Chronic Use Drives Rise in Opioid Consumption Among Medicare Disabled

An increase in chronic users may be the reason behind increased opioid consumption among disabled Medicare beneficiaries. A study of disabled beneficiaries under age 65 published in Medical Care showed that the percentage of beneficiaries with any opioid use decreased slightly from 43.9 percent in 2007 to 43.7 in 2011. However, the percentage of chronic users rose from 21.4 percent to 23.1 percent. Although they recognize that some chronic use can be beneficial, the authors suggest that Medicare administrators and clinicians find ways to monitor pain management to avoid unnecessary use.

Study

The authors were interested in opioid use among disabled workers who received social security disability benefits due to musculoskeletal conditions, which are commonly treated with opioids. They examined opioid prescription fill patterns among a pool of disabled Medicare beneficiaries under age 65, as SSDI beneficiaries make up most of that group, from 2007 through 2011. Individuals were present an average of 3.3 of the 58 years studied.

Results

Overall use peaked in 2010, but declined slightly in 2011. However, chronic use increased. In the authors’ words, the chronic use was “intense,” with 20 percent receiving 100 milligrams of morphine equivalents per day and 10 percent receiving 200 milligrams or more. Although musculoskeletal conditions are more prevalent in the disabled Medicare population (65 percent compared to 50 percent in the general U.S. adult population) and even more extreme among chronic users (94 percent), this did not appear to account for chronic use. The presence of regional differences in prescription fills regardless of the strictness of state drug laws was troubling to the authors, because it suggested inconsistent approaches. For example, “oxycodone was prominent on the eastern seaboard, whereas Texas prescribers all but eschewed these products,” despite similar regulations among states.

The authors encourage the possible use of quality measures for chronic opioid management, as well as measures to limit the number of prescribers per user, monitoring, and consultations with pain specialists. They recognize that such programs will require expenditures. However, they believe “inaction will also come at a substantial cost.”

Decline in Medicare Patients’ Heart Hospitalizations Sends Hearts Racing

Medicare patients saw a 38 percent decrease in heart attack hospitalizations between 1999 and 2011. The amount of Medicare patients hospitalized with blood-clot-related strokes fell 34 percent, and angina-related hospitalizations decreased by an astounding 84 percent. Additionally, the risk of dying within a year of being hospitalized decreased by 13 percent for patients suffering from heart failure and stroke and by 23 percent for those who suffered heart attacks.

Though doctors are not able to pinpoint an exact cause for the encouraging decreases, the steady decline is likely attributed to people smoking less, the diabetes epidemic’s affect on afflicted peoples’ diets and exercise habits, and the fact that more elderly adults are taking cholesterol-lowering medications.

Perhaps, the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) may have helped in attaining these successes.

Section 10411 of the ACA was designated the Congenital Heart Futures Act (Act), enacted March 2010. Through this Act, HHS established a National Congenital Heart Disease Surveillance System through the Centers for Disease Control and Prevention (CDC), which facilitates research into the types of health services used by patients and to identify possible areas for educational outreach and prevention. The collected data will be stored in a national, population-based database that can be used by researchers and the public to monitor the epidemiology of congenital heart disease.

The Congenital Heart Disease Surveillance System is designed to:

  • collect data regarding congenital heart disease’s prevalence in the United States;
  • collect and store congenital heart disease data regarding risk factors, population demographic factors, causes, treatments, and outcome measures that would provide best practices and guidelines for patients; and
  • ensure the collection and analysis of longitudinal data related to all individuals who have congenital heart disease.

Under the ACA, the director of the National Heart, Lung, and Blood Institute is also authorized to expand congenital heart disease research and any related activities.

Dr. Harlan M. Krumholz, director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation in Connecticut, is encouraged and says that with an increased focus on heart disease, doctors’ ability to identify and treat high blood pressure and secure fast, appropriate treatment to heart attack sufferers improved between 1999 and 2011. Krumholz also attributes the decline in hospitalizations to the fact that “[a] lot of people and organizations have been working really hard for the past 10 to 15 years to make better use of the knowledge we have.” It is possible that the ACA surveillance system contributed to this knowledge.

