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  • US News: Time for Chronic Pain Treatment Without Opioids – and Policies That Make it Possible

    Two researchers believe that when it comes to pain treatment, if the US truly wants to alter the future, it could do well to look to the preopioid past—and then make policy changes that would increase patient access to nondrug approaches to chronic pain.

    In a recent opinion piece published in US News and World Report, authors Jason Doctor, director of health informatics at the USC Leonard D. Schaeffer Center for Health Policy and Economics, and Joan Broderick, senior behavioral scientist at the University of Southern California Center for Economic and Social Research, write about the ways pain treatment should change in light of the Comprehensive Addiction and Recovery Act passed by Congress earlier this year. That act, aimed at battling the opioid abuse epidemic, includes the establishment of a Department of Health and Human Services task force that will review and modify best practices for pain management.

    Broderick and Doctor assert that simply reducing the amount of opioids prescribed won't by itself address the issue of what to do for the millions of Americans who will continue to suffer from chronic pain. That, they argue, will require the HHS task force to take a kind of back-to-the-future approach.

    "The task force needs to look back prior to the [opioid abuse] epidemic when the first-line treatment for chronic pain was not drugs," they write. "Teams of occupational and physical therapists, social workers, physicians, and psychologists—frequently operating in multidisciplinary centers—addressed the social, psychological, economic, and physical components of pain."

    When it comes to the treatments themselves, Broderick and Doctor don't mince words. "They worked," they write. "They made patients physically stronger and gave them the self-management skills that helped them lead more fulfilling and productive lives."

    The problem, they write, is that the current health care environment stacks the deck against nondrug approaches—something that must change.

    "That earlier era of chronic pain management can be revived with less expensive avenues of access, better incentives, and improved reimbursement," they write. "Medicare can lead the way in making pain coping skills widely available. Most important, it needs to create billing codes that make the services reimbursable." Broderick and Doctor also argue for quality performance standards "that would promote integrative solutions."

    The changes advocated by Broderick and Doctor echo the policy changes identified by APTA as crucial to improving patient access to PTs for treatment of pain. Those changes include the repeal of the Medicare therapy cap, more extensive direct access provisions, better private insurance coverage, and limits on physician self-referral.

    APTA's #ChoosePT campaign, which targets the opioid abuse epidemic, is at the center of the association's activities during National Physical Therapy Month. Housed at MoveForwardPT.com/ChoosePT, #ChoosePT resources now include a video public service announcement, as well as other targeted advertising and media outreach. APTA is also a member of the White House’s working group addressing the opioid epidemic.

    DEA Reduces 2017 Opioid Production Quotas – Mostly by Eliminating 'Buffer'

    It's good news, just maybe not as good as it seems at first blush: yes, the US Drug Enforcement Administration (DEA) is reducing the amount of opioid controlled substances that can be manufactured in 2017, citing slowing sales and a drop in demand from physicians. But most of that reduction is related to the DEA's decision to eliminate a 25% "buffer" of excess production to offset potential shortages.

    Last week, the DEA announced that production quotas for "almost every" Schedule II opiate and opioid medication will be reduced by 25% for the coming year, with a few—including hydrocodone—being cut by a third. Details on quotas for individual drugs were released in a final order available for public inspection at the DEA website.

    According to a statement from the DEA, the reduction is intended to support the agency's responsibility to create quotas that "reduce or eliminate diversion from 'legitimate channels of trade.'" That non-legitimate use of opioids, often described as an epidemic, has received widespread media attention, and is the basis for APTA's #ChoosePT campaign to educate the public on physical therapy as a safe and effective alternative to opioids for the treatment of some types of pain.

    In its statement on the quotas, the DEA cites data from the National Survey on Drug Use and Health that the nonmedical use of controlled prescription medication was second only to marijuana in terms of the number of Americans 12 and older who reported drug use. At an estimated 6.5 million, that number is more than the number of cocaine, heroin, and hallucinogen users combined.

