Washington, D.C. – U.S. Senator Joe Donnelly joined a bipartisan group of Senators this week urging the U.S. Department of Health and Human Services Sylvia Mathews Burwell to evaluate whether certain questions on the hospital patient satisfaction surveys are a contributing factor to the nationwide prescription opioid abuse epidemic. This survey, the results of which impact some Medicare reimbursements, includes questions that ask discharged patients to rate how often their pain was controlled and how often hospital staff did everything they could to help treat their pain, leading some health care providers to believe it may encourage health professionals to prescribe opioid pain relievers to improve hospital performance on quality measures that reward high quality hospitals. As the prescription drug abuse epidemic grows and continues to devastate families across the country, efforts to reduce the inappropriate supply and use of prescription opioids will be important to combatting this crisis.
Donnelly and his colleagues wrote in a letter led by U.S. Senator Susan Collins (R-ME), “Such an ample supply of prescription opioids is subject to misuse and diversion, which has become one of the foremost public health challenges facing our nation… For millions of patients who are suffering from illness or injury, prompt delivery of pain control – which may or may not include opioid pain relievers – is proper and humane. Yet inappropriate use of opioid pain relievers does not provide any clinical benefit and may actually pose a risk of harm. The evidence suggests that physicians may feel compelled to prescribe opioid pain relievers in order to improve hospital performance on quality measures…We hope this is a robust examination of this issue and includes more input from hospitals and providers, many of whom have expressed concern to us about the survey’s impact on opioid prescribing practices.”
According to an Indiana State Department of Health report, drug overdoses from opioid pain relievers contributed to 20% of overall drug overdose deaths in 2012. The report notes that the rise in heroin overdoses may result from increasing rates of opioid addiction, as approximately four out of five new heroin users have abused prescription opioids prior to using heroin. Nationally, the Center for Disease Control reported that healthcare providers wrote 259 million prescriptions for painkillers in 2012, enough for every American adult to have a bottle of pills.
The full text of the letter follows. To see the signed letter, click here.
The Honorable Sylvia Mathews Burwell
Secretary of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Dear Madam Secretary:
The prescription drug abuse epidemic is a nationwide and growing crisis that continues to have devastating effects on families across America and on public health and safety. In many states, it has also become a heroin crisis, overwhelming our communities and families with often tragic consequences. Recently, the Centers for Disease Control and Prevention (CDC) announced that deaths from opioid pain relievers as a result of misuse and abuse have soared over the last fifteen years. Moreover, the CDC reports that healthcare providers wrote 259 million prescriptions for painkillers in 2012, enough for every American adult to have a bottle of pills. It is alarming that Americans consume opioids at a greater rate than any other nation, including twice as many opioids per capita as Canada. Such an ample supply of prescription opioids is subject to misuse and diversion, which has become one of the foremost public health challenges facing our nation.
The evolving scope of this crisis leads us to write you about one factor that may be contributing to these staggering statistics. As you know, the Centers for Medicare and Medicaid Services (CMS) operates the Hospital Value-Based Purchasing Program, an important part of our efforts to transition Medicare from a program that rewards providers for the volume of services provided to one that rewards high quality care. Under the Hospital Value-Based Purchasing Program, CMS will withhold 1.75 percent of participating hospitals’ base operating diagnosis-related group payments in fiscal year 2016 and redistribute those funds to hospitals in accordance with their performance on certain quality measures. One quarter of this adjustment is based on the patient experience of care, which CMS measures according to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This survey asks discharged patients to respond to questions including, “During this hospital stay, how often was your pain well-controlled?” and “During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?”
Pain control is a critical component of quality inpatient care. Patients can often be expected to experience pain, as pain is naturally associated with many events that may necessitate an inpatient stay, like acute surgery or trauma. Moreover, for many years, patients faced many barriers to accessing effective pain treatment because pain management was unfortunately ignored and often needlessly less than optimal.
The pendulum, however, may have swung too far. For millions of patients who are suffering from illness or injury, prompt delivery of pain control – which may or may not include opioid pain relievers – is proper and humane. Yet inappropriate use of opioid pain relievers does not provide any clinical benefit and may actually pose a risk of harm. The evidence suggests that physicians may feel compelled to prescribe opioid pain relievers in order to improve hospital performance on quality measures.
As we take steps to reward high quality care in the Medicare program, it is critical that we correctly measure the quality we are rewarding. Currently, there is no objective diagnostic method that can validate or quantify pain. Development of such a measure would surely be a worthwhile endeavor. In the meantime, however, we are concerned that the current evaluation system may inappropriately penalize hospitals and pressure physicians who, in the exercise of medical judgment, opt to limit opioid pain relievers to certain patients and instead reward those who prescribe opioids more frequently. We understand that HHS has begun an examination of whether there is a connection between these measurements and potentially inappropriate prescribing patterns, and whether the survey should be modified to address this concern. We hope this is a robust examination of this issue and includes more input from hospitals and providers, many of whom have expressed concern to us about the survey’s impact on opioid prescribing practices. We ask that you apprise us of the results of this examination when it is complete.
Senator Joe Donnelly (D-IN)
Senator Susan M. Collins (R-ME)
Senator Kelly Ayotte (R-NH)
Senator Shelley Moore Capito (R-WV)
Senator Lamar Alexander (R-TN)
Senator Bob Corker (R-TN)
Senator Heidi Heitkamp (D-ND)
Senator Kirsten Gillibrand (D-NY)
Senator James Lankford (R-OK)
Senator Jeff Merkley (D-OR)
Senator John Barrasso (R-WY)
Senator Jack Reed (D-RI)
Senator Jim Inhofe (R-OK)
Senator Richard Burr (R-NC)
Senator Tim Kaine (D-VA)
Senator Mike Rounds (R-SD)
Senator Mark Kirk (R-IL)
Senator Jeanne Shaheen (D-NH)
Senator Pat Roberts (R-KS)
Senator Steve Daines (R-MT)
Senator Mike Enzi (R-WY)
Senator John Boozman (R-AR)
Senator Claire McCaskill (D-MO)
Senator Dianne Feinstein (D-CA)
Senator Dan Coats (R-IN)
Senator Angus King (I-ME)
 CDC Newsroom Archives. “Drug overdose deaths hit record numbers in 2014,” December 18, 2015. Accessed from http://www.cdc.gov/media/releases/2015/p1218-drug-overdose.html.
 “Opioid Painkiller Prescribing.” CDC Vital Signs. Accessed fromhttp://www.cdc.gov/vitalsigns/opioid-prescribing/.
 Paulozzi, Leondard. “Vital Signs: Variation Among States in Prescribing of Opioid Pain Relievers and Benzodiazepines – United States, 2012,” Morbidity and Mortality Weekly Report2012. Accessed from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6326a2.htm.
 Gunderman, Richard. “When Physicians’ Careers Suffer Because They Refuse to Prescribe Narcotics,” The Atlantic 2014, http://www.theatlantic.com/health/archive/2013/10/when-physicians-careers-suffer-because-they-refuse-to-prescribe-narcotics/280995/.