AHLA's Speaking of Health Law
AHLA's Speaking of Health Law
AHLA’s Opioid Podcast Series: Physician Perspective
Hospitals, physicians, and pharmacies are on the front lines of the opioid crisis. AHLA’s Opioid Podcast Series explores the critical legal and operational issues related to the opioid epidemic from each of these perspectives and offers expert insight for addressing them. This podcast features the perspective of physicians.
To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.
Welcome. My name is Ellie Bae and I am the Vice President Education for the A H L A Public Health Systems Affinity Group. Today we have part three of a three part podcast series on the opioid epidemic. With me today, Emily Gray. Emily is the section manager of the Brazil Sachse and Wilson Healthcare section. She represents healthcare providers in a wide range of issues, including routine operational matters, regulatory compliance, fraud and abuse, licensing, provider enrollment, contracting, joint ventures, and healthcare transactions, including hospital and physician integration. Emily is the chair of the A H L A Hospitals and Health Systems Practice Group and is active in the American Bar Association, the Louisiana State Bar Association's health law section, the Louisiana Law Institute, and the Baton Rouge Law Bar Association. She is a frequent speaker and author on healthcare issues for the Louisiana Hospital Association and the hla Emily is also the co-author of the Physician Office Management of Pain Medication Usage in the May edition of the HLA Connections Magazine. This, again, is one of a three part series of podcasts regarding the articles concerning the opioid epidemic. Emily, thank you for joining us. Uh, the article that you co-wrote left us with some really great pointers, um, that I'd like to discuss each one in a little more detail. Uh, the first, if we could describe policies on opioid prescriptions based on applicable state law for physicians and mid-level practitioners with prescriptive authority, what is one policy that you would suggest implementing now? Um, and would that answer be different for smaller groups or larger groups?
Speaker 2:Well, thanks very much Ellie. And, um, I would say that the policies, um, that I would focus on first, uh, would be the ones that would be be responsive to what we see in enforcement patterns and what we're seeing in enforcement. Uh, are the regulators really looking to, uh, patterns in practices being the biggest issue. So situations where we have high amounts being prescribed, situations where we have, uh, beneficiaries who are clearly doctor shopping, getting prescriptions for opioids, and also where we see prescribers ordering opioids for a large number of patients. So we wanna focus in the practice on policies that are gonna minimize that. Uh, I think dosage limits, uh, are the best way to go about this. And we are seeing a lot of states mandating certain dosage limits. Some are mandating a seven day supply. States like Connecticut, Louisiana, New Jersey. Uh, we have some that are doing a five day supply, Massachusetts, north, North Carolina, and there's even some Florida legislation that's looking at a three day limit. Uh, so in addition to the timeline, um, of, you know, how long the prescription is for, you also have to pay attention, uh, to the overall dosage to how much of the drug is being provided. So my recommendation would be the same for a large practice in a small, if you're just gonna do one policy to kick things off, really focus on those dosage limits, looking to your state law for guidance, and I think that's gonna provide a lot of help.
Speaker 1:That's a great tip. Another point that your article made was to ensure prescribers obtain, uh, education on drug addiction, abuse and treatment, particularly where mandated by state law. Are there any specific courses you would recommend?
Speaker 2:Well, Ellie, you're right that a lot of states are imposing these mandatory requirements. Uh, and what we're seeing is that where the requirements are being imposed, the states themselves are, are making the education available. So the boards of medical examiners, the boards of nursing, the pharmacy boards, we're even seeing professional liability insurers kind of teaming up with these boards to make sure that the education is available for the prescribers, physicians, nurse practitioners, and the like. So the programs sponsored by the state, I really think are the best way to go because they're designed to those state specific issues that the prescribers really need to be paying attention to. And the programs so far are working to provide education about safe prescribing practices and are designed for the physician, for the nurse practitioner to inform them about challenges with opioids, about identifying abuse, uh, in the patients and how to deal with those issues. So I really would look to the state board of medical examiners Board of nursing, uh, and those age types of agencies that are putting the continuing education forth.
Speaker 1:Those are good places to look for. Sure. Um, another point that your article made was to suggest to make sure that prescribers review the state PD D M P before prescribing opioids. What might be some good techniques, practices or education to help prescribers remember to check their their PDMP first?
