Greed vs. Good Intent: The Making of the Opioid Crisis

My first job out of college in the late 80’s was as a research tech at a biotech firm where my naïve ideas about developing cures to improve health quickly gave way to an appreciation for the actual mission of drug manufacturers: making money by bringing patentable products to market. The process is rife with ethical conflicts of interests because pharmaceutical companies are in the business of selling drugs rather than prudently parsing how and when they should be used. The latter responsibility falls primarily to doctors and, in hospitals, nurses, who have significant influence over when they are given. Logically, those companies market to doctors prescribing controlled substances, and increasingly in those years, directly to patients who were guided to lobby their caretakers for medications. Not surprising that opiate manufacturers also capitalized on policies designed to eliminate pain by funding regulatory bodies charged with accreditation of healthcare organizations (see below). A major factor in the creation of opioid crisis has been the promotion, and lack of regulation of pharmaceutical drug companies’ promotion and sales.

By the late 90’s, as a young doctor just out of residency in emergency medicine, I took my idealism into my little corner of the medical world where I set out to practice with integrity. I was sure my lifelong affinity to fringe artsy friends, a few of whom got into drugs and died of overdoses, had equipped me to understand how exceptional the use of narcotic analgesics had to be. It came naturally to look for alternatives to narcotics whenever possible. Enter the next phase of greed vs. good intent. Hospital profit margins were increasingly tied to patient satisfaction scores and the healthcare industry became transformed to service for customers rather than healing and the preservation of health for patients. The total elimination of pain was  correlated with higher satisfaction scores and hospital policies were designed to encourage caretakers to use narcotics more liberally. Some of my colleagues joined in resisting that push at some risk to jobs others gave in taking the path of least resistance. A major factor in the creation of the opioid crisis has been the market driven operation of hospitals for competitive advantage over health outcomes.

Our healthcare regulatory agencies often attribute challenging trends in medical care, as caused by a failure of education and training. Enter the 5th Vital sign, pain level, as part of a campaign to teach its fundamental critical value. In the mid 90’s an organization known as the American Pain Society, advocating against the under-treatment of pain, proposed evaluating pain as a vital sign. The idea caught on nationally like wildfire, spurred by early adoption by the Veteran’s Health Administration (VHA) and The Joint Commission on Accreditation of Healthcare Organizations (JCAHO).  Pharmaceutical companies actually sponsored JCAHO to promote the movement. Soon after that, the aggressive treatment of pain with opioids was given greater potential for abuse by the Centers for Medicare and Medicaid Services (CMS) through the governmental implementation of a patient satisfaction survey called the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Patients were asked to rate their care including the complete relief of pain as part of the survey which creates an incentive to over-treat if as many organizations have done, tied practice ratings to financial reward. These parameters are hard wired into our current national health care system. No amount of medical education and training is going to speak louder than suggesting to clinicians they can expect higher salaries if they avoid disagreements with patients demanding narcotic analgesics. A major factor in the creation of the opioid crisis is the unintended consequences of federal legislation.

Finally, there were the pain management specialist clinics or “Pill Mills.” There is no doubt some physicians were irresponsibly prescribing opioid narcotics for financial gain and were greed-driven and irresponsible. I was living and working in Florida Emergency Rooms redirecting patients to pain management clinics and the newly minted “pain management specialists” during the first decade of the 21st Century which ultimately culminated in the DEA sweeping in to shut down over 250 such practices. It is ironic that I was a relative under-prescriber in the midst of treating some of the most acutely injured (emergency physicians prescribe about 5% of all opioids). Many of those arrested, convicted and serving sentences currently were the business owners who recruited corruptible physicians into dubious practices and Florida was full of such characters in those years. My standard response when one of these enterprising entrepreneurs approached me at the gym with creative easy-money propositions of this sort was “I already have a job, I’m an emergency physician.” I’ve always been suspicious of businessmen that made or make their fortunes running lucrative healthcare organizations. Yes, some physicians played a role in creating the opioid crisis, but why did the Governor of the state veto a “Pill Mill Bill” designed to attack illicit and legal narcotics sales in a state devastated by opioid addiction. Could some legislators have a hand in creating and perpetuating the opioid crisis?

The Physician-Patient Relationship, Patient Satisfaction and the Duty to Care

Most of the world would agree any physician’s primary duty is to the health of the patient. In the case of emergency physicians, we assume it would be particularly important the doctor control the practice and patients generally assume this is true. However, what if control of patient flow is not in the hands of the physician, or that even the priority of the care provided is set by policy rather than medical judgement. What happens when the pressure to see more patients faster and keep them happy during the process takes that control almost completely out of the physician’s hands? What if the outcome of treatment and health are not measures of satisfactory medical care, but the provision of quick service, medication, hospital admission, food, and entertainment are?

