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  • Anjana Kundu, MD

How proactive pain care is paramount with the American Health Care Act

Updated: Sep 26, 2020

With passage of the American Health Care Act (AHCA) in the House, the implications for its impact on the people, healthcare institutions and employers are worth serious considerations. The proposed cuts to healthcare funding would have the greatest impact on patients with chronic conditions, chronic pain, mental health and children’s health. It becomes paramount that we invest in effective pain management utilizing proactive strategies to contain the financial impact from both, chronic pain and the fallout from significant slashing of funding allocated to pain care and related conditions including opioid addiction and mental health disorders.

Although the decision from the Senate will ultimately determine the fate of millions of Americans, understanding the proposal and its impact may help support the efforts of many who are working to sway the tide and reduce the burdens its passage poses.

Some broad strokes of AHCA (or the Republican health-care reform) include:

  • A repeal of insurance mandates under the Affordable Care Act (ACA or Obamacare),

  • Extensive cuts in long-term Medicaid spending (including mental health, addiction services, elements of pain care such as PT/OT, and preventive health screening visits)

  • Ability for insurers to charge higher premiums for pre-existing conditions, chronic diseases and if there’s a lapse in coverage; insurers can increase the premiums to 1:5 ratio (from current 1:3) for those with preexisting conditions or seniors, making it hard to afford coverage in many instances.

  • By 2019 eliminating over 1 billion dollar for preventing health care (cancer screenings, vaccinations etc.), it would increase the burden of chronic disease related costs.

  • Federal grants for state high-risk pooling,

  • Loosening of restrictions on insurers, and

  • A private-insurance tax-credit scheme that makes care more expensive for poor people and the most costly patients.

As a pain care provider, I see 3 areas that stand out and would see a major impact from the AHCA.

1. Impact on Pain Care

Pain care amounts to 635 billion dollars annually with 1 in 3 Americans suffering from a chronic pain condition. This doesn’t even include the lost wages due to inability to work for their own or their children’s pain care needs.

Up to 40% of children reports pain at least once a week and 1 in 3 school aged children suffer from chronic pain.

Incidence of pain amongst people with chronic diseases and amongst seniors is as high as 80%.

It is no mystery that with our well meaning regulatory initiatives (JCAHO mandate to assess, treat and reassess and document pain and its treatment) for pain care have resulted in unintended outcome of an opioid crisis and addiction epidemic. Some states are worse hit than others with Kentucky, West Virginia and Ohio being amongst the top. The statistics regarding the impact of opioid crisis are staggering;

More than 33000 deaths occurred related to opioid overdose in 2015.

Deaths due to addiction have surpassed those by MVA or guns related violence in 2015.

Should the AHCA become a law, 1.3 million people stand to lose coverage for pain care, addiction treatment or mental health benefits alone.

Although 31 states and DC expanded the Medicaid programs to cover addiction and mental health services under the ACA, Ohio, Kentucky and West Virginia would stand to lose the most.

In Ohio, Medicaid pays for 49.5% of medication-assisted treatment using buprenorphine (used to manage chronic opiate use disorder), with 44.7% in West Virginia and 44% in Kentucky.

With the decrease in Medicaid benefits, loss of insurance coverage either due to inability to work secondary to pain, addiction or mental health disorders or because of higher premiums and out of pocket expenses, there’s bound to be an increase in visits to the ER of the uninsured and perhaps in much dire conditions. According to one report, 69 % of visits to ER are pain related and with the proposed changes in effect, these visits would be expected to rise.

This imposition of a higher burden on hospitals for uncompensated care, can be countered to some extent by development of proactive, comprehensive and more effective pain care strategies including non medication therapies can keep these visits lower.

2. Impact on Children

Like the patients with chronic pain, children are also amongst the most vulnerable to drastic changes in healthcare coverage under the AHCA, as children make up 50% of the population covered by Medicaid programs, although they are only 25% of the US population.

Under the AHCA, children are subject to get less comprehensive healthcare services, preventive care and higher costs for parents to provide coverage.

This would be a result of the AHCA proposed financing-reform mechanisms for states in two ways; capping the funding per person for state funding and via block grants for pregnant women, children and parents. These reforms could slash benefits and enrollment for children on Medicaid, including some essential services for childhood growth like the Early Periodic Screening Diagnosis and Treatment benefit that covers testing for lead poisoning, in-home care, speech therapy, occupational therapy to name a few. So not only would the kids get less comprehensive services, but also that the federal block grant provisions will erase protections in place that limit premiums and out-of-pocket expenditure on behalf of children. That would leave the states to cover the Medicaid shortfalls through reducing benefits and making parents pay more. The effects of those changes would be particularly significant for children with the most extensive health-care needs such as chronic conditions, chronic pain and mental health needs.

Another factor at play currently is the more lax and generous guidelines for state enrollment of children to receive benefits, than those under Medicaid and the Children’s Health Insurance Program. But under the AHCA triggered financial limitations, the states would be forced to revisit the children’s expanded eligibility, providing less comprehensive and expansive Medicaid coverage for low-income children, as possible cost cutting avenues for fiscal sustainability. This might be the easiest target for states, not only because of simultaneous cuts to federal contributions—but it also appears to be incentivized.

3. Impact on the Healthcare Institutions

The House bill would significantly impact the way health care is delivered, especially at Children’s hospitals, as they are reliant on Medicaid funding to serve about 50% of their patients.

Reductions in covered benefits and enrollees would result in decreased revenues, while their operating costs remain unchanged. This limits the ability of these institutions to provide the quality of care to the needy children regardless of their insurance, and reduce their ability to provide uncompensated care for uninsured kids, which is likely to rise as discussed above.

The bundled payment models with a fixed reimbursement amount are likely to be implemented sooner. Hospitals would need to invest in care teams and programs that ensure best outcomes per treatment encounter with rapid recovery, minimum length of stay, and minimum readmission rates in order to exact maximum reimbursement for care provided while keeping the operational costs under check.

Effective pain management is in important driver of length of stay, readmission rates and patient satisfaction.

Whether you are a parent, a patient, a healthcare provider or an employer, we all stand to risk a massive imprint from escalating healthcare related costs, and decreasing healthcare quality and number of services.

It is high time that we not only become proactive partners in managing our health, but also align with and support the efforts of organizations such as the American Medical Association, American Academy of Pediatrics, American Society of Anesthesiologists, American Pain Society to name a few, in protecting the best interests of the American people.

Please share your thoughts and comments below or contact us to explore proactive strategies for customized, robust, and sustainable pain care solutions.

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