Speaker 2:Right. Hopefully a lot of prescribers are, are already in the practice of doing this. And of course, PDPs are prescription drug monitoring programs. These are electronic databases. They track prescribing and dispensing of controlled substances, and they're designed to be a resource to help identify patients who are doctor shopping. You can figure out, uh, if a patient has received multiple prescriptions for a controlled substance and, uh, they're often accessed not only by prescribers, but also by pharmacies. And all 50 states actually have these, uh, the requirement as to whether you absolutely prescribers have to check it before prescribing can vary by state. In some states it's mandatory all the time, and others it goes to medical judgment. So hopefully a lot of prescribers are already in this practice. Um, and if they're not, it's an important tool to help identify these patients who may be struggling, maybe doctor shopping and to address those problems. So to, to kind of get into the habit, if a prescriber isn't already in it, I would suggest that setting an alert in the emr, um, or prescribing software would be a good way to have that pop up before you do that initial prescription. Or if somebody is still on paper forms to update those forms to include some kind of a, a check mark or a reminder to check the pdmp.
Speaker 1:That that's a good suggestion. Certainly the, uh, EMR one, I think could be easily implemented. Um, another point of your article talked about monitoring changing policies of hospitals, pharmacies, and payers, um, and the impact that those policies may have on a physician practice and its patients. Certainly some changes to policies and procedures may be publicly available on websites or other communications, but some may not. What do you think is a good way to keep abreast of important policy changes that may impact, um, a physician practice that one of our members may be representing, um, or a a a national payer?
Speaker 2:There is so much coming out that it's, uh, there's something new on opioids every day, and it is hard to imagine that you'd have a client that would be able to read all of it at once. Shoot, it's hard for the lawyers to read all of it at once. Um, so we can kind of divide these, I feel like, into two areas. We have some of the stuff that comes out and it impacts the physicians and the prescribers. And then we have another set of information coming out that really impacts the patients after they leave the practice. So the ones that are gonna impact the physicians directly are gonna be the ones coming out from the state boards of medical examiners, for instance. As we see these new rules coming in about the mandatory continuing education about dosage limits, um, about checking the pmp, where the prescribers need to be looking is that the literature that comes out of their, uh, state licensing board. So watching what's coming out of the board of medical examiners is gonna keep them informed. The the boards are gonna keep the prescribers aware of what the new requirements are as they're going into effect. Another area that impacts the physicians more directly, uh, would be the hospital policies going into effect. And we know that we have hospitals that are working right now, and we're seeing a variety of policies coming out to deal with opioids in the hospital. And when the ho the physicians are practicing in the hospital. And I would say just there, keep abreast of the notices that the hospitals are sending out. Uh, read the stuff that's coming through because you need to be aware of it. The other category I mentioned, which is going to really impact the patients after they leave the physician's office, those are gonna be situations involving the payers and the pharmacies Specifically, we're gonna see, uh, the physi, the payers and the pharmacies imposing limits, the same kind of limits we're seeing coming out of the boards of medical examiners. It may be a seven day supply, uh, which CVS announced that it would be doing back in February of 2018. Uh, we may have a payer that limits payment to a certain number of days prescribed. So there are a couple ways you can go about this. I think physicians certainly are not gonna want to deal with or learn about it and deal with it as a result of patient complaints. So my recommendation would be to let patients know, uh, when you are prescribing these controlled substances, that there are certain limits under state law that are going into effect. There are limits that the pharmacies are imposing, and there are limits that the payers are imposing so that you don't end up with patients being surprised and upset after they leave the office. Additionally, uh, if you have a practice that wants to be very proactive about it, uh, at the point where a patient is being prescribed opioids, uh, the practice could call the pharmacy, call the payer to find out exactly what the policy is there.
Speaker 1:Oh, that definitely good pointers there. Um, one thing you mentioned is, you know, there's something new coming out every day about opioids, um, and we all know that to be true. So given this ever-changing, um, climate, what is one thing that you think is most important when advising physician clients regarding the opioid crisis?
Speaker 2:You know, I'll tell you, our physician clients are so inundated with government regulation. I find that my clients get very frustrated and feel like this is yet another set of rules. Um, so I would say the important thing is to keep perspective as a lawyer and to help our clients keep perspective as well. Uh, rather than just push back and say, oh, the government is telling us to do this. I think think it's important to keep, uh, in mind that this is really a patient care issue, that we're all trying to align in the healthcare system to address this significant problem. It's challenging for physicians to change their practices. It's challenging when they're used to pres prescribing a certain course for a patient with a certain condition. But what's important to keep in mind is that, for example, 80% of all heroin users started out on prescription opioids. This is a big problem. It's not really just about government rules and the government interfering in their practices, but rather it's about how we can all work together as a system to address this problem. So we're not dealing with just junkies on the street. We're really looking at professionals and mothers and fathers in the high school athlete who is, has prescribed opioids as a result of an injury. So I, I think keeping that perspective and being mindful about these prescriptions, uh, is really important for physicians. And helping them see the bigger picture, uh, as their advisors, as their counselors, uh, is really gonna help them as they change their practices, which is hard, and they focus on these new details that they have to manage. Uh, and realizing that, you know, while it is regulation and more rules that they have to follow, there's such a bigger picture that they have the opportunity to address.