Turns out we now know that patients reporting the highest satisfaction in hospital surveys are more likely to be hospitalized, are charged more for medical care, spend more on prescription drugs and 25% more likely to die. Even worse, the healthier the patient reporting high satisfaction based on the surveys, the more likely they are to do poorly or die.

But how and why did we get into this mess? The short answer is that a patient paying for medical care is not the same as a customer buying, say, a car.  Yet, businessmen who took control of hospital and healthcare administration, applying a formula borrowed from sales and marketing of other “goods,” considered that immediate gratification equals excellent customer service. In fact, most healthcare organizations and the federal government continue to make the same error.  (More on how we got to a place where non-medically trained individuals became the most important decision-makers in healthcare organizations in a future.) Lets focus on the recent history for the time being.

Patient satisfaction really got its start when two researchers at Notre Dame, one an anthropologist (Irwin Press, PhD) and another, a statistician (Rod Ganey, PhD) developed a market survey for hospital administrators around the mid 1980’s. At first, only a few hospitals used this Press-Ganey tool, and mainly as a marketing device. The situation got out of control (even out of the control of Press & Ganey) once the federal government got involved in 2002.

In that year, two government agencies, the Centers for Medicare and Medicaid (CMS) and the Agency for Healthcare Research and Quality (AHRQ), got together to make their own survey. They called it the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. At first reporting these results was voluntary around 2005. Then as part of a plan to reduce the national deficit, hospitals were paid for publicly reporting patient satisfaction results which they did voluntarily. Once 95 % of them agreed to do so, by 2007, Medicare reimbursement was tied to those results under “pay for performance.” So you might well ask, “What’s the problem? The government started paying hospitals more based on patient customer service.” Sadly, these surveys are on not based on what patients need, from a medical standpoint, but what they want, so better health outcomes is not the result. Instead, patients are paying more and getting sicker or dying.

At least equally concerning is the issue of the system redirecting physicians and other caretakers from their primary duty to the health of the patient, to patients’ immediate gratification. Cynically one might surmise that hospitals are more concerned with their increasing their bottom line and the government with decreasing theirs. Alarmingly,  there is increasingly less concern with the opinion of patient caretakers who are charged with protecting the patient’s best interests and health.

How We Got Here

I’ve been an emergency physician for almost two decades now and can honestly say I’ve learned to distrust our American Healthcare System. It’s not because I doubt the level of education of doctors but because less than a quarter of the cost we pay is for care provided by physicians. It is because it’s virtually impossible to not to have to pay the balance: ultimately, we pay to be made to feel happier over  healthier.  The system does not value the time physicians take to listen, but rather rewards ones that focus on efficiency of time. It discourages the ones that are transparent, empathetic and honest, while rewarding those that only pretend to be kind. Turns out you can easily force professionals to kowtow and appease if you treat them as expendable employees. Those are also some of the “whys” to the loss of respect in the medical profession:  our system no longer values the integrity to say “no” but rewards doctors for saying “yes,” even if it might cause harm. Finally, the system we have in place blames those same professionals for the ill effects of the behavior it engenders once the fall out predictably manifests itself.

I started this blog as a way to translate some of the jargon and bring understanding and transparency to people, so that anyone can understand how problems like the opioid epidemic is the result of misapplied national policies in the interest of profit and a culture of greed, rather than ignorance or the work of a few bad actors or uninformed pill pushers. I hope to warn patients that jargon such as “quality measures” and “meeting benchmarks” increase profits do not our health.

We, doctors, generally know this because we are often also patients, or their family members or surrogate decision makers. Over the years, many of us in medical education have bent the ears of students, residents, patients, colleagues, family members, hell just about anyone who will listen about how critical ethical medical practice is to our health system and ultimately our own health. In future posts, I hope to share with you how our system deteriorates and only keeps from collapsing because a lot of great people know this at least as well as I do and risk their jobs, happiness and reputations daily to make it work, and a lot more that no one seems to want to admit. Here we go….

L.E. MD

Welcome!

Welcome! After 20 years of caring for an endless variety of patients, it is painfully clear to me what is most lacking in healthcare today is trust.  The deterioration of trust between all stakeholders involved in the complex equation of medical care in America, appears to me to originate in a lack of honest communication. My hope is to share what’s not being said so we can help each other truly heal.