CVS Health to sell Omnicare

Posted on November 5, 2022 by Pharmaciststeve

The last few years that I worked as a pharmacist, I worked as a temp pharmacist and one of the locations that I worked at, was one of Omnicare’s LTC pharmacies. When I had my own independent pharmacy, we serviced nursing homes.  I left working as a pharmacist before CVS bought Omnicare.  I worked a lot of closing shifts and we used both a local Walgreens and CVS for picking use meds that we had a order for that the pharmacy was out of stock.   I don’t remember the exact time frame but at some point… The Omnicare was told by CVS that they did not want to be a backup pharmacy for Omnicare.

Them selling Omnicare off, does not surprise me. When you are providing services to nursing homes… you do not have not control over the cost of deliveries or the number of deliveries that a particular facilities requires. From what I have seen/heard about how CVS functions… they are very focused on controlling costs.

This quote from the article: it is “determined that its LTC business was no longer a strategic asset.. that sounds like “corporate speak” for the Omnicare division was either losing money or they believe that they can take the money generated from selling the division and make more money putting it to work in some other business.  I am really surprised that they kept this business this long.

CVS Health to sell Omnicare

https://drugstorenews.com/cvs-health-sell-omnicare?oly_enc_id=1561H7059134A4V

In an SEC filing on Wednesday CVS said that it is “determined that its LTC business was no longer a strategic asset, and during the third quarter of 2022 committed to a plan to sell.”

CVS Health announced on Wednesday that it plans to sell Omnicare, its long-term care pharmacy business. The Woonsocket, R.I. company reported a $2.5 billion loss related to Omnicare in the third quarter.

Omnicare serves senior living communities, skilled nursing facilities and Programs of All-Inclusive Care for the Elderly.

“We continue to evaluate our portfolio strategically and are making decisions around assets that don’t fit into our portfolio strategically. Omnicare is a good example of that,” Karen Lynch, president and CEO, said Wednesday morning during the Q&A with analysts on the company’s third-quarter earnings call.

In a Securities and Exchange Commission filing on Wednesday CVS said that it is “determined that its LTC business was no longer a strategic asset, and during the third quarter of 2022 committed to a plan to sell.”

What’s next for CVS?

During the Q&A with investors, Lynch also said, “We will continue to evaluate our options on primary care. And as I said, we believe that we need to do M&A, and we continue to evaluate those options in the marketplace.”

CVS acquired Omnicare in 2015 in an approximately $12.3 billion deal.

 

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When a process/guidelines has very little valid medical rational

Posted on November 5, 2022 by Pharmaciststeve

I’m going to use an analogy to make my case.  I remember from plane & solid geometry that it takes 3 points of support to a horizontal solid plane to make it stable.   For those of you who never had to take a plane & solid geometry course, think how easy/hard it would be to sit on a stool that only had one or two legs supporting it compared to a stool that would have three legs.

Both versions of the CDC guidelines (2016 & 2022) is primarily based on three medical premises that has – at best – very poor/inadequate medical evidence supporting their processes and/or conclusions.

First is the fact that the CDC guidelines used in both versions, studies that were mostly rated “3” or “4” in the quality of the data used to come to the conclusion of the study.  A study with a rating of “1” is considered highly reliable and those rated “3” or “4” is consider poor and/or unreliable regarding the data used and the conclusions.

After the 2016 guidelines were published I have seen numerous times where other professionals have questioned the use of such poorly rated references used to support the conclusions for the 2016 guidelines.; Yet, it would appear that the FIVE “experts” seemingly chose to use the same references for the 2022 guidelines.  Does this mean that using more reliable references would not support the desired conclusions to support the 2022 guidelines ?