    In terms of the amount of opioids available for prescription, the reductions may not represent a big change. According to the DEA, "much of" the reduction is related to the elimination of an across-the-board 25% buffer to accommodate shortages that never occurred since the DEA started the buffer program in 2013. That year, the production of hydrocodone spiked at 150,000 kilograms, or about 163 tons; in 2017, that quota will drop to 108,000 kilograms.

    The #ChoosePT campaign targeted at the opioid abuse epidemic is also at the center of the APTA's activities during National Physical Therapy Month. Housed at MoveForwardPT.com/ChoosePT, resources now include a video public service announcement, as well as other targeted advertising and media outreach. APTA is also a member of the White House’s working group addressing the opioid epidemic.

    CDC: 2 in 10 Health Care Workers Didn't Get Flu Vaccines; 3 in 10 in Long-Term Care Settings

    About 20% of health care personnel didn't receive influenza vaccines during the 2015-2016 flu season, with employees in long-term care settings reporting an even higher—albeit improved—rate of non-vaccination, according to new data from the US Centers for Disease Control and Prevention (CDC).

    The report, based on an opt-in Internet panel survey of 2,258 health care personnel during March and April 2016, found that the overall rates didn't change much between the 2014-2015 and most recent flu season, with the most recent 79% rate more or less unchanged from the previous year's rate of 77.3%. Among settings, personnel working in hospital settings reported a higher rate of vaccination (91.2%) compared with those working in ambulatory care (79.8%) and long-term care (69.2%) settings.

    Not surprisingly, vaccination rates were highest among workers whose facility required vaccination (96.5%), but that rate fell to less than half (44.9%) for personnel whose employers didn't require, promote, or offer onsite vaccination programs. Coverage was highest among physicians (95.6%) and lowest among assistants and aides (64.1%). Physical therapists (PTs) and physical therapist assistants (PTAs) were not specifically listed in the data, but "other, clinical" was listed at a 94.4% overall rate.

    The only real gains from the 2014-2015 flu season and the most recent season were made in personnel working in long-term care settings, where vaccination rates rose from 63.9% to 69.2%. Authors of the CDC report described vaccinations in these settings as "especially important because influenza vaccination effectiveness is generally lowest in the elderly."

    CDC researchers link the lack of vaccination coverage to employers who don't require, promote, or offer onsite vaccination, writing that "health care personnel working in long-term care settings consistently are the least likely to report that their employer either required or promoted vaccination, or made vaccination available at no cost." In long-term care settings, 40.6% respondent reported that their employer offered no onsite vaccination or promotion.

    Infectious disease control should never be an afterthought. Check out APTA's resources at its Infectious Disease Control webpage.

    Now Available: Your 2015 PQRS Data – and Possible Payment Reductions for 2017

    Participating in the Physician Quality Reporting System (PQRS)? You can now check on your 2015 reporting results, and find out if those results mean you're subject to any payment adjustments for 2017.

    The Centers for Medicare and Medicaid Services (CMS) announced that the reporting results—known as the Annual Quality and Resource Use Reports (QRURs)—as well as the feedback reports are now available for online viewing. The 2015 PQRS feedback report contains all detailed information used to determine your 2015 reporting results and indicates if you are subject to the 2017 PQRS negative payment adjustment. CMS is advising PQRS participants to review all information for accuracy.

    You can access the reports through the CMS "enterprise portal," but to do that you'll need an enterprise identity management (EIDM) account (CMS provides instructions for creating an EIDM). Also available: a user guide to the reports.

     In addition to the reports, CMS has also announced that will soon send out individual notices to providers who did not met PQRS requirements in 2015. Those providers are subject to a 2.0% Medicare Part B payment reduction beginning in 2017.

    If you have been identified for a 2017 payment reduction based on the report, and you think that decision was made in error, you'll need to ask for an informal review. CMS offers instructions on that process on the PQRS Analysis and Payment webpage.