Not all the news is positive. The director of women’s heart health at the Heart and Vascular Institute at New York’s Lenox Hill Hospital, Suzanne Steinbaum, worries that the positive trends will reverse if obesity and diabetes in young Americans, who are ineligible for Medicare, continue to grow. She notes that heart attack rates are increasing in younger women, especially African Americans, and the CDC notes that there are 800,000 heart-related deaths each year.

Howard Herrmann, director of Interventional Cardiology and Cardiac Catheterization at the Hospital of the University of Pennsylvania, stresses continued vigilance in heart disease awareness and prevention as a key factor to keeping the rates of heart disease and death on a downward trend.

With the ACA surveillance system as a potential backdrop for proactive physician and patient approaches to heart health, how many more lives and health care expenses can be saved?

AHA Seeks Metamorphosis of OIG’s ‘Kafkaesque’ Overpayment Burden

On August 21, 2014, the American Hospital Association (AHA) sent a second strongly worded letter to the HHS Secretary complaining of the HHS Office of Inspector General’s practice of improperly using extrapolation to determine a hospital system’s estimated Medicare overpayment, as well as its misconstruction and misapplication of a number of other Medicare regulations and policies. Rick Pollack, Executive Vice President of the AHA, told Secretary Burwell that he had hoped the OIG’s extrapolation approach, which “grossly exaggerates” overpayments and “leads to excessive recoveries” had been halted after the AHA submitted a June 2, 2014 letter to former Secretary Sebelius. In the earlier letter, Pollack complained, “The Kafkaesque burden of imposing duplicative audits on hospitals and recouping payments from them without correcting the OIG’s manifold and glaring errors is abusive and unfair to hospitals and a waste of government resources.” (See Hospitals claim OIG compliance audits are redundant and not following the law, June 5, 2014.)

Recent Audit

The August letter states that the recent audit report calculated overpayments due for erroneously paid inpatient claims because patients’ medical records did not include admission orders signed by physicians. However, the letter argues that the claims were made prior to 2013 and that regulations did not require such an order until October 1, 2013. In Pollack’s prior words, “The OIG invented a physician order requirement that . . . did not exist.” Furthermore, the OIG failed to offset the hospital system’s alleged Medicare overpayments due for inpatient claims that should have been billed as outpatient claims by the amount of Part B payments that the hospital would be entitled to receive.

Other Complaints

In addition to the issues discussed above, the AHA’s earlier letter accused the OIG of misinterpreting section 1870 of the Social Security Act (the Act), which presumes that hospitals are “without fault,” absent contrary evidence, when overpayment determinations are made after the third year following the year in which the Part A payment was originally made. The AHA stated that hospitals could not be at fault after 2012 for payments made in 2009, but the OIG interpretation deemed hospitals to be at fault for any incorrect application of Medicare manual provisions. The AHA also accused the OIG of basing audits on claims made more than four years ago, which could not be reopened, and conducting audits redundant to recovery audit contractor (RAC) audits.

When Social Media Meets Non-Compliance in Nursing Homes

 

Sugar Land, Texas, is home to Silverado Senior Living, a nursing home that is ground zero for a conflict between a family and a health care provider accused of abusing and imprisoning a resident. The most recent battle, allegedly led the provider to revoke the visitation rights of three children and their spouses in order to prohibit them from visiting their 93 year old mother who is a resident of Silverado. According to a Southeast Texas Record report, the conflict allegedly stems from two legal proceedings, a family dispute, and social media posting that Silverado, allegedly demanded that the children take down. Whatever the true root of the conflict, if true, the allegations embedded in two different legal proceedings suggest Silverado Senior Living may face serious trouble both from the resident, her children, and potentially the federal health care programs.

Civil Rights

According to a recent civil rights complaint, filed in a federal court in Texas by Mackey Glen Peterson, Don Leslie Peterson, and Lonny Peterson, the children of the resident, Ruby Peterson, Silverado banned the children from visiting their mother because of posts the children made on social media about the conditions of their mother’s confinement. The Southeast Texas Record reported that the nursing home allegedly banned the children and their spouses from visiting their mother because of the “posting of exploitive and invasive materials which also violate the privacy rights of other Silverado residents.” According to the complaint, Silverado agreed to reinstate their visitation rights if they removed all the posts, pictures, and videos. The suit alleges that the brothers’ First, Fifth, and Fourteenth Amendment rights were violated by the social-media ban and seeks recovery for the violations and the resulting fear of arrest the children allegedly suffered as a result of Silverado’s actions.