No one seems to questions that FIVE “experts” are given credit for the creation of this 200+ page set of guidelines, and of the 20 +/- pages of references and footnotes, ONE WHOLE PAGE has abt 12 references with the first name on each referenced article being the same person who is “ONE OF THE FIVE EXPERTS” who created the 2022 CDC dosing guidelines.  Is that a blatant conflict of interest or just self-serving ?

https://www.cato.org/blog/cdc-replaces-flawed-2016-opioid-prescribing-guideline-flawed-2022-opioid-prescribing-guideline

“The Guideline recommendations are still primarily based on “Type 3” and “Type 4” evidence ”

Earlier this year Chuck Dinerstein, MD, MBA published a article that is basically the genealogy of the MME system.  Clearly documenting that this system has no science nor double blind clinical study supporting its conclusions.

https://www.acsh.org/news/2022/03/01/true-story-morphine-milligram-equivalents-mme-16154

One of the oldest internet published MME conversion programs https://globalrph.com/medcalcs/opioid-conversions-calc-original-single-agent/

has the following footnotes:

Published equianalgesic ratios are considered crude estimates at best and therefore it is imperative that careful consideration is given to individualizing the dose of the selected opioid. Dosage titration of the new opioid should be completed slowly and with frequent monitoring. 

bulletFactors that must be addressed during the conversion process include: Age of the patient or presence of coexisting conditions. Use additional caution with elderly patients (65 years and older), and in patients with liver, renal, or pulmonary disease.

bullet Conversion ratios in many equianalgesic dosing tables do not apply to repeated doses of opioids.

bulletThe amount of residual drug in the patient’s system must be accounted for. Example: fentanyl will continue to be released from the skin 12 to 36 hours after removal of the patch. Residual effects from discontinued long-acting formulations should also be assessed before converting a patient to a new opioid.

bullet The use of high but ineffective doses of a previous opioid may result in overestimation of the converted opioid.

bullet Ideally, methadone conversions (especially patients who were previously receiving high doses of an opioid) should only be attempted in cooperation with a pain specialist or a specialist in palliative medicine.

bullet Meperidine should be used for acute dosing only and not used for chronic pain management (meperidine has a short half-life and a toxic metabolite: normeperidine). Its use should also be avoided in patients with renal insufficiency, CHF, hepatic insufficiency, and the elderly because of the potential for toxicity due to accumulation of the metabolite normeperidine. Seizures, confusion, tremors, or mood alterations may be seen. In patients with normal renal function, total daily doses should not exceed 600mg/24hrs.

I found no mention, in the either sets of guidelines, that pharmacogenomic DNA testing, to determine if the pt is a fast/ultra fast metabolizer which would be valid justification of the pt’s in need of higher single doses, more frequent dosing and/or higher total mgs/mcgs per 24 hrs.

Third, everyone needs to watch this video https://stanford.zoom.us/rec/share/F6IC_Sitiu4lmGQgBbD9wVvOb5iG9Eal7fnJrqC2G2lMMEjDM8H4mv4D_hOjD6mY.jqBbyLkUm9RvzhKS

The presenter, attorney Dr. Jennifer Alva indicates that the PDMP/Narxcare reports contains a high percentage of unreliable data points on pts that results in bad/false Narxcare score, resulting in a pt  being falsely labeled as having a “high score” of being at risk of overdosing or dealing with OUD.

She also suggests that most states have turned their PDMP record keeping over to Experian/Bamboo Health/Narxcare.  I recently read where all of the medical databases that Bamboo Health maintains has been mover “off-shore “. Somewhere  “across the pond”, where our HIPAA rules are not applicable. Apparently leaving this company to be able to sell our health data to any entity willing to pay for it. I guess that the DEA no longer needs a court warrant to search PDMP’s databases and they can go on a “data fishing expedition” all they want, without the constraints of our legal system and our laws.

Here is a post on my blog displaying a typical Narxcare report format Images from a Narxcare report – PLEASE SHARE

Please note that apparently Bamboo Health is using a LME value ( Lorazepam Milligram Equivalents)

In doing some research… appears that an association of Pharmacists: The American Association of Psychiatric Pharmacists     may have created this LME system. appears that it may have been first published in Aug 2014

and here is a hyperlink to a full chart of LME’s  https://deprescribe.web.unc.edu/wp-content/uploads/sites/20194/2020/04/Benzo-Equivalency-Table_UNC.pdf

It seems that the entire prescribing/dosing of opiates seems to be supported not much better than trying to sit on a stool with legs being made out of “cooked spaghetti “. Yet, it seems like a lot of various entities in healthcare and law enforcement puts a lot of faith & creditability in the reliability of this poorly design system. As well as the QOL of pts that is having this applied to their medical care with seemingly no follow up as to how the guidelines are applied and/or pt’s outcomes are affected.

