Minnesota Physician cover stories

October 2017

Past cover stories

The value of Medicaid

A safety net for children

 

By Kelly Wolfe

 

Imagine you’re pregnant and you unexpectedly go into premature labor, delivering your baby two months early. While you have health care coverage through your employer, you discover upon discharge from the hospital that your insurance won’t cover the 24-hour nursing care your baby will require, nor does it cover the equipment or medications your infant will need to survive. Thankfully, your child is eligible for Medicaid and you can now access these services.

 

Opioid Prescribing Improvement Project

A safety net for children

 

By Kelly Wolfe

 

Imagine you’re pregnant and you unexpectedly go into premature labor, delivering your baby two months early. While you have health care coverage through your employer, you discover upon discharge from the hospital that your insurance won’t cover the 24-hour nursing care your baby will require, nor does it cover the equipment or medications your infant will need to survive. Thankfully, your child is eligible for Medicaid and you can now access these services.

 

Quality reporting

The importance of accounting for social conditions

 

By Paul Kleeberg, MD, and Phil Deering, BA

 

Like many Minnesota physicians, Dr. Lynne Ogawa first saw her Minnesota Statewide Quality Reporting and Measurement System (SQRMS) outcomes toward the end of the last decade. At the time, the family practice doctor saw patients at the Fremont Clinic, located in the heart of North Minneapolis.

 

Why just retire?

Consider physician emeritus

 

By Michael J. Weber, JD, and Nancy Lee Nelson, JD, MPH, RN

 

If you are like many other Minnesota-licensed physicians, you might be unaware of the option to retire as a “physician emeritus.” To retire as a physician emeritus, a physician has to complete a short application with the Minnesota Board of Medical Practice.

 

Regenerative Medicine Minnesota

Transforming the future of health care

 

By Jakub Tolar, MD, PhD, and Andre Terzic, MD, PhD, FAHA

 

We have grown accustomed to the medical miracles—antibiotics to combat infection; transplantation to replace failed organs; and biologics to control high cholesterol, rheumatoid arthritis, or psoriasis—that have transformed patient care. Despite remarkable advances, many serious health problems resist conventional medicine and surgery, causing suffering and shortening lives.

 

The Minnesota Adult Abuse Reporting Center

Protecting the vulnerable

 

By Commissioner Emily Piper, JD

 

An older adult woman living in northern Minnesota was at her most vulnerable—recovering from surgery after a stroke—when she became the victim of financial exploitation by her own daughter.

 

The CARES Model

A way to engage your patients

 

By Archelle Georgiou, MD

 

Sixty-two percent of Americans say they want to deliberate with their physician about their treatment options. And, to help make the right choices, consumers have been armed with an array of health information sites, symptom checkers, cost calculators, and provider quality scores and report cards.

 

Minnesota Prescription Monitoring Program

Important updates responding to an epidemic

 

By Barbara A. Carter

 

In a recent survey conducted by the American Medical Association, in which 44 of the 49 state prescription drug monitoring programs (PDMP/PMP) responded there was a 180 percent increase, between 2014 and 2016, in the number of physicians’ and other health care professionals that had registered for an account with a PDMP/PMP.

 

Regenerative Medicine:

Efficacy, Economics, and Evolution

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Opioid Prescribing Improvement Project

Working with providers to tackle the crisis

 

By Jeff Schiff, MD, MBA, and Sarah M. Rinn, MPH

 

Hardly a day goes by without a news story about the worsening of the opioid crisis. Closer to home, we are confronted every day with the challenges of treating patients in pain and balancing treatment choices against harm. Since 2013, opioids have claimed more Minnesota lives than car crashes. As prescribing providers, we find ourselves in the middle of this crisis. With about 50 percent of these deaths coming directly from pill overdoses and three quarters of the heroin/IV fentanyl deaths linked back to a start with pills, it is our prescribing practices that need consideration. While the current situation is unacceptable, this crisis gives us the opportunity to strengthen our role as stewards of the health of our patients and the entire population. In Minnesota more than virtually any other state, we have the ability to be those stewards.

 

The start of the epidemic

The opioid crisis can be traced back 20 years to concerns about the adequate treatment of pain. Pain treatment, the absolute reduction of pain to zero, became a goal supported by pharmaceutical manufacturers and later picked up the Joint Commission in its “fifth vital sign” approach. Both these expectations and their solution are now seen as unworkable.

 

Furthermore, the physiologic and psychological aspects of the progression from acute pain to chronic pain have been elucidated over these years. We now think of pain generators moving from peripheral nociceptive origins to central sensitization-based origins. We know that individuals with past cultural or psychological trauma, anxiety, and depression move into these central pathways with greater frequency.

 

Despite years of study, we have no proof that opioids effectively treat patients as they progress into chronic pain. Despite many attempts, there are no studies that definitively show that pain assessment or functional status is improved with chronic use of opioids.

 

Let’s look at the numbers

The Minnesota Department of Human Services (DHS) serves approximately 1.2 million Minnesotans enrolled in the Minnesota Health Care Programs (MHCP). The population covered under the MHCP includes populations typically covered under Medicaid (children, parents, individuals with disabilities, and senior populations), as well as low-income adults. In 2014, DHS began analyzing prescription opioid claims data in order to understand the impact of opioid prescribing on the population we serve. We identified about 19,000 individuals on chronic opioids, or about 3.5 percent of our population. This percentage is consistent with national estimates of the number of U.S. adults prescribed long-term opioid therapy (Boudreau et al., Pharmacoepidemiol Drug Safety, 2009). We also discovered that over 5,000 individuals went from being opioid naïve to being new chronic opioid users in that year. That number represented about 1 percent of the individuals whose data were available for our analysis, and this rate is maintained in subsequent annual analyses.