    For additional assistance regarding EIDM or the content or data contained in the PQRS feedback reports, contact the QualityNet Help Desk at 866/288-8912 (TTY 877/715- 6222) 7:00 am–7:00 pm CT, Monday through Friday, or by email at qnetsupport@hcqis.org. If you are having trouble accessing the PQRS feedback reports, contact the Physician Value Help Desk at pvhelpdesk@cms.hhs.gov or 888/734-6433 (select option 3).

    Changes to ICD-10 Take Effect Oct 1

    With ICD-10 reaching its 1-year anniversary in the United States, the Centers for Medicare and Medicaid Services (CMS) has announced that the "grace period" for coding will end October 1. After that, CMS will become much less flexible about the codes it will accept. In response, APTA has created an opportunity for members to receive discounts on an online portal that helps physical therapists find the most specific ICD-10 codes.

    During the ICD-10 grace period, CMS accepted codes that were technically inaccurate, so long as they were from "the right family." According to CMS, adoption of the new codes has been a relatively smooth process, paving the way for the agency to require that providers accurately code to the highest level of specificity beginning in October—a requirement that will not be phased in. More information about the change can be found in a CMS questions-and-answers document available online (look for questions 23 through 33).

    Just in time for the changeover, APTA has announced the addition of an offer that could help members meet the new ICD-10 specificity requirements. Members are now eligible for discounts on Cypher, a cloud-based tool that can help PTs identify the most specific ICD-10 codes—including the additional 1,900 codes CMS added recently, and the more than 3,600 codes added in March. More information on the program is available at the Cypher Member Value Program webpage.

    Another important ICD-10 issue: Beginning October 1, providers must use the 2017 ICD-10 codes, which include new codes, as well as some revised and reorganized codes. The 2017 codes should be used for discharges occurring from October 1, 2016, through September 30, 2017, and for patient encounters occurring from October 1, 2016, through September 30, 2017. CMS offers a webpage with links to the 2017 codes.

    Latest News Reports Touch on Cost, Politics of Opioid Epidemic

    As National Physical Therapy Month approaches in October, APTA continues to share its #ChoosePT message to help the public better understand how physical therapy can play a role in addressing pain and reducing opioid use. It's a message that remains relevant, set against a news cycle that seems to add a new, often harrowing perspective on the opioid epidemic nearly every day.

    Here's a brief roundup of some recent notable reports and stories.

    The prescription opioid epidemic has cost the US $78.5 billion.
    Science Daily reports on a recent study that estimates the cost of the prescription epidemic at $78.5 billion, with about one-third of those costs related to health care, and one-fourth borne by the public sector.

    Private insurers have witnessed a 1,300% increase in costs related to opioid treatment between 2011 and 2015.
    A report in Kaiser Health summarizes research that found insurers' annual payments to providers, hospitals, laboratories, and treatment centers related to treatment for opioid abuse grew from $32 million in 2011 to $446 million in 2015.

    The rate of opioid-dependent babies born in the US has doubled.
    According to a report in Live Science, researchers have found that the rate of newborns diagnosed with neonatal abstinence syndrome—essentially, withdrawal symptoms experienced after being exposed to opioids while in the womb—has increased from 2.8 cases per 1,000 births in 2008 to 7.3 per 1,000 in 2015.

    Drug companies have adopted "a 50-state strategy" to "kill or weaken" anti-opioid legislation.
    The Associated Press has released a lengthy investigative piece that chronicles the efforts of prescription drug makers to use their already-formidable lobbying arm to fight restrictions on opioids, including "funding advocacy groups that use the veneer of independence." The tactics are being used at both the federal and state levels, according to the report.

    Both Trump and Clinton have weighed in.
    From Business Insider: a look at how both presidential candidates have talked about the opioid epidemic—with 1 candidate pressing for the wider adoption of pain treatment guidelines that "identify treatments other than opioids."