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Alcohol death rate in US is rising, government reports say

Posted on November 4, 2022 by Pharmaciststeve

Alcohol death rate in US is rising, government reports say

https://www.foxnews.com/health/alcohol-death-rates-us-rising-government

A CDC report found the rate of related deaths rose by 26% in the first year of the pandemic

Deaths that can be directly attributed to alcohol rose nearly 30% in the U.S. during the first year of the COVID-19 pandemic.

Two new reports from the Centers for Disease Control and Prevention showed which states are seeing the highest numbers and which groups are impacted. The agency already said such deaths rose in 2020 and 2021.

According to the World Health Organization, the harmful use of alcohol is a causal factor in more than 200 disease and injury conditions, with 3 million resulting deaths annually.

AFTER FENTANYL KILLED HER SOULMATE, RECOVERING DRUG USER FIGHTS TO END STIGMA OF ADDICTION

Bottles of Jim Beam brand bourbon whiskey for sale at the James B. Beam distillery in Clermont, Kentucky, US, on Tuesday, July 26, 2022.  (Photographer: Luke Sharrett/Bloomberg via Getty Images)

The rate of those deaths had been increasing by 7% or less each year, but rose 26% in 2020 – the highest rate in at least 40 years.

There were more than 52,000 such deaths last year. That number rose from 39,000 in 2019, for both men and women. The deaths are 2.5 times more common in men.

In this Nov. 30, 2017 photo, a patron sips his drink while having a meal at a bar in New Jersey. ((AP Photo/Julio Cortez, File))

CHILD DEATHS FROM ACUTE KIDNEY INJURY RISES TO 133 IN INDONESIA

The rate also remained higher for people ages 55 to 64, but also jumped 42% among women ages 35 to 44.

A second report looked at a wider range of deaths that could be linked to alcohol, including cancers and motor vehicle accidents.

Corona Extra beer arranged in the Brooklyn Borough of New York, U.S., on Tuesday, Nov. 23, 2021.  (Photographer: Gabby Jones/Bloomberg via Getty Images)

Researchers said more than 140,000 of that broader category of deaths occur annually, based on data from 2015 to 2019. That is more than 380 deaths each day.

About 82,000 are from drinking too much over a long period of time and 58,000 are from causes tied to acute intoxication.

CLICK HERE TO GET THE FOX NEWS APP

The study found that as many as 1 in 8 deaths among U.S. adults ages 20 to 64 were alcohol-related deaths.

New Mexico had the highest percentage of alcohol-related deaths, at 22%.

Mississippi had the lowest.

Filed under: General Problems | 2 Comments »

The CDC Replaces Flawed 2016 Opioid Prescribing Guideline with a Flawed 2022 Opioid Prescribing Guideline

Posted on November 4, 2022 by Pharmaciststeve

I think that I posted when they announced that they were going to renew the 2016 guidelines, that over my 5+ decades of watching bureaucrats… when an existing rule/law/regulation gets re-opened to improve it… it seldom makes things better….  more often than not… things get worse.  With this version of the opiate dosing guide, there is only five “experts”  with at least one returning from the original committee… there is some 20 pages of footnotes and references and one ENTIRE PAGE – containing abt 12 references with the first name listed as a author on all these references is one of the five “experts” on this edition of the guidelines.

Since the publishing of the 2016 guidelines, a physician published a article – which basically created the genealogy of the MME system – which showed that the conclusions of the MME system have no science behind them nor double blind clinical trials.   Yet these five “experts” referenced the same MME system as to determine “recommended” daily opiate limits. Since pain management is dealing with a subjective disease. There are no definitive tests to determine if the pt is in pain nor the intensity of their pain and the typical chronic pain pt… their intensity of pain will vary – sometimes dramatically – day to day and/or within a single 24 hr period.

