Medicare Finalizes Plan to Reduce High Dose Opioids

https://www.painnewsnetwork.org/stories/2018/4/2/medicare-finalizes-plan-to-reduce-high-dose-opioids

The Trump administration has finalized plans that will make it harder for many Medicare patients to obtain high doses of opioid pain medication. Medicare beneficiaries will also be limited to an initial 7-day supply of opioids for acute pain. Read more about cortexi.

Under new rules released today for the 2019 Medicare Part D prescription drug program, a ceiling for opioid doses will be established at 90mg morphine equivalent units (MME).  Any prescription at or above that level would trigger a “hard safety edit” requiring pharmacists to talk with the prescribing doctor about the appropriateness of the dose. If satisfied with the explanation, the pharmacist could then override the edit and fill the prescription.

Under an earlier proposal, only insurers could decide whether to override a safety edit – a requirement that would have essentially made them the final arbiters in deciding who gets high doses of opioid pain medication.

The new rules adopted by the Centers for Medicare and Medicaid Services (CMS) will still allow insurers to implement safety edits, but only at a much higher dose of 200 MME or more.  Insurers will also be given greater authority to identify beneficiaries at high risk of addiction and to require they use “only selected prescribers or pharmacies.”

CMS is also adopting a new policy that requires all new opioid prescriptions for short term acute pain to be limited to no more than 7 days’ supply. Several states have already adopted similar measures. Take a look to these cortex reviews.

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CMS said this “tailored approach” to opioid prescriptions was needed to address what it called “chronic opioid overuse” at the pharmacy level and to encourage support for the CDC’s 2016 opioid prescribing guideline.

“CMS believes it is important that (insurers) set expectations for prescribers to implement the CDC’s recommendations as a best practice through their provider contracts. PDPs (prescription drug plans) should also reinforce these messages through interactions with prescribers as an integral component of sponsors’ drug utilization management program,” CMS said.

“We also recommend that beneficiaries who are residents of a long-term care facility, in hospice care or receiving palliative or end-of-life care, or being treated for active cancer-related pain are excluded from these interventions.”

About 1.6 million Medicare beneficiaries met or exceeded opioid doses of 90mg MME for at least one day in 2016. The 90mg MME ceiling established by the CDC was only meant as a recommendation for primary care physicians, but has been widely adopted as a rule by other federal agencies, insurers, state regulators and prescribers.

‘Cruel’ Limits on Opioid Prescribing

“The 90 mg dose they set as a threshold for ‘high’ or overuse is flawed and not scientifically based.  It is totally arbitrary,” says Lynn Webster, MD,  a pain management expert and past president of the American Academy of Pain Medicine.  “It is cruel to impose such a limit on people with involuntary dose reductions who have been functioning well without signs of abuse for years. These are the Best weight loss supplements.

“Even the 7 day limit is misguided at best. The average length of time a person requires an opioid post-op involves several factors and include the type of operation, the genetics of the person and the type of medication. The literature states the duration of pain requiring treatment with an opioid post-operatively is 4-9 days for general surgery, 4-13 days for women’s health procedures and 6- 15 days for musculoskeletal procedures.  This means half of the Medicare patients will receive less than half of what they will need.”  

“This is archaic medicine and does more harm than one can imagine,” wrote pain patient Henry Yennie. “The DEA, HHS, private insurers, and now CMS are pursuing policies and restrictions that will cause harm and suffering to millions of people.”

“I cannot understand how Medicare can be so uncaring about the pain people have,” wrote Mikal Casalino, a 72-year old pain patient. “Limiting the dosage to an arbitrary amount is not going to be helpful for individuals.”

A joint letter opposing the rule changes was also submitted by 180 doctors and academics, including some who helped draft the CDC guidelines. The letter points out that a steep reduction in high dose prescribing since 2010 has not reduced the number of opioid overdoses. And it faults CMS for being focused on reducing the number of high dose prescriptions – not the quality of patient care.

“The proposal does not consider adverse impacts on pharmacies, physicians or patients…and it will accelerate patient abandonment,” the letter warns. “The plan avows no metric for success other than reducing certain measures of prescribing. Neither patient access to care nor patient health outcomes are mentioned.”