    Housed at MoveForwardPT.com/ChoosePT, the #ChoosePT campaign now includes a video public service announcement, as well as other targeted advertising and media outreach. APTA is also a member of the White House’s working group addressing the opioid epidemic.

    JAMA: Better Health Care Workplace Violence Prevention Plans Needed

    With half of all workplace assaults involving health care workers already, and the number of violent crime episodes in hospitals on the rise, it's time for health care facilities to address workplace violence "aggressively and comprehensively," say authors of an editorial recently published in JAMA.

    The "Viewpoint," (first-page sample only available for free) written by 2 employees of the Joint Commission and a representative from a Veterans Health Administration workplace violence prevention program, cites data from the Joint Commission, Occupational Safety and Health Administration (OSHA), and Bureau of Labor Statistics (BLS) to outline what they assert is a growing problem. Among the data:

    • Within health care settings, approximately 24,000 workplace assaults occurred between 2010 and 2013, with most threats and assaults occurring between noon and midnight.
    • Between 2012 and 2015, the incidence of violent crime events in hospitals rose from 2.0 to 2.8 per 100 beds.
    • According to BLS, 50% of all workplace assaults involve health care workers, while workers in this labor segment only account for 20% of all workplace injuries.
    • An OSHA study of 100 health care worker or patient fatalities in health care settings found that nearly a third (27%) were attributable to assaults and violence.
    • A Joint Commission study of 33 homicides, 38 assaults, and 74 rapes in health care workplaces between 2013 and 2015 concluded that "root causes of these events were failures in communication, inadequate patient observation, lack of or noncompliance with policies addressing workplace violence prevention, and lack of or inadequate behavioral health assessment to identify aggressive tendencies in patients," authors write.

    Authors of the JAMA article assert that increasing workplace safety will require health care employers to step up the creation of violence prevention programs. These programs, they write, must be rooted in a recognition that "personnel underreport violent events because they believe these experiences are part of the job, reporting is either cumbersome or unlikely to result in action from leadership, or they fear retaliation for reporting." To counter that tendency authors urge the development of reporting systems that are "simple, trusted, secure, and with optional anonymity," result in "transparent outcomes and delivery of a report confirmation," and are "fully supported by leadership, labor unions, and management."

    "Safety in health care workplaces relies on leadership enacting appropriate polices; trained employees intervening and reporting; multidisciplinary teams using evidence-based threat assessments and management practices, communicating safety plans, and analyzing environmental context; and ongoing evaluation of program effectiveness," authors write. "A workplace violence prevention program should be a required component of the patient safety system of all health care organizations."

    Landmark NIH Plan Delivers 5-Year Roadmap for Rehabilitation Research

    Rehabilitation research, one of APTA's longstanding areas of advocacy, has just received a major boost with the publication of a revised National Institutes of Health (NIH) Rehabilitation Research Plan, a 5-year roadmap intended to address a broad swath of research science. Nearly 2 years in development, the revision is the first change to the plan made in over 2 decades, and was guided by a blue ribbon panel that included prominent APTA members and physical therapy researchers.

    The plan, which will guide NIH support for rehabilitation medicine, addresses 6 priority areas: the need for rehabilitation research, NIH's investment in rehabilitation research, current rehab research activities at NIH, coordination with other federal agencies, and opportunities, needs, and priorities. According to NIH, each area has witnessed significant change since the 1993 edition of the plan, attributable to everything from an increase in rehabilitation researchers and growth in evidence to advances in brain-computer interfaces and other technologies that have altered the rehabilitation landscape.

    Among the topics covered within the priority areas: investigation of new approaches to assistive technology in the home; increasing resources to recruit more researchers; ramped-up efforts to analyze biological, chemical, and genetic components of recovery; and intensified research on rehabilitation and disability across the lifespan.

