Author Archives: David Baratta

Subcommittee Hearing Sheds Light on Opioid Overdose Deaths among VA Patients

On October 10, 2013, the House Committee on Veterans’ Affairs’ Subcommittee on Health held a hearing on the topic of the “VA’s [Veteran Affairs] Skyrocketing Use of Prescription Painkillers to Treat Veterans.”  The committee called on doctors, military personnel, family, and government officials to learn more about the alarming increase of prescriptions to veterans by VA hospitals and its effect on patients.

The problem has been dramatically increasing since September 11, 2001, as a wave of new veterans returned home from the multiple theaters of the War on Terror.  The Center for Investigative Reporting has found that prescriptions of four drugs – hydrocodone, oxycodone, methadone, and morphine – have been prescribed 270% more over the past 12 years and contributed to a fatal overdose rate of double the national average among VA patients.  In addition, a study by the San Francisco VA Medical Center found that patients with PTSD and depression were more likely to receive higher-dose opioid prescriptions, 2 or more opioids concurrently, sedative hypnotics concurrently with other opioids, or obtain early opioid refills.  This is despite the fact that opioids can hinder recovery from PTSD and other mental health conditions.

One contributing factor is the sheer number of patients, therefore limiting the amount of doctor-patient time that would otherwise be afforded in VA hospitals.  Josh Renschler, Sergeant US Army (Ret.), spoke at the hearing about how his primary care VA appointments would sometimes be 3 months apart despite the pain from a mortar attack in 2008 being “wildly out of control.”  Between appointments, the only care he could receive was increased prescriptions, causing him to take up to 12 pills a day, some of which were prescribed simply to counteract the effects of others.  Another contributing factor to the increase in opiate prescriptions is veterans’ limited access to help outside the VA.  A submission to the hearing by the Iraq and Afghanistan Veterans of America (IAVA) noted that some barriers to treating chronic pain included “formulary barriers, inability to access state prescription monitoring programs (which would allow [medical personnel] to see if patients have previously been prescribed controlled medications like opioids), and barrier[s] to consulting with experts outside of the VA.”

In some cases, doctors do not want to prescribe opioids, but are forced to by the hospital administration.  One doctor at the subcommittee hearing, Dr. Pamela J. Gray, recounted that she was forced to prescribe opioids against her better judgment.  She was hired by the VA Medical Center in Hampton, Virginia where she was forced into a “pain specialist” role even though she had no prior specialized training.  She explained that she dealt with difficult pain patients with “large doses of Schedule II narcotics.” (Schedule II narcotics are those with medical benefits that otherwise have a high risk of abuse and dependency.)  When she attempted to move away from opioid prescriptions, she received pressure from service chiefs, nurses, the Chief of Medicine at the hospital, and even non-medical personnel such as patient care advocates and administrative assistants to keep her prescription rates steady.  Her continued efforts to reduce prescriptions and even to help patients seek mental health consultations eventually cost Dr. Gray her job.

The VA is aware of the problem and working towards a solution.  In 2009 it implemented VHA [Veteran’s Health Administration] Directive 2009-053 which, among other things, provided a plan to treat pain in VA patients. The plan included behavioral and mental health monitoring, physical rehabilitation, use of advanced diagnostic services, seeking of specialty consultations, and monitoring effectiveness of prescribed drugs to determine if they should continue to be used.  However, despite recognizing the severity of the problem and that more complex treatments are needed, prescriptions continued to rise.

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How the NFIB v. Sebelius Ruling Will Increase the Amount of Uninsured under the ACA

In a March 2012 report, the Congressional Budget Office (CBO) estimated that by 2022, the Patient Protection and Affordable Care Act (ACA) would reduce the number of nonelderly people without health insurance by 33 million, leaving another 27 million still uninsured.  A significant part of that 33 million included the 17 million more people the CBO estimated to qualify for Medicaid by 2022 under the ACA.  They had not previously qualified because the ACA increased the eligible income to those making up to 138% of the Federal Poverty Level.  This increase in eligibility would have been implemented by making all federal Medicaid dollars given to the states contingent on states increasing the pool of eligible individuals.

On June 28th, the Supreme Court ruled in National Federation of Independent Business v. Sebelius, however, that the federal government could not withhold current levels of Medicaid funding to force the Medicaid expansion.  Instead, it could only withhold the additional funds it planned to give out, making the Medicaid expansion optional state-by-state.

Based on the Sebelius ruling, the CBO reworked its estimates in a July 2012 report that concluded, because of the Supreme Court ruling, six million fewer people would qualify for Medicaid than previously estimated. Of those six million, however, an additional three million would qualify for the new exchanges.  Therefore, the net loss of insured people thanks to the Supreme Court ruling was three million.  In updating their numbers, the CBO did not attempt to guess which states would or would not expand their Medicaid program, but attempted to “reflect an assessment of the probabilities of different outcomes…and are, in their judgment, in the middle of the distribution of possible outcomes.”

These figures are being discussed again because of a June 2013 study by HealthAffairs, which did attempt to guess state-by-state who would be expanding their Medicaid programs and its affect on the uninsured.  They note that, after the Supreme Court decision, 14 states had announced their intent to opt-out of the expansion, six were undecided, three were leaning against the expansion, and two were leaning toward the expansion.  They found that if all currently undecided states opted in, 29.8 million people would remain uninsured by 2016 (compared to 26 million people uninsured according to the CBO by the same year).  That number would rise to 31 million if all of the undecided states opted out.  They also note that around 80% of those uninsured would be US citizens, and no matter which way the undecided states go, 4.3 million children and 1 million veterans would likely remain uninsured.

As of a September 17, 2013 a report by the Advisory Board Company found that the number of undecided and not participating states had increased. They found 15 (up from 14) states firm in opting out of expansion, seven (three) leaning against expansion, five (six) undecided or exploring an alternative model, four (two) leaning towards expansion, and overall 20 (25) firmly participating.  Therefore, the percentage of states that could be opting out has increased from 34-46% to 44-54% of states.  This will in turn increase the number of uninsured people.  As the merits of the ACA continue to be debated on Capitol Hill in light of the budget debate, and more states become firm in their plans to opt-in or opt-out of the Medicaid expansion, the number of those who are ultimately uninsured could rise and continue to undermine the goal of universal health care.

 

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