By Terri Lewis, Ph.D.
(Dr. Lewis continues to mine the chronic pain survey that she conducted, and the National Pain Report helped promote this summer which attracted 3,000 respondents and over 200,000 lines of commentary from chronic pain patients, loved ones and providers. We also continue to learn that chronic pain patients often have more than medical condition. She has submitted the results to the federal government.)
The Center for Medicare Services (CMS) tracks illness complexity through Medicare and Medicaid billing data. The last large data publication is for the year 2015, but it provides us with insight about the prevalence of multiple chronic comorbid conditions (MCC) by age and payment source down to the level of state and county. With this data we can get some insight into the health complexities of persons who use multiple medications, including opioids, to treat various health challenges. But within the data that is published, CMS only tracks the most frequent conditions associated with the preponderance of billing claims. This amounts to 19 conditions associated with claims data across all body systems, physician specialties, and billing claims made and paid.
In Table 1 below, we see columns for condition, percent of the population, age, sex, and program. Dual enrollees are persons who are eligible for both Medicare and Medicaid and nondual are associated with one program or the other. In Table 2 we see the percentage of users who are reflected in the data, along with the number of conditions that are ‘comorbid’ or associated with each other. One can infer that the more conditions one is dealing with, the more likely it is that the individual will have multiple physicians, receive services from multiple specialties, and as the conditions increase, are more likely to receive multiple prescriptions.
What about the large percentage of medical conditions that are not represented in this data? The survey results indicate that many of you are dealing with the conditions in the table above. But most of you are also dealing with significant disease processes that are invisible to the published CMS data tracking system. It makes me wonder whether this lack of reporting and tracking might be one of the reasons which we fail to understand the problem of ‘chronic pain’ overall as it is represented in the 20% of the population.
The impact of MCC among the 2988 respondents to the survey response looks something like this example in Table 3. Each cell is one person. Each person identified the diagnoses (1-5+) for which they were being actively treated. The majority of these diagnoses are known to also generate chronic, intractable pain. Three hundred twelve (312) separate disease categories were identified across all ICD-10 body systems that are reflected in CMS billing claims, but which remain invisible in the current published CMS data tracking system.
Table 3. Reported Comorbidities
Respondents characterize their disease and pain symptoms in terms of the length of time from diagnosis. In about five percent (5%) of the cases, individuals report that their disabilities and management issues have been present from birth and have persisted into adulthood. The clear majority of cases are the result of illnesses with onset after the age of 18 years and are reflected as chronic illness with persistent, progressive symptoms, or as the result of disability acquired secondary to medical harm. Medical harm is defined as injury acquired as the result of a medical treatment or procedure.
Table 5. Current Medication Status
Table 5 provides some insight into the status of interactions with opioid medications for respondents with high needs and multiple comorbidities. Many have experienced a change to their opioid prescribing routines that include discontinuance or forced taper, step therapies, loss of a prescribing physician, pharmacy refusals, insurance changes, or regulations that prohibit some types of payment arrangements.