    A call for a revision to the plan, and the establishment of a 5-year update cycle, were among the recommendations from an NIH blue ribbon panel that was co-chaired by former Physical Therapy (PTJ) Editor-in-Chief Rebecca Craik, PT, PhD, with members that included Anthony Delitto, PT, PhD, and current PTJ Editor-in-Chief Alan M. Jette, PT, PhD.

    Improvements to rehabilitation research and support of NIH work in this area are among APTA's public policy priorities. In addition to its individual advocacy efforts, the association is a member of the Disability and Rehabilitation Research Coalition, a group of more than 40 organizations working together to promote this type of research.

    "The rehabilitation research plan now published will be a major resource, both for researchers and the agencies that provide funding," said Justin Moore, PT, DPT, chief executive officer of APTA. "Rehabilitation science can help providers truly transform lives, and this new plan marks a long-awaited and significant step forward."

    Development of the plan was led by the National Center for Medical Rehabilitation Research (NCMRR), under the leadership of Director Alison Cernich, PhD. NCMRR is part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

    FDA Clears First Device Specifically Designed to Assess Function After Concussion

    The US Food and Drug Administration (FDA) has given its first-ever clearance for marketing of devices designed to help clinicians assess cognitive function immediately after a suspected brain injury or concussion.

    Called Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and ImPACT Pediatric, the tool was approved under a new FDA category titled "Computerized Cognitive Assessment Aid for Concussion." The test battery is already used by more than 7,400 high schools, 1,000 colleges and universities, and 900 clinical centers as a way to test cognitive skills such as word memory, reaction time, and word recognition. ImPACT is designed for use on individuals aged 12 to 59, and operates on a desktop or laptop computer; ImPACT Pediatric is intended for children aged 5 to 11, and is run on an iPad.

    While not intended as the sole tool for making a diagnosis or return-to-play decision, the ImPACT device can provide additional evaluative information though comparisons with age-matched databases or patient baseline scores, according to an FDA news release. Pittsburgh, Pennsylvania-based ImPACT Applications submitted more than 250 peer-reviewed articles—half of which were independent clinical research studies—supporting the safety and reliability of the devices.

    Prior to the ImPACT approval, the FDA had cleared only devices that help determine the need for imaging after a head injury.

    $20 Million NIH Health Disparities Program Includes Project Focused on Increasing Physical Activity in Communities

    The National Institutes of Health (NIH) is starting a new community-based research program to address health disparities related to chronic disease. One the program's first targets: a project that will focus on improving physical activity and healthy eating for a community in Flint, Michigan.

    The program, operating under NIH's National Institute on Minority Health Disparities (NIMHD), will establish so-called "transdisciplinary collaborate centers" (TCCs) to address "the need for more robust, ecological approaches to address chronic diseases among racial and ethnic minority groups, underserved rural populations, people of less privileged socioeconomic status," and other groups subject to discrimination, according to an NIH news release. The TCCs will involve coalitions of research institutions, community organizations, providers, health care systems, and state and local public health agencies to develop interventions "that can be implemented in real-world settings."

    NIMHD plans to spend about $20 million over 5 years to support 2 projects—one will apply "community-engaged health disparities research" around interventions aimed at increasing physical activity and healthy diet; the other aims to control hypertension among American Indians, Alaskan natives, native Hawaiians, and other Pacific islanders.

    The first program, known as the Flint Center for Health Equity Solutions, will evaluate the effectiveness of interventions that approach physical activity and diet issues from multiple levels, including programs that involve local churches, peer coaching, family reunification, and support for individuals in recovery from substance abuse.

    "Multilevel interventions that take into account complex interactions between individuals and their environments can better address the determinants of health and enhance chronic disease prevention and health promotion for local communities," said NIMHD Director Eliseo Perez-Stable in the news release. "Studies in these centers will add to our knowledge of what works in health disparities populations, thus advancing knowledge towards our nation's health."

    How do health disparities affect physical therapist practice, and what are some of the driving forces behind them? Check out APTA's health disparities webpage for more insight.