NATIONAL HARBOR, Md. -- Opioid undertreatment can be as much of a problem as overtreatment, Barbara McAneny, MD, president of the American Medical Association (AMA), said here.
"The pendulum swung too far when pain was designated a vital sign, and now we are in danger of it swinging back so far that patients are being harmed," McAneny said to applause Saturday at the AMA interim meeting. McAneny, an oncologist in New Mexico, illustrated her point with the story of one of her patients, a man with prostate cancer that has metastasized to his bones.
The patient's pain medication regimen wasn't working, "so I increased the dosage of his opioids from two per day to three ... and of course he ran out early." McAneny contacted the patient's primary care doctor -- whose practice is closer to the patient than hers -- and he agreed to give the man the required paper prescription for a large amount of time-release morphine. But the prescription, which required prior authorization via the patient's health plan, was denied, and the pharmacist checked the state's prescription drug monitoring program database and saw that the patient had multiple prescriptions over the years.
"The pharmacist suspected that my patient was a drug seeker, and did not alert me that his prescription was denied," she continued. "My patient, a very proud man, felt shamed and didn't know what to do. So, he went home to be as tough as he felt he could be. That worked for about 3 days -- and then he tried to kill himself."
Fortunately, his family found him in time, and his life was saved. After a week in the hospital, his pain ended up being controlled on the regimen that McAneny had suggested.
This story highlights the healthcare system's dysfunction, she said. "The health plan does not have the chart, doesn't know the patient, and basically countermanded my orders without even telling me -- using the prior authorization process. How have we let health plans determine the course of care? They call this quality?"
McAneny cited a which found that more than 90% of physicians surveyed said that prior authorization has led to delays in care. "This is unacceptable," she said. "We need to reduce the intensity of prior authorization, ensure that it is evidence-based and streamlined through automation that doesn't create another physician workflow problem." She noted that the association is leading a coalition to standardize and streamline prior authorization requirements.
At the same time, the opioid crisis also needs to be addressed, McAneny said. "We need to use our expertise in patient care to change the dialogue to appropriate pain control through a selection of possible therapies ... and to treat opioid use disorder as the relapsing chronic disease that it is."
In particular, she said the AMA "[applauds] Pennsylvania in their recent victory to remove prior authorizations from medication-assisted therapy. This is a great example of rational insurance design. We don't want to lose the teachable moment for patients motivated to treat their addiction."
Doctors also are anxious about the increasing consolidation in healthcare, she continued. "I feel a sense of urgency as we are witness to greater concentration of wealth and power in the hands of ever-larger corporations, with more and more middlemen pulling down large salaries while our patients go broke and physician practices struggle to survive. Concern about increased consolidation and what it means for patients is why the AMA opposed, and helped to defeat, the mergers of Anthem and Cigna, and Aetna and Humana, last year."
She also pointed to a problem within the profession: sexual harassment. "I was disappointed to read the recent study indicating large numbers of our female colleagues are still being harassed," McAneny said. "We cannot point fingers at others if our own house is not in order. It must stop now. Time's up!"
One problem all doctors face is "EHR abuse," she said, referring to electronic health records. "Much of the EHR technology is dysfunctional; it grew out of the billing software, so it doesn't give us the decision support or the information we need."
"The vendors of these systems like to paint doctors as Luddites who don't like technology," she added. "We love technology; we just want technology that works" and is interoperable.
On another front, McAneny advocated for more legislation to prevent gun violence. "Just in the last 2 weeks we have mourned still more senseless deaths from the mass shootings in Pittsburgh, and in Thousand Oaks," she said. "Friends, these deaths -- from mass shootings, from suicide, from children gaining access to a parent's firearm -- are preventable. Thoughts and prayers just won't cut it any more. Policymakers at the state and federal level must act on common-sense, data-driven measures to prevent yet more carnage."
Delegates also heard from Vidya Kora, MD, chair of the board of directors at AMPAC, the AMA's political action committee. "In this election cycle, AMPAC carefully threaded the needle to find candidates who were not on the extreme end of their respective parties," he said. "Our advocacy efforts focused on solution-oriented candidates who were committed to making progress on very complicated healthcare-related issues."
This year, "AMPAC contributed over $1.4 million in direct contributions to 291 candidates for House and Senate from both political parties," Kora continued. "A total of 250 AMPAC-supported candidates won election or re-election ... [We are] eager to build relationships with newly elected members and educating them on issues that matter most to physicians."