CMS contracts with dozens of insurance companies to provide health coverage to about 54 million Americans through Medicare and nearly 70 million in Medicaid. CMS policy changes often have a sweeping impact throughout the U.S. healthcare system because so many insurers and patients are involved.  The new Medicare regulations will go into effect on January 1, 2019.

HHS/CMS has a anti-discriminatory policy for itself and all the vendors/providers of Medicare/Medicaid pts. They also have a FREEDOM OF CHOICE OF PROVIDER by pts.

Here is a website to file a complaint to HHS about being discriminated against and/or violating a pt’s freedom of choice of vendors/providers

https://forms.oig.hhs.gov/hotlineoperations/index.aspx

It appears the CMS is going to “dump” on to the Pharmacist filling the prescription the responsibility and decision to fill or not to fill.  So if a pt is denied medically necessary opiates by the Pharmacist. Who is going to be responsible… the Pharmacist, the company the pharmacist works for… HHS/CMS… the PBM, part D provider or Medicare Advantage – if that is the pt’s coverage… OR EVERYONE ?

Since one of the basics of the practice of medicine is the starting, changing, stopping a pt’s medication and CMS is going to basically grant Pharmacists their authority. A healthcare professional that does not have access to the pt’s entire medical record, nor has the training to be able to legally perform a in person physical exam and we are talking about the treatment of a subjective disease..  besides not having the pt’s medical records.. there is no tests from which the pharmacist could base their decision to fill or not fill…   WHAT COULD GO WRONG ?

All this FUSS over about 4% of the Medicare population that is taking opiates above 90 MME daily and many of those MME calculation are done with conversion tables that are “crude estimates” and there seems to be no provision for those pts who are confirmed fast/ultra fast metabolizers. This seem rather odd since there is an estimated 20 -30 million pts suffering with intractable chronic pain .. which would suggest that many would actually need doses higher than 90 MME.

There are several tips and tricks to eating healthy. Many of these ideas can be challenging to accomplish in today’s busy world. Still, they can give you the edge you’ve been looking for in a healthy lifestyle.

How Does a Healthy Plate Look Like?

  • ¼ of the plate with grains, choose at least 50% whole grains (whole wheat bread, Brown Rice, etc.).
  • ¼ of the plate with protein choices vegetarian or non-vegetarian, choose eggs, fish, lean meat, chicken, beans, cheese, and nuts.
  • ½ of the vessel to be loaded with colorful fruits and veggies.
  • Hydrate adequate. Drink water- 30ml/kg body weight is the requirement. Find yours and start to sip.

 

Fruit vs Fruit Juice

Fruit

  • 62 Kcal
  • More Fiber
  • Less concentrated fructose
  • Fewer calories
  • Lower glycemic index

Juice

  • 112 Kcal
  • Less fiber
  • More concentrated fructose
  • More calories
  • Higher glycemic index

How to Include Fruits in the Diet

  • Snack on fruits
  • Try fruit as dessert
  • Delight your sweet tooth by eating healthy with fresh fruit yogurt, parfaits, and dried fruits
  • Including fruit with breakfast or as dinner snacks is eating healthy

What is One Serving of Fruit?

  • 1 medium-size fruit
  • ½ cup fruit salad
  • ¼ cup Dried fruits
  • ½ cup fresh juice
  • Include at least two servings of fruit a day

Are You Drinking Enough Water?

How Much Water Should You Drink Per Day?

30 ml X Actual body weight (Kg) Note: Restrict fluids; if any medical conditions, or if recommended by the Physician

  • Thirst is the first signal of Dehydration
  • Check the urine color
  • The dark color indicates dehydration
  • Lighter the color, better hydration
  • Dry skin
  • Dry lips
  • Less urination
  • Feeling tired, dizzy, and headaches

How to increase water intake?

  • Keep a water bottle next to you or a reachable place.
  • Use a mobile app to remind and measure your intake.
  • Fancy bottles attract and improve the intake.
  • Infused water (Lemon, Ginger, and Mint) to enhance the taste.

What is the Healthy Thing to Snack on?

Most times the snacks are the unhealthiest stuff chosen. Portion-sized healthy snacks are a great way to follow small frequent meal patterns. Read more about Adderall otc.