 

Put on a timeline, these new chronic users traversed the “post-acute” space from five to 45 days. This is a timeframe where some tissue healing can still occur, but also when prescribing leads to dependence. This interval represents an inflection point; the space where patients go from being treated for an acute injury or surgery, to chronic use, to dependence and high potential for addiction and death.

 

The Opioid Prescribing Improvement Program

In 2015 with support of the Minnesota provider community, the Minnesota DHS enacted the Opioid Prescribing Improvement Program (OPIP). The purpose of this program is to move upstream, prevent new chronic use, and assure the safety of those receiving chronic opioids. The program has five components:

 

  • Developing state guidelines for the three phases in the prescribing cycle:  acute (1–4 days); post-acute (5–45 days); and chronic (46 days and beyond. The chronic interval was started 45 days after a review showed no basis for the classic 90-day start and expectation that in virtually all circumstances adequate tissue healing should occur by the end of the 45-day interval). The guidelines build on the work of the Institute for Clinical Systems Improvement (ICSI) and the Centers for Disease Control and Prevention.
  • Developing and reporting providers’ prescribing results for their Medicaid patients compared to their anonymized peers.
  • Setting thresholds for improvement for those who prescribe beyond an expected range based on our Work Group’s recommendations and the prescribing practice of their peers.
  • Creating a quality improvement process for prescribers who remain out of range for a period after being informed (e.g., checking the Prescription Drug Monitoring Program [PDMP], reviewing prescribing cases with clinic colleagues, assuring that other therapies have been used as well). For prescribers who still remain out of normal ranges, they would be disenrolled from the Medicaid program. The provider’s individual information, up to the time of disenrollment, is protected peer review.
  • Supporting a marketing campaign that encourages prescribers to have early and effective discussions with their patients about dealing with pain and setting appropriate limits on opioid prescribing.

 

The implementation of this program to date has been a journey by many dedicated individuals. The state guidelines, reporting criteria, and thresholds are the work of the Opioid Prescribing Work Group (OPWG). The group, chaired by Dr. Chris Johnson of Allina, includes physicians, pharmacists, pain treatment providers, public members, law enforcement, and others. The group’s guidelines are available in draft form at https://www.mn.gov/dhs/opwg and will be released in a completed form this fall.

 

  • The recommended guidelines highlight some important aspects of prescribing:
  • Limiting acute prescribing to 100 morphine milligram equivalents (MME) for most diagnoses with a limit of 200 for major injuries and surgeries.
  • Prescribing with increased caution, increased review of risks for dependence and diversion, and increased referral to non-pharmacologic therapies as the post-acute period advances. Planning should be done early in this post-acute phase to wean patients off of opioids as their tissue healing progresses.
  • Taking a harm reduction approach for patients already or newly using opioids for chronic pain, which emphasizes lower doses that are associated with greater safety, access to naloxone, and assessments to assure safety.

 

The Work Group has learned a great deal by looking at prescribing data within the Minnesota Medicaid program, and at new state- and national-level data as it is published. Recently published CDC data indicates that Minnesota continues to have a relatively low rate of prescribing. In 2016, we wrote 46.9 prescriptions for each 100 Minnesotans. This was the fifth lowest in the nation. However, national prescribing data at the county level reveals significant variation in our prescribing rates. In several Minnesota counties, the rate of prescribing nears or exceeds a rate where 100 prescriptions are dispensed for every 100 persons—enough for every person to receive one.

 

This significant variation in prescribing is also found within the Medicaid-enrolled provider population. The Work Group examined the variation in prescribing within provider groups by specialty. By ranking prescribers who wrote for opioids by the total amount of opioid they prescribed and then separating each specialty into quartiles, a wide variation in prescribing is noted. For initial opioid prescriptions written to previously opioid naïve enrollees, the prescribing rates between the lowest and highest quartile of prescribers varied by factors of 4 to 22 depending on specialty. For example, family practice providers in the top quartile prescribe approximately 10 times as much as the lowest quartile and six times as much as the median of the specialty. The same amount of variation maintained and increased slightly across all specialty groups when the prescribing period was lengthened to 45 days, the post-acute period.

 

The Work Group is currently looking at measures for reporting prescribing results back to providers. Prescribers will get confidential information on their rates of prescribing over 100 and 200 MME in the acute period, and over 700 MME total accumulated dose in the post-acute period. For those who treat patients with chronic pain, the Work Group recommends reporting the number of patients who are prescribed above the safety thresholds of 50 and 90 MME per day.

 

By looking at prescribing behavior via this quality improvement mechanism, we believe that we can adequately support pain management, while greatly reducing the risk of developing opioid dependence to MHCP patients and all Minnesotans.

 

We in Minnesota, like everywhere, are changing the way we address pain for our patients. This change in our prescribing culture will have its bumps and challenges, but Minnesota’s provider community has proven itself to be dedicated to the well-being of our citizens and invested in quality improvement. We look forward to continuing to work with the prescribing community to decrease variation, lower opioid exposure, and improve care for Minnesotans experiencing pain.

Jeff Schiff, MD, MBA, is medical director of Minnesota Health Care Programs at the Minnesota Department of Human Services

 

Sarah M. Rinn, MPH, is coordinator of the Minnesota Opioid Prescribing Improvement Project.

 

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