In June, 2022 a SCOTUS ruling (9-0 vote) https://www.pharmaciststeve.com/supreme-court-tells-cops-to-stop-playing-doctor-but-will-they-listen-or-back-to-business-as-usual/  basically told the DEA that they cannot use objective criteria when judging a prescriber in how they treat/dose opiates for pts dealing with subjective diseases – like pain.  Here we are a few months later with the CDC coming out with objective criteria … suggesting how prescribers should dose opiates in treating chronic pain.  If SCOTUS tells the DEA not to use objective criteria to decide if a prescriber is properly treating a chronic pain pt.  Then how can it be legal for FIVE “experts” to create objective criteria in how prescribers should treat chronic pain pts.  Isn’t that  why a person gets a medical degree and passes the state’s medical licensing boards…  to practice medicine and treat pts.  The practice of medicine can be broken down into two primary functions – diagnosing the medical issue(s) that the pt is dealing with and starting, changing, stopping a pt’s therapy.

Isn’t the CDC attempting to supersede  the FDA dosing guidelines and interfere with the professional discretion granted to the prescriber by the state licensing board ?


The CDC Replaces Flawed 2016 Opioid Prescribing Guideline with a Flawed 2022 Opioid Prescribing Guideline

https://www.cato.org/blog/cdc-replaces-flawed-2016-opioid-prescribing-guideline-flawed-2022-opioid-prescribing-guideline

Responding to medical experts, including the American Medical Association, who have been complaining for years that the Center for Disease Control and Prevention’s 2016 Guideline for Prescribing Opioids for Chronic Pain lacked a strong basis in the evidence—and after it issued an Advisory in 2019 stating the Guideline was misinterpreted and “misapplied” by state lawmakers and health care practitioners—the CDC announced it was going to revise the Guideline before the end of 2022. Unfortunately, 38 states have already cast the flawed 2016 Guideline in stone by enshrining—and misapplying—all or part of it in statutes that dictate how health care practitioners may treat patients in pain.

In February of this year, the CDC released a draft of the revised Guideline and requested comments. I provided my comments here. In those comments, I stated. “Notwithstanding the well‐​intentioned exhortations and disclaimer in the draft 2022 opioid prescribing guideline, the recommendations change very little from those put forth in 2016.”

The CDC goes to great lengths to stress throughout the draft 2022 Guideline that the document is meant to serve as a list of suggestions and recommendations and is by no means intended as a mandate, emphasizing that physicians should use their best clinical judgment to provide individualized treatment to their patients. However, I commented, “The CDC guideline will inevitably become interpreted and adopted as hard and fast rules by state and local governments, pharmacies, health plans, and third‐​party payers, despite guideline warnings against doing so.”

I also criticized the draft for suggesting dosages based on “morphine milligram equivalents” of opioids:

For example, the guidelines still rely on Morphine Milligram Equivalent (MME) dose recommendations, even though there is no pharmacologic or biochemical basis for relying on equianalgesic conversion factors.

The use of MME conversion tables is nothing more than junk science. As Dr. Nabarun Dasgupta of the University of North Carolina Injury Prevention Center has written:

Contrary to conventional wisdom, conversion values are not based on pharmacologic properties. Instead, they arose 60 years ago from small single‐​dose clinical studies in postoperative or cancer populations with pain score outcomes; toxicologic effects (e.g., respiratory depression) were not evaluated.

On November 3, the CDC published the final version of the 2022 Clinical Practice Guideline for Prescribing Opioids for Pain. The Guideline no longer recommends MME dosage thresholds, but it still urges practitioners to be cautious about prescribing more than 50 morphine milligram equivalents of opioids per day, stating :

Many patients do not experience benefit in pain or function from increasing opioid dosages to ≥50 MME/​day but are exposed to progressive increases in risk as dosage increases. Therefore, before increasing total opioid dosage to ≥50 MME/​day, clinicians should pause and carefully reassess evidence of individual benefits and risks. If a decision is made to increase dosage, clinicians should use caution and increase dosage by the smallest practical amount.