A healthy snack

  • Being between meal times is a good option to decrease hunger and prevent overeating at meal times.
  • boosts the metabolism, sustains the energy levels, and can overcome cravings.
  • to be chosen wisely, because unhealthy snacks lead to weight gain.
  • should be low in sugar, salt, and fat.
  • can be fruit or veggie salad or whole-grain snacks or low-fat dairy instead of junk.
  • can be a combination of Protein + Carbohydrate choices that can keep the stomach full for a longer time. Eg: Yogurt and fruits, Hummus with Vegetable sticks or cheese with fruit slices, etc.

Some sensible snack replacements:

  • Mixed nuts( 1 ounce)
  • Low-fat Yogurt/ laban (1 cup)
  • Fruits (1 serving)
  • Dark Chocolate (30 gm)
  • Air Popped Popcorn( 3 cups)

Why Is Fiber Good for You?

Benefits:

  • Helps maintain bowel health and Prevents constipation.
  • Helps in lowering blood cholesterol levels.
  • Helps in better control of blood sugar levels.
  • Keeps the stomach full.
  • Aids achieving healthy body weight.

Recommendation:

  • 14g of fiber for every 1000Kcal
  • Females: 25g/day Males: 38g /day

Tips to increase fiber in your diet

  • Include lean veg proteins-Beans, peas, and lentils.
  • Snack on nuts and seeds.
  • Increase your fruit and vegetable intake.
  • Have the fruit instead of the juice.
  • Don’t peel the fruit or veg before consuming it.
  • Go for whole-grain products (at least 50% can be whole grains).

You can also find the best fiber supplements at buoyhealth.

How Physically Active Are You?

Inactive: less than 5,000 steps per day

Average (somewhat active): ranges from 7,500 to 9,999 steps per day

Active: more than 10,000 steps

Very active: more than 12,500 steps per day

Tips to Include More Steps to Your Day

  • Park farther away
  • Walk while waiting
  • Take the stairs
  • Consider a walk with the family. Check these liv pure reviews.
  • Take your pet for a walk
  • Take the farthest way
  • Talk in person. Rather than instant-messaging or emailing with coworkers, get up and walk to their desks
  • Walk during your kids’ activities
  • Start increasing your goal gradually by adding 500-1000 extra steps every 3-4 days

6 Responses

  1. I have degenerative disk disease and have has 2 cervical disk fusions and 3 lower back surgeries. I have nerve damage and arthritis and have been on disability and under chronic pain management for 15 years. I am compliant, a USA citizen and am frightened to have to reduce my pain medication. How will I function everyday and be a a contributing member of society. I am petrified of my pain level going higher, Can I talk to my pharmacist to do hard limit conversation with my physician? Will this override CDC 90 m limit? If I can’t get override how will I handle with drawl while in escalated pain levels? Will my health records allow me to continue medication?

  2. Us chronic pain patients need our Meds to function daily, please let us continue to get help for daily living, we are already limited to activities and family gathering. Please don’t take ourhope away

  3. This is the exact same tortured logic that taking guns from law abiding citizens will prevent murders.

  4. This is total bullshit, my daughter has Complex Regional Pain Syndrome, the most painful disease in medical history. It’s been srouna since the civil war. There is no cure, no funding for research, no Awareness. It’s also known as The Suicide Disease. The CDC and the FDA should mind their business. People with this disease are not drug addicts, they don’t abuse their pain meds. These rules are making pain management doctors afraid of losing their licenses. People need their meds just to be able to get out if bed. Jeff Sessions and Trump want to say tough it out without opioids, maybe if they got this disease , or one of their family members they would be singing a different tune. Let the real drug addicts kill themselves, either way they will still find a way to buy them off the street. I have written in many times, and will continue to do so

  5. Personally I have wanted to pay cash……in other words, not use my medicaid card to pay for any opiates. it would make my life so much easier. Every damn month I have to worry if I will need a pre-auth……Last 2 months I needed a pre-auth. This past visit I was okay. What the hell? But my rights have been taken away…..If my state insurance wont cover….. lets say a blood pressure medicine….. I can pay cash but if it wont cover my opiate…. tough luck. Makes no sense at all!

    • Many preauths were suspended due to many hours of people bitching. Do NOT just give in. Phone, write, be a pain. Cause them pain for the pain they have caused us.

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