use of some of these more efficacious drugs for economic reasons and are making their use more difficult, but not impossible.

In future discussions about health care policy, this asymmetry of health care risk and incentives, which hurts patients and society, needs to be acknowledged and rectified by incentivizing our institutional partners for the effort they are making to decrease the use of opioids, to decrease the potential for addiction and illicit drug use and helping to combat the opioid crisis affecting every community in our country.

Philip L. Glick, M.D., is a pediatric surgeon, professor of surgery and management at the University at Buffalo and a practicing member of UBMD.

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