Silverado’s Motivation

Did Silverado Senior Living shut its doors on the children of a resident because of some inadequacy the children were exposing through social media? Was Silverado concerned that awareness would effects its conditions of participation? Or was Silverado really protecting the privacy of its residents, as it claimed? The allegations in a state court filing related to a protracted probate court battle between the Peterson children, if they turn out to be true, suggest something on the nefarious side. Allegations in the guardianship proceedings of false imprisonment, conspiracy, assault and battery, intentional infliction of emotional distress, and involuntary drugging by Silverado staff indicate that the nursing home may have been attempting to shield itself from scrutiny when it allegedly took steps to restrict the speech of its resident’s children.

Guardianship Complaint

The Harris county probate court battle, filed on behalf of Ruby Peterson, sheds additional light on the real nature of the conflict by diving deeper into the cause of the children’s outrage. The legal contest pits Carol Ann Manley and David Peterson, Ruby’s son and daughter, against the authors of the civil rights complaint, Ruby’s other sons and the siblings of Carol and David. The state court complaint, boldly alleges that through a conspiracy between Carol Ann Manley, David Peterson, and Silverado, Ruby is being held at Silverado Senior Living against her will and being abused while she is there.

Chemical Restraint

The most serious allegations in the lawsuit are the claims by Ruby’s sons that Silverado personnel are abusing Ruby through involuntarily chemical restraint. The sons allege that they have seen Silverado staff “spike” Ruby’s vitamin drink by putting as many as 11 different medications in her drink without her awareness. The complaint alleges that Ruby was drugged against her will three times a day and woken in the night for additional drugs. The sons’ allege that the restraint leaves their mother incoherent, confused, and slumped over her wheelchair.

In addition to being unethical, due to the Omnibus Budget Reconciliation Act (OBRA) of 1987 (P.L. 100-203) and the Nursing Home Bill of Rights that it created, chemical restraints are illegal. Under, 42 C.F.R. 483, the regulations that set out the conditions of participation for skilled nursing facilities (SNFs), a nursing home like Silverado is apprised of a direct mandate not to use medication to involuntarily restrain its patients. Specifically, 42 C.F.R 483.13 states that “the resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.”

Thus, in addition to opening itself to liability with Ruby Peterson and her family, if the allegations are true, Silverado has potentially exposed itself to the myriad administrative sanctions that accompany violations of a Medicare provider’s conditions of participation. Is it possible that Ruby’s children turned to social media as a means to expose the alleged unlawful actions of Silverado?

Ethics and Profit

If the allegations are grounded in fact and Silverado did have something to hide, a question remains: why would a nursing home drug its own residents? One theory, presented by the California Advocates for Nursing Home Reform (CANHR), suggests that due to understaffing and costs, nursing homes engage in involuntary chemical restraint as a means to control behavior in a simpler and more cost effective manner than legal and traditional forms of behavior modification. According to a story in the Examiner, “some experts estimate that 50-75% of nursing home and assisted living patients are being improperly and/or illegally chemically restrained with these highly dangerous drugs.” The cause, allegedly, is that corporations charged with caring for the elderly are putting costs above ethical considerations. An AARP article suggests that the phenomenon is happening at an alarming rate as a result of physician kickbacks and practices that keep patients’ families in the dark.

What is Really Going On?

Whether there really is a connection between the alleged involuntary chemical restraint and the social media posting is a fact that remains to be seen. Silverado may very well have been attempting to protect legitimate patient interests. The nursing home may have been reasonably acting to stop an inappropriate practice. The allegations could be without merit. However, the abuse allegations, if they turn out to be true, suggest another scenario. If the story is as the Peterson children have told it, Silverado may have had its mind on Medicare billing privileges and its conditions of participation when it took the alleged steps to quiet the speech of Ruby Peterson’s children.