The 2015 Annual Meeting of the National Alliance of Medicare Set-Aside Professionals (NAMSAP) began yesterday and continues until Friday, October 2nd at the Royal Sonesta in New Orleans. NAMSAP gathers an array of Medicare compliance industry decision makers together to create a dialogue about the ongoing issues surrounding MSAs, especially in the workers’ compensation arena. That national perspective was on full display in several sessions addressing opioid prescribing practices, the treatment of chronic pain and “evidence based medicine.”
Wednesday afternoon, after a session on MSP compliance which repeatedly stressed the importance of “good faith” in claims handling and settlements with MSAs, Marjorie Eskay-Auerbach (a JD, MD with SpineCare and Forensic Medicine PLLC in Tucson, Arizona) gave a technical presentation on “Applying Evidence-Based Medicine Guidelines to Fusions for Injured Workers.” She focused particularly on fusions for lower back pain, and generally derided the notion that structural issues shown on MRI are in and of themselves an indication for lumbar fusion.
As part of this position, Eskay-Auerbach warned against the “over-medicalization of lower back pain” and explained that there is a “huge genetic element” to spine changes on MRI, many of which are age-related. She cited the “Twin Spine Study” of 2009 as a key piece of evidence in this regard. The study found that twins with different occupations (one understood to be physically demanding and another with a desk job) showed almost exactly the same degenerative changes on MRI, without necessarily being in pain. “Pain is not an indication for lumbar fusion,” Eskay-Auerbach said. “Just as failure of conservative treatment in degenerative disc disease is not an indication for fusion.”
Eskay-Auerbach, a surgeon herself, also referred to the vague quality of surgical guidelines issued by surgical groups, noting their political incentives to expand indications. Calling such guidelines “deliberately vague,” she explained that some surgical groups have published guidance using the phrases “appropriate length of conservative care” and “carefully selected patients” without defining what constitutes an appropriate length of time or what “carefully selected” means. Further, Eskay-Auerbach questioned the increased rates of surgery as they began to rise in the late 90s, claiming that the increases seem tied more to the marketing of devices and surgical hardware and associated profits. She substantiated this by noting that there isn’t any “greater understanding” of the spine conditions now treated with fusion than there was before lumbar fusion became popular for lower back pain and degenerative disc disease.
Much like Dr. Eskay Auerbach, Dr. Meredith Warner (of Warner Orthopedics and Wellness in Baton Rouge) is also a proponent of evidence-based medicine. Her presentation on Thursday morning, “Long-Term Narcotic Use in the MSA,” focused on the role providers play in over-prescribing opioids and the addiction that can potentially stem from such practices.
“We’re not allowed to talk about it,” she said, “but as the number of opioid prescriptions have increased, so have rates of heroin use and hep C. [Doctors and prescribers] know more than patients do. Most patients, with the exception of a few that might have nefarious motives, are doing what their doctors tell them to do. So if they wind up addicted, whose fault is that really?”
Also like Eskay-Auerbach, Warner emphasized that early MRI is not useful and that “everybody has” changes on MRI, with very few exceptions. Oftentimes, she said, “normal findings are used to rationalize treatment,” much like, according to Warner’s experience, lower back pain is used to rationalize continual escalation of morphine-equivalent doses. She also warned against complacency related to “tamper proof” formulations of old painkillers and new narcotics entering the market that are resistant to crushing and injection. The attendees were visibly surprised when Warner used a screenshot of a chat room explaining how to get around the “crush proof” new formulation of Opana ER. A patient explained in the post how one can circumvent the gelling that occurs with crushing by grinding the pills with a B12 supplement. “I kid you not,” Warner said, “All I had to do to find this was Google ‘how to abuse Opana ER.’”
While Warner’s fellow panelist Steven J. Miller of SJM Enterprises carried the discussion toward the realm of pharmacy and doctor liability in cases where a patient becomes addicted or dies, in addition to the exponential increases in MSA costs when narcotics are involved, both speakers focused on the social and moral implications of over-prescribing and continuing to acquiesce to the treatment of chronic pain with opioids. “Hospitals and clinics are heavily dependent on patient satisfaction and pain control,” Warner said, “But the fact is, these drugs do not work [for chronic pain], we know they don’t work, and we know they generate even more disability – so why do we keep giving them out?”