Dr. Richard Stieg of Denver, Colorado is 78-years old. He’s a former president of the American Academy of Pain Medicine. He has seen a lot of things in pain management.
But nothing he has seen is quite like what he sees now.
“This is the most chaotic time I’ve ever seen,” he said. “I’m glad I’m nearing retirement.”
Dr. Stieg spoke at the Southern Pain Society meeting in Orlando, Florida this week where his message was about how medical providers need to identity and define risk strategies for themselves and their patients if they choose, or as he said “have the courage” to treat some of their patients with opioids.
The risks are plentiful:
The scrutiny of the regulatory agencies in local, state and federal governments, plus what Dr. Stieg terms as guidelines imposed mostly by non-medical bureaucrats in managed care companies and other third parties provide what he said is a “double edged sword” for both patients and providers.
Dr. Stieg remembers a simpler time.
When a pain patient was looking for help 30-to-35 years ago, there were alternatives like programs that emphasized physical restoration, biofeedback as well as psychological and dietary counseling.
Those programs were then largely covered by a patient’s insurance.
Since managed care began, and, as he said, “started ratcheting down coverage for chronic pain, mental health and other chronic illness,” these programs are largely not insured today. Most patients can’t afford to pay for them out of pocket, so many who could benefit, aren’t able to.
“Without having those options, we found ourselves prescribing strong pain medication more frequently because we had fewer alternatives to try and also found that pharmaceutical companies started to develop more opioids and dominated our medical meetings with information about them.”
The pendulum had swung all the way from never using opioids in the late 1970s to using them almost indiscriminately.
Now, because the DEA and state officials have begun to crack down, the pendulum is swinging back, and Dr. Stieg feels like it might be swinging back too far and too fast.
He told the story of a recent visit by a patient who had been denied a prescription by her health plan–a prescription that she had been using for two years. She told the doctor she was informed by her health care plans that she now needed a prior authorization before they would fill it.
Dr. Stieg reminded her that every patient in his practice (including her) had received a letter from him two years ago saying his practice, a small practice, didn’t have the time or the resources to do that. anymore.
To punctuate that, he had her stay in the office (she was his last patient of the day) and listen to what he had to go through.
“I called the health plan and after waiting on hold for a while I spoke with a person. I asked if he had a medical or pharmacy background and he said no,” Dr. Stieg recounted.
I explained to him who I was and my background and the unique reasons that the woman was receiving the medication that she had been prescribed for the past years.
” He said, you really need to talk with a pharmacist.”
Dr. Stieg asked to be transferred to one. This may sound familiar to any of you who have tried to get answer from your health plan.
After minutes more of being on hold, the customer service rep came back on and told Dr. Stieg that the pharmacist said it was denied.
Dr. Stieg pressed, saying he wanted to talk personally to the pharmacist who he did (after another short delay), explained everything to the pharmacist who ultimately said that both he (Dr. Stieg) and the patient would have to submit written appeals.
It took 25 minutes and the answer was no.
The patient was amazed and obviously upset.
For Dr. Stieg, that story, which he planned to tell the audience in Orlando is emblematic of the problem in health care too—too many bureaucrats in government, health care plans and pharmacies and not enough common sense.
Dr. Stieg, who will retire in the next year or so, has embarked on a program in his practice to taper about 100 of his patients who use opioids. (We reported on it recently–click here).
He’s doing it because he doesn’t believe those patients will be able to find doctors who are less inclined to accept new patients who are taking opioids because of the regulatory scrutiny.
“Doctors are frustrated, patients are frustrated and they both should be,” he said. “We can do better.”
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