An interview with Dr. Iteld

Dr. Iteld has been working with a lobbyist group to promote and encourage an initiative to expand the Centers for Medicare & Medicaid Services (CMS) payments for non-opioid drugs. Here is an interview with him about these efforts:

Lawrence Iteld. MD in Washington, DCYou recently participated in meeting on Capitol Hill.  With whom did you meet?

We met with policy advisors and legislative aids at the White House, members of the Senate and the House of Representatives.

What was the purpose of that meeting?

Our purpose is to expand CMS compensation to hospitals for the use of non-opioid medication in peri-operative settings.

Why has this become such an important issue?

There are many non-opioid medications that can be used during surgery to reduce or eliminate the need for opioids during the first several days of recovery. After that time, the need for opioids is minimal or unnecessary in most situations.

Prior to 2015, Medicare reimbursed hospitals for these medications on a case-by-case basis. Because of this, usage increase by more than 200% between 2013 and 2015. In 2015, CMS included these medications, including Exparel, in the “surgical bundle.” Due to this move, the usage stabilized or declined over the subsequent two years.

The medication is far from exorbitantly priced. We are talking about a medication that costs $300 and only requires a single dose. However, many hospitals now limit or even restrict availability due to bundled payments.

What is changing that it’s an issue now?

For calendar year 2019, CMS is recommending unbundling reimbursement to ambulatory surgical centers, but has not made a final decision about Outpatient Prospective Payment System (OPPS) done in a hospital setting.

The reason we are taking the issue to Capitol Hill is because “outpatient” means a stay of less than 48 hours. So many procedures that can be done with an overnight stay — for example, joint replacements, and some cancer procedures, as well as innumerable other surgeries — would be excluded from this medication and opioid usage would continue.

What did you hope to accomplish?

Our goal for the trip was to encourage and elicit support from the White House and legislators to expand CMS payments to include these procedures.

We are NOT trying to take opioids away from patients with chronic pain or in hospice settings. We want to increase the availability and awareness of opioid-sparing techniques for acute surgical procedures.

You advocate for non-opioid surgery. Would you please expand on that?

Many surgical procedures are often an initial exposure, which can lead to dependence, some times as high as in 20% of patients. While most patients never become long-term users, there are many studies showing that up to two-thirds of prescribed pain pills are not used following surgery. It is these very pills that wind up on the streets and in our children’s hands, and are the core of the opioid crisis.

The opioid epidemic took a generation to develop and will not be solved overnight. Our belief is that this is an important starting point, and we hope that Washington incorporates opioid-reducing techniques into its overall strategies.

What are the next steps?

Our hope is that CMS will include OPPS for 2019, and then we can work toward in-patient procedures for 2020.

Since most commercial and state insurance programs follow CMS guidelines, we will look to work with surgical and anesthetic societies to educate their members about best practices for opioid reduction, increase patient awareness, and implement direct-to-consumer awareness tactics.

A final note:

We have gone opioid-free for most procedures in my practice. This protocol provides equivalent or better pain control than relying on opioids, and offers a better patient experience. I encourage other surgeons to do the same.

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