07/29/2023
Do no harm???? What every American needs to know about recent changes made by Medicare that are making our elderly population suffer….
Never has it been more challenging and frankly at times depressing to be a physician caring for our “elderly” patients who are in pain (Medicare beneficiaries). Medicare, over the past couple of years, has adopted incredibly restrictive guidelines with respect to several critically needed pain management procedures. This was done to curb cost, but inadvertently at the expense of increased pain and suffering among our citizens in greatest need.
How did we get here? Unfortunately, there is a well-known history of abuse and misuse among pain management providers who care for Medicare beneficiaries. This trend continues and is more pronounced in some states than others. Countless medically unnecessary procedures continue to be performed on Medicare recipients at risk of their safety and well being and at tremendous cost to the broken government run healthcare system. Medicare, despite our urging, does not credential providers which means the provider who is placing a spinal injection a few millimeters from the spinal cord of you or your relative legally needs no formal training to do so. Hence, the flood gates opened when greedy doctors took advantage and starting doing (along with their staff – PAs, APRNs, “techs”) needless injections at nauseum seemingly on anyone with a Medicare card and a pulse. Shameful. Medicare did indeed need to do something, but they got it wrong.
I have worked closely with Medicare as the primary pain management advisor from Connecticut for over 15 years to help them better understand appropriate pain management care for their beneficiaries and implement reasonable and sound policies regarding the same. They used to listen. We would meet in person, discuss data, and thoughtful, fair policies would ensue. We would meet in person after office hours given this is all volunteer work by the physicians (the process was the same for all recognized medical specialties, not just pain management). Now, the same meetings occur in the middle of a workday via a telephone conference call (no video, no faces, no relationships). Ironically, the last meeting I was to attend, before recently resigning from this position, was made known to me 4 hours before the meeting was to start. With a full patient schedule already booked, I was unable to attend. The message is clear – Medicare says they value our expert input, but it’s all a façade. They take hours of our volunteered time, ask us to present data and studies, and then merely do whatever they decided they were going to do before we even met after spending about a year developing each policy. The system is broken and everyone, especially the elderly patient, loses.
The new Medicare pain management policies are incredibly and inappropriately restrictive. They completely go against the sacred oath we take regarding “do no harm.” For example (one of many), arthritis pain (facet joint pain) in the spine is very common and very treatable with certain procedures if performed by a trained expert (Medicare doesn’t care who is performing them). There are multiple facet joints along the spine. Medicare, in their wisdom despite our passionate advising, deemed that we can only treat 2 facet joint levels now – ONCE A YEAR (the standard for the rest of U.S. insurance companies is up to twice a year). Arthritis does not “know to stop at two levels.” Arthritis does not discriminate between affecting the left side vs. the right side, or both. Now, many times a day my conversations go like this: “Well Mrs. Smith, I would like to offer you that procedure for your 4-facet joint level pain which gave you 100% relief for 6 months, but I can only do half of that procedure now so we can hope for 50% relief for 6 months. You will need to wait 6 months before we can treat you again. I am truly sorry.” Ironically, despite the pressure of the DEA, the press, and insurance companies, we are now prescribing more and more opioids to Medicare beneficiaries which are not without risk and with substantial increased cost to the system. The opioid epidemic is perpetuated partially by the failure of Medicare to provide care for their beneficiaries. We know these medications can be addictive, and from a medical perspective they can adversely affect the elderly in many other ways: sedation, constipation, immune compromise, depression, increased falls, etc. One of the most common ways by which young folks get their hands on opioids is from their elder family members – a gateway to a life of hell and premature death in too many cases. Additionally, more and more Medicare beneficiaries are being referred for invasive and risky surgical interventions at considerable cost to the system. Many of these surgeries could be avoided with appropriate pain management care; care which we cannot render given the clinical handcuffs imposed by Medicare.
No one takes care of Medicare beneficiaries to get rich. The payment rates, which consistently decrease annually, are abysmal. They sometimes barely cover the cost of the treatment. That being said, treating our dear elders provides incredible personal and professional satisfaction: restoring and helping maintain their quality of life and their ability to function safely and independently without potentially addictive medications and invasive surgery. It is most challenging to find joy when we are being forced to withhold potentially beneficial care, especially when the patient flourished with appropriate, highly effective treatment in the past, and hopes (expects) for the same level of care now and in the future.
Bottom line: Medicare needs to credential and audit the providers doing these potentially high risk, yet potentially highly effective procedures. Just doing that would provide them the cost savings they are seeking and much more. They need to listen to the experts. There is always hope that these recent policies will be modified in time, but for now, our patients suffer with increased risk of adverse outcomes due to a lack of access to effective, time-tested treatments. It is the humbling duty of the pain management physician to somehow hold our suffering patients through this most challenging phase while maintaining the energy to do this day after day after day. Personally, I am losing sleep wondering if I am truly upholding my oath, taken almost 25 years to the day, promising to “do no harm.”
