January 31, 2018 | Sherry Dillon, RN, CPHRM
Should opioid overuse be considered an HAC?
Look anywhere in the mainstream media and one will undoubtedly find stammering statistics, vlogs, blogs, case studies, tweets, political campaigns, and opinions regarding the opioid epidemic facing the United States today. Discussions, remedies, and potential long-term solutions to this crisis have been explored by almost every expert in the industry including Centers for Medicare Services (CMS), The Joint Commission (TJC), the National Quality Forum (NQF), and the Pharmacy Quality Alliance (PQA), to name a few. However, a controversial blog recently published by Health Affairs has received abrupt attention from the medical community, as it contends that long-term opioid use should be considered a Hospital-Acquired Condition (HAC). Why is this controversial? Certain HACs are not reimbursable by CMS under the Inpatient Prospective Payment System guidelines for Medicare/Medicaid Participation. If opioid overuse and subsequent addiction becomes recognized as an HAC, what would that mean for public reporting, patient safety measurement, and reimbursement for hospitals?
Root of the opioid epidemic
The blog authors first discuss root causes of the opioid epidemic as good intentions gone awry. They say it starts with clinical providers, who are treating inpatient pain management with higher doses and frequencies of opioids, then discharging patients on similar prescriptions following acute care visits. However, they allege there is an ulterior motive behind the rise in opiate prescriptions—patient experience standards set by TJC and CMS. The TJC states that effective pain should be considered the fifth vital sign. Additionally, over the past two decades CMS has ramped up use of patient experience survey results to enforce Value-Based Purchasing penalties against institutions with low effective pain management scores. Although designed with good intentions to optimize the patient experience, these standards make pain management an essential measurement of care quality and the patient experience. Ironically, TJC and CMS could be the two entities that push for new regulations and standards as an antidote to the crisis—a crisis they themselves may have started.
The epidemic is real
According to The Centers for Disease Control (CDC), more than three out of five deaths related to drug overdose involve the use of an opioid. Even more staggering is the fact that overdose deaths related to opioids, including heroin, have increased more than five times since 1999. In 2016 alone, there were over 42,000 deaths from these drugs—40 percent were related to prescription opioids.
Definition of a hospital-acquired condition
Is perioperative overuse of opioids within the hospital truly an HAC? CMS’ definition of an HAC includes the following criteria:
- The condition arises during the hospitalization
- High cost, high-volume, and problem-prone condition
- The condition could have and should have been prevented through evidence-based guidelines
The authors of the Health Affairs article respond with a resounding “yes”. Let’s come back to this question. For now, let’s present recommended evidence-based guidelines that the Health Affairs authors believe will help mitigate the opioid crisis in the hospital setting.
Best practice guidelines
Taken from the CHCA/HealthTrust perioperative Pain Management Collaboration Summit, held in late 2017, the guidelines below serve as a blueprint to prevent ongoing opioid overuse:
In order to hold a hospital accountable for opioid overuse as an HAC, there must be a way to track and trend the opioid use with credible and meaningful data, guidelines, and clearly defined measures. Three opioid overuse HAC measures—stewarded by the Pharmacy Quality Alliance—were endorsed by NQF in 2017. These measures could be considered by CMS for future IPPS final ruling, but no dates or official statements have been released yet. The measures outlined below could serve as a way to measure opioid use:
- Use of opioids at high dose in persons without cancer
- Use of opioids from multiple providers in persons without cancer
- Use of opioids from multiple providers and at high dose in persons without cancer
Based on current information, the verdict is still out as to whether opioid overuse will be classified as an HAC. However, one thing we can all agree upon is that the opioid epidemic is real; it has devastated communities across the United States; and it’s responsible for tens of thousands of overdoses each year. The opioid crisis is not going away anytime soon, and it will take work to make the necessary changes. The time is now for legislation, the hospital community, technology companies, healthcare quality leaders, and major payors of healthcare to collaborate to solve this problem.
Knowing what it would take to define and measure opioid overuse as an HAC, do you think it’s the right thing to do?
According to the NQF, a daily dosage of >120 mg of morphine-equivalent drugs for 90 days or longer is considered high dose.