Chronic pain management is one of the most difficult problems we encounter in the office. Physicians want to help patients with chronic pain live more productive and comfortable lives. We feel the sometimes conflicting responsibilities to adequately control pain while at the same time taking care to avoid becoming suppliers for the prescription drug abuse epidemic that is sweeping our country. More middle aged people in Washington state die of prescription drug overdose than die in motor vehicle accidents. The Agency Medical Directors Group (AMDG) in WA has proposed regulations for physicians to follow to try to more safely manage chronic pain with opioids. The AMDG slogan from their web site is:
Representatives of DSHS must have been absent from this collaboration because I was amazed to learn this week that in Washington State DSHS and Molina,the DSHS managed care plan we use at our office, refuse to pay for urine drug screening. This in and of itself may seem not unreasonable, but the reason I was so dismayed is that the AMDG regulations specifically call for urine drug testing to prevent diversion of opioids and to try to identify patients getting opioids from multiple prescribers. Specifically the proposed regulations state:
“If a decision has been made to prescribe opioids for chronic non‐cancer pain, the prescriber should get a baseline UDT and screen all patients for risk level to develop an appropriate monitoring plan as well as a basis for consultation or referral. Although UDT and other screening tools are helpful in identifying aberrant behavior, it is also important for prescribers to use their clinical judgment in the development of a monitoring plan. The Prescriber should repeat random UDT based on the patient’s risk category.”
It is clear that providers are going to be held to the standard of doing urine drug screening in patients for whom they prescribe prescription opioids for chronic pain. Failure to comply with these regulations could place a physician’s license to practice medicine at risk, and is certainly going to put physicians at risk for lawsuits if an overdose or adverse outcome happens to a patient being treated without compliance with the guidelines. So what is a physician to do in this situation. Here are a few options:
- Refuse to treat DSHS patients with opioids for chronic pain. This may not be an option because our DSHS contract demands that we treat DSHS patients with the same quality of care that we treat everyone else.
- Refuse to treat DSHS patients at all. For many this is a very attractive option because DSHS pays at the lowest rate of any third party payer, even lower than Medicare. Given one more reason to opt out may be enough to convince some busy doctors to bail on this unprofitable part of our workload.
- Refuse to treat DSHS patients unless they pay for their own urine toxicology screens. This may also not be legal, but since it is a non-covered service I think physicians could bill DSHS patients for the service as long as we get a signed consent from the patient recognizing that they are responsible for paying the fee.
- Refuse to treat chronic pain at all. This also would be attractive to many physicians since this is one of the least satisfying, most demanding, and highest risk parts of our practice. Already many patients complain that they cannot find a doctor for chronic pain management.
- Hope that this decision to refuse to pay for urine drug testing is reversed prior to full implementation of the regulations, and hope that none of our DSHS patients die in the meantime. The lack of true coordination between DSHS and AMDG is shameful. As a result WA physicians are not able to safely manage DSHS patients pain due to the payment rulings. I’m going to send this post to my state representatives and Senator to see if they have any influence to make this happen.
Every day I see incredibly stupid government regulations, but this one on chronic pain management is near the top in Washington for medical policy. Stay tuned for a future article on the refusal to allow electronic prescribing of controlled drugs by the DEA. That is dumb rule to trash another day.