Speaker 1:Definitely in that front stream of defense is where physician practices lie. Um, as you were discussing, you know, the most important thing of when advising physician clients, I couldn't help but think of, um, all of these recent cases regarding physician practices or physicians who, um, were found out to be pill mills or, or things of that nature. Um, is there anything that you found in your research or in your day-to-day practice that can help, uh, our lawyers differentiate between, you know, leading a practice into maybe better clinical standards or realizing that their clients may have an issue with their opioid prescriptions? Um, history and and practice.
Speaker 2:I, I would say that going back to actually what we first started talking about, what, which was the dosages. So I think if you have, um, a practice that is just doing a lot, a lot of prescribing, I think it's a matter of getting that under control. Um, as I mentioned at the outset, the folks who are looking at federal enforcement, um, are the ones who really have bad patterns. We have a lot of data mining available for the regulatory agencies for enforcement. And I think it is important to counsel clients and let them understand that their practices can be easily identified through that data mining, uh, type software type program. Um, and that not only for purposes of patient care, but also for purposes of enforcement, because the government does have a big hammer to come down upon, uh, bad practitioners, which is what we all need as a society, what we want as a part of the healthcare system. Um, but to avoid being inadvertently caught up in that, um, it's important to pay attention to those three things I mentioned at the outset that the, the enforcement folks are looking at, which are patterns involving high amounts prescribed, uh, practitioners who have, uh, beneficiaries in their practices who are clearly doctor shopping. And that you do that by checking the pmp, uh, and then finally the ones who are getting real high dosages. So those are the things that the practices need to be mindful of. They need to be mindful that yes, patient care issue, but also an enforcement issue and the data's out there when you're prescribing these drugs.
Speaker 1:Those are great points. Um, what challenges lay ahead for physician practices, um, knowing that that might be different than the challenges that we've discussed in other podcasts for hospitals or pharmacies, um, especially with respect, obviously to the opioid epidemic, ways to manage ways to come through, et cetera.
Speaker 2:That's, that's a great question, and I think with the physicians and other prescribers on the very front lines, they are gonna have the very first interaction with the patients. And I think what we'll see developed, um, as we are seeing more focus on the opioids, restricting access to opioids and potentially an unintended consequence, um, that law enforcement has actually identified is that as the supply of opioids is reduced through limits when manufacturers through the supply limits, et cetera, one of the things that has been seen, uh, by, uh, law enforcement is, uh, these patients turning to heroin when opioids are no longer available and there are some documented, um, increases in usage of heroin. It is, you know, again, not just junkies on the street, we are seeing professionals, we are seeing parents, we are seeing all kinds of folks moving into that space because the opioids are no longer available. So I, I think that's something that may be an unexpected, uh, consequence that practitioners may be on the lookout for, and certainly that's gonna impact hospitals as well. Uh, but it's, uh, one of those things to be aware of and a challenge I think we're gonna gonna see facing our providers.
Speaker 1:The opioid epidemic continues to grow every day in new and different ways. As you mentioned, it's not your traditional junkie, it's our next door neighbor, um, and our coworker, family and friends. Um, given that and given that things are developing so quickly, um, you know, it's been a couple months since you drafted the article. Is there anything that's come to light since then that you'd like to discuss now that maybe you didn't have an opportunity to in the article or that you think is important to communicate to the members at this time?
Speaker 2:I think one of the things that we're seeing develop is, uh, additional policies where you're seeing the wheels in motion. It takes a little while, um, for folks to evaluate their systems to come up with new policies. I think what we're seeing since I wrote the article is more hospitals really getting focused on their policies, what they're gonna do differently within the confines of the hospital. So I think physicians can look even more to hospitals for guidance, uh, particularly when they are practicing within those facilities. Hospitals are a valuable resource for physicians as they look to get their arms around what you can do in a particular community with your parti particular patient base to address the opioid epidemic.
Speaker 1:Thank you so much and, and thank you for your article and for your participation today on the podcast. Um, I know as both hospital and physician counsel, I found it very helpful and I'm hopeful that everyone listening today to this podcast will find it equally helpful. So thank you so much Emily,
Speaker 2:And thanks so much for having me, Ellie. It's really a pleasure.