To prevent the recommendation from being “misapplied,” the Guideline adds the following disclaimer to the above paragraph:

The recommendations related to opioid dosages are not intended to be used as an inflexible, rigid standard of care; rather, they are intended to be guideposts to help inform clinician‐​patient decision‐​making.

Alas, the 2022 Guideline still includes the now‐​discredited MME conversion table that providers can refer to when prescribing opioids.

The Guideline recommendations are still primarily based on “Type 3” and “Type 4” evidence, evidence with important limitations.

If the past is prologue, expect the Guideline’s suggestion to use caution approaching a dose of 50 MME to morph into another de facto mandate as lawmakers, pharmacies, and insurance plans fixate on that number. As Josh Bloom and I have written before:

When a government agency “recommends” a policy, it’s akin to a recommendation from Tony Soprano; it is inevitably interpreted as a mandate, obeyed by state and federal agencies, health insurers, and even pharmacies.

Perhaps most egregiously, the rationale of the 2022 Guideline remains predicated on the flawed assumption that overprescribing opioids caused the overdose crisis. There is no correlation between prescription volume and the nonmedical use or addiction to prescription opioids. And the percentage of people aged 18 or older addicted to prescription pain pills has been unchanged at less than one percent this entire century. The CDC should follow the evidence and abandon this mistaken premise.

Finally, as I concluded in my comments on the draft proposal back in February 2022:

1‑The Centers for Disease Control and Prevention should not be issuing opioid prescribing guidelines. Professional specialty organizations, overseen by practicing clinicians and clinical educators, are the institutions that should be issuing standard of care and best practices guidelines.

2‑The CDC guideline will inevitably become interpreted and adopted as hard and fast rules by state and local governments, pharmacies, health plans, and third‐​party payers, despite guideline warnings against doing so.

3‑The 2022 guideline very closely resembles the 2016 guideline and is based on weak evidence; in the case of Morphine Milligram Equivalent recommendations, the guideline is pharmacologically unsound, and the conversion tables are based largely on decades‐​old subjective studies that didn’t even examine toxicologic effects such as respiratory depression rates.

4‑The overdose crisis is largely caused by a growing population of nonmedical drug users intersecting with increasingly dangerous drugs being developed for the black market fueled by drug prohibition. Efforts to address the problem through reductions in opioid prescribing have only exacerbated the situation by driving nonmedical users to more dangerous drugs while depriving pain patients of necessary relief.

5‑The Centers for Disease Control and Prevention should abandon its efforts to establish a prescribing guideline and defer to the professional institutions usually charged with establishing best practices.

Nothing in the just‐​published Guideline makes me want to reconsider that conclusion.

Filed under: General Problems | 4 Comments »

CVS Health is standing up to protect their own profits – using a “smoke screen” and accusing others of profiteering

Posted on November 4, 2022 by Pharmaciststeve

CVS Health is standing up for Louisianans

https://www.cvshealth.com/news-and-insights/articles/cvs-health-is-standing-up-for-louisianans

“By inserting themselves in the state’s process of selecting a firm to manage prescription drug coverage for the Office of Group Benefits, special interest groups representing Louisiana’s independent pharmacists attempted to line their own pockets at the expense of the state’s taxpayers, employees and retirees.

“Following a fair and competitive procurement process, CVS Health stood ready to provide a prescription drug benefit plan for state employees that the state’s independent analysis estimated would save more than $100 million in the first year, while also including a fair and market-based rate for reimbursing independent pharmacists. Instead, those same pharmacists opted to put profits over patients – inserting themselves into a process where the state had already outlined providing them fair compensation.

