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“Tell me about any pain you are having.”

It’s a question I frequently ask my patients, even if pain is not their ‘chief complaint’.  I ask it this way for two primary reasons.  First, pain is a common and often unrecognized problem among older adults.  Studies estimate that chronic pain is present in 50-80% of older adults.  Second, older adults tend to under-report their own pain.  Many believe that pain is a ‘normal’ part of aging.  Some prefer not to mention their pain because they don’t want to burden their caregivers.  Others may come from a background that considers complaints of pain or discomfort as a sign of weakness.  These dynamics lead to a tragic and preventable reality: the silently suffering senior.

Nowhere is this more true than in the long-term care facility.  For a variety of reasons, access to pain relief for older adults who live in assisted living facilities and nursing homes may be even more limited than for those who live at home.  These reasons are well outlined in a recent article in the monthly newsletter of the American Medical Directors Association (AMDA).

The article makes several important points.  First, pain medications are notoriously under-prescribed in long-term care facilities.  Residents of assisted living facilities cannot receive even one acetaminophen (Tylenol) unless there is a specific order from the doctor, and one study found that more than one third of people living in a long-term care facility had no such order.  Furthermore, many of these pain medications are ordered ‘as needed’ or ‘P.R.N.’ which requires the resident to ask for the pain reliever before it can be given.  Yet, many residents are reluctant to ask (for the reasons outlined above), and they may have not receive the mdicine within a reasonable amount of time even when they do ask.  Some may not have the cognitive ability to request medication at all.  Patients with chronic pain in a long-term care facility should never be treated with only ‘PRN’ medications.

Every day, the physicians of Doctors Making Housecalls visit residents in assisted living facilities.  We always keep these principles in mind as we strive to relieve the pain and suffering of our patients.  If you or a loved one lives in an assisted living facility, there are some important steps you can take to ensure that pain is adequately treated.

1) Ask often about pain.

2) Keep a record of the pain medication regimen, and if you or your loved one is having chronic, daily pain, ask if a scheduled daily dose of pain reliever can be prescribed, rather than relying on ‘PRN’ dosages.

3) If there seems to be a disconnect in treating pain at the facility, ask specific questions of the staff or the doctor, to determine if there are particular concerns or contraindications to prescribing painkillers.  While some older adults cannot tolerate certain pain medications, because of their health conditions or other medical treatments, this point is often overemphasized.  Many older adults can safely receive higher doses of pain relievers than they are actually given.

4) Explore nonmedical pain treatments, such as ice, heat, physical therapy, and massage.  These strategies have been well documented to assist with pain control, but they tend to be overlooked in our highly medicalized health care system.

David Fisher, MD

For the past two decades, the income disparity between primary care  physicians and other medical specialists has become increasingly dramatic, with 3 to 6 fold differences now being the norm.  Predictably, low pay for internists, family physicians and pediatritians has devastated the ranks of these specialties, with significant, far-reaching consequences.

The shrinking pool of “personal, attending physicians”  who care for the whole person, coordinate care, and guide patients through the labyrinths of the modern healthcare industry, has been shown in many studies to result in disjointed care, duplication of effort, medication administration errors, and runaway costs.  One can only imagine the cost, both human and financial, if disparities in pay persist or grow worse, and primary care practices all but disappear from the landscape.   

The roots of the problem extend back to the goals of the 1965 legislation which created Medicare.  Among those goals was a keen interest in encouraging the dissemination of new technology.  That goal resulted in higher pay rates for performing procedures — using one’s hands – compared with providing cognitive services — using one’s mind.  The so-called cognitive or “evaluation and management (E&M)” services refer to services provided to diagnosis or treat medical problems, as well as services involved in coordinating care and counseling patients and their caregivers. 

If things started off on the wrong foot from the primary care perspective, the gap between “rich and poor” specialists started to get much bigger 20 years ago when Congress, in effect, delegated decisions about physician pay to a special committee of the American Medical Association (“AMA”).   

For the longest time, primary care physicians seemed to docilely accept their fate.  But the natives grew increasing restless as the income of primary care physicians fell further behind the procedure-oriented specialities, and failed to keep pace with increases in practice expenses or even the rate of inflation.   Meanwhile, growth in the administrative demands and clinical expectations placed on primary care practitioners continued unabated.  Over the past decade, these factors forced older primary care physicians out of practice and debt-burdened medical students into higher paying specialties, diminishing the ranks of primary care physicians to devastating levels.  

Now, with the filing of a lawsuit in federal court by six Georgia PCPs, the battle against the AMA-led process that favors higher payments for the procedure-instense specialties at the expense of primary care physicians (PCPs), is quickly escalating into a war.  I say “It’s about time!” 

Filed in U.S. District Court in Maryland, the lawsuit maintains that the Centers for Medicare and Medicaid Services (CMS) and its parent agency, the U.S. Department of Health and Human Services (HHS), are in violation of federal law because they rely too much on the AMA’s special committee — the Relative Value Update Committee (the “RUC”) — to set physician pay.   The lawsuit states that “CMS has failed to realize that 20 years of control by the RUC over the physician fee schedule has resulted in a process that is irrational, arbitrary, and absolutely destined to lead to the continued devastation of primary care.”

The Physicians who filed the lawsuit claim that the RUC is an “unchartered and unofficial Federal Advisory Committee,” and is thus operating in violation of several laws, including the Patient Protection and Affordable Care Act passed last year.  The AMA has maintained that the committee is just an independent group exercising its First Amendment right to petition the federal government.  Be that as it may, the RUC represents the rights of some physicians far more than others; in fact, the lack of representation on the RUC is perhaps the main reason primary care gets shafted when it comes to setting pay rates:  Only two of the 26 voting members of the committee represent primary care, even though the majority of practicing physicians in the country are primary care specialists.  

The federal lawsuit highlights the problem of disproportionate representation, and the fact that Federal agencies “have relied and continue to rely upon the AMA RUC to make critical national policy determinations with regard to physician payment for primary care.”

A huge study involving 400,000 individuals published in the late August issue of the Journal of the American Medical Association (JAMA) demonstrated conclusively what most of us have known for some time:  Hospitalizations wreak havoc with a patient’s medication regimen.  

 The study found that hospitalization wass associated with a significant risk of unintentional discontinuation of medications in all five medication groups studies.  The medication groups studied were those involved in treating chronic conditions: statins, antiplatlets or anticoagulants, levothyroxin, respiratory inhalers and gastric acid suppressors. 

In 2 of the 5 groups, the downstream effects of unintentional discontinuation was associated with an increased risk of death, emergency room visits and hospitalization.  Admission to an intensive care unit (ICU) increased the risk of unintentional discontinuation in 4 of the 5 medication groups 

The investigators note that better communication and a system-based method have been advocated as possible solutions to improve medication continuity and safety.  The strategies vary but their is contingent on including all relevant clinicians and the patients themselves. 

They go on to say that formal programs such as medication reconciliation and standard discharge summaries can provide a means to improve interdisciplinary communication, including with primary care clinicians.  Identification of high-risk patients and transfers in care may help improve program efficiency and focus valuable resources.

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