“This situation has set a dangerous precedent, endangering the healthcare coverage of state employees, threatening the fiscal solvency of the state employee and retiree benefit plan, and emboldening special interest groups whose sole concern is lining their own pockets. This bullying behavior, at a time when the state is facing unparalleled economic uncertainty from a global pandemic and countless natural disasters, is nothing short of shameful. Moreover, it represents an alarming trend that all states should be concerned about.

“While we are disappointed in the outcome, we remain fully committed to working with public and private clients across Louisiana to deliver pharmacy coverage that puts patients first and brings down the costs for prescription drugs. Sadly, the independent pharmacists cannot say the same.”

Several years ago, the Treasurer of Arkansas and the Arkansas Pharmacist Association did a price survey on the cost of the state employee medication costs. The program was managed by Caremark – which is owned by CVS Health.  The survey involved 250-260 different medications and the prices that were being paid by Caremark to the various local pharmacies where state employees got their medications filled.

ON AVERAGE, a medication filled at a CVS community pharmacy got paid by Caremark abt 60.00 MORE than what was paid to other pharmacies in the state that were competitors of CVS health drug stores for filling the same medication, strength and quantity.

Does this suggest that CVS Health is well versed in how a corporation can “line their own pockets at the expense of the state’s taxpayers, employees and retirees”

There is THREE PBM’S that control abt 75% of the Rx market place, both in what medications are covered and what they pharmacies get paid for filling such medications.  If you include the TOP 5 PMB’S you are talking about controlling abt 90% of the market.

If anyone questions the “bad financial behavior ” of the PBM industry just do a web search using the phrase “prescription benefit managers law suits”.

Over the last 5 yrs, the top 5 PBM companies are now owned by companies that are in the insurance business.  Before this, PBM’s and insurance companies were suing each other over claimed over charging or under payments.

Filed under: General Problems | 1 Comment »

The “BAD AND THE UGLY – there is NO GOOD” of the PDMP’s and Narxcare and the INACCURATE CONCLUSIONS from those databases

Posted on November 3, 2022 by Pharmaciststeve


This is a video about ONE HOUR LONG… normally, I don’t sit thru such a long video.  This is a VERY INTERESTING presentation put on by Dr. Jennifer Alva – an attorney with a very broad legal background. She talks about how the various state PDMP who has apparently turned their data collecting responsibility over to  Experian   who now owns Bamboo Health 

who owns/operates  Narxcare  that produces a SUBSTANCE ABUSE SCORE.. on pts prescribed controlled substances.

You just have to listen to Dr Alva’s explanation of how faulty data is collected and assigned to pts and prescribers and how the DOJ/DEA is accepting the conclusions from data mining these faulty data points and use it to go after prescribers to prove that the prescribers are illegally prescribing controlled substance

 

https://stanford.zoom.us/rec/share/F6IC_Sitiu4lmGQgBbD9wVvOb5iG9Eal7fnJrqC2G2lMMEjDM8H4mv4D_hOjD6mY.jqBbyLkUm9RvzhKS

Here is a up coming seminar concerning the MME system

Guest Speaker Series

Wednesday, November 16, 2022

Dr. Nabarun Dasgupta

Nabarun Dasgupta, MPH, PhD

Dr. Nabarun Dasgupta is a scientist at the Opioid Data Lab (OpioidData.org) at the University of North Carolina with 2 decades of experience in opioid epidemiology and overdose prevention. His passion is telling true stories about health, with numbers. Centered in epidemiology, his multidisciplinary approach draws on large database analytics, qualitative field studies, laboratory investigations, randomized trials, and community-based interventions. Through his work he aims to amplify community and patient voices in public health. He works closely with patients with pain conditions and believes they can be equal partners in scientific research. His lab at UNC tests street drugs (https://streetsafe.supply) from around the country to understand the implications of illicit drug supply fluctuations on health. He also tracks street prices for prescription medications (StreetRx.com). He is the co-founder of Remedy Alliance For The People, a ground breaking national naloxone bulk distribution non-profit supplying millions of doses of the opioid reversal antidote to harm reduction programs (RemedyAllianceFTP.org). Follow him on Twitter @nabarund

FREE VIRTUAL CME LECTURE | November 16, 2022

Inches, Centimeters, and Yards: How MME Hidden Variations in MME Calculations Influence Opioid Safety

Zoom Webinar | 11:00am – 12:00pm PST |  REGISTER NOW

ACCREDITATION

In support of improving patient care, Stanford Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

CREDIT DESIGNATION

American Medical Association (AMA)
Stanford Medicine designates this Live Activity for a maximum of 1.0 AMA PRA Category 1 CreditsTM.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Accreditation Council of Pharmacy Education (ACPE)
Stanford Medicine designates this knowledge-based activity for a maximum of 1 hour. Credit will be provided to NABP CPE Monitor within 60 days after the activity completion.

Universal Activity Number List: UAN: JA0000751-0000-22-017-L08-P

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Stanford Medicine designates this live activity for a maximum of 1.0 ANCC contact hour.

ASWB Approved Continuing Education Credit (ACE)
As a Jointly Accredited Organization, Stanford Medicine is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. Stanford Medicine maintains responsibility for this course. Social workers completing this activity receive 1.0 general continuing education credits.

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Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibly for the content of the programs.

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Stanford Medicine has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This live activity is designated for 1 AAPA Category 1 CME credits. PAs should only claim credit commensurate with the extent of their participation.

Physical/Occupational Therapy
Stanford Health Care Department of Rehabilitation is an approved provider for physical therapy and occupational therapy for courses that meet the requirements set forth by the respective California Boards. This course is approved for 1.0 hour CEU for PT and OT.

 

Filed under: General Problems | 3 Comments »

CDC Just Changed Its Opioid Prescribing Guidelines. Here’s What to Know

Posted on November 3, 2022 by Pharmaciststeve

CDC Just Changed Its Opioid Prescribing Guidelines. Here’s What to Know

https://www.medpagetoday.com/neurology/opioids/101559

Guidance covers acute, subacute, and chronic pain and replaces 2016 guidelines

Hard thresholds for pain medication doses and duration are no longer promoted through the CDC’s new Clinical Practice Guideline for Prescribing Opioids for Pain.

The new guidance — which covers acute, subacute, and chronic pain for primary care and other clinicians — updates and replaces the controversial 2016 CDC opioid guideline for chronic pain. The 2016 guideline was interpreted as imposing strict opioid dose and duration limits and was misapplied by some organizations, leading the guideline authors to clarify their recommendations in 2019.

The 2022 recommendations are voluntary and give clinicians and patients flexibility to support individual care, said Christopher Jones, PharmD, DrPH, MPH, acting director of CDC’s National Center for Injury Prevention and Control in a CDC press briefing. They should not be used as an inflexible, one-size-fits-all policy or law, or applied as a rigid standard of care, or replace clinical judgement about personalized treatment, he emphasized.

“Patients with pain should receive compassionate, safe, and effective pain care,” Jones stated. “We want clinicians and patients to have the information they need to weigh the benefits of different approaches to pain care, with the goal of helping people reduce their pain and improve their quality of life.”

The guidance, published in Morbidity and Mortality Weekly Report, addresses four key areas: initiating opioids for pain, selecting opioids and dosages, deciding prescription duration and conducting follow-up, and assessing risk and potential harms of opioids. It suggests that clinicians work with patients to incorporate plans to mitigate risks, including offering naloxone.

The 100-page document indicates opioids should not be considered as first-line or routine therapy for subacute or chronic pain, and points out that non-opioid therapies often are better for many types of acute pain.

“For patients receiving opioids for 1 to 3 months (the timeframe for subacute pain), the 2022 guideline recommends that clinicians avoid continuing opioid treatment without carefully reassessing treatment goals, benefits, and risks in order to prevent unintentional initiation of long-term opioid therapy,” wrote Debbie Dowell, MD, MPH, chief clinical research officer for CDC’s Division of Overdose Prevention, and guideline co-authors in a commentary published in the New England Journal of Medicine.

For chronic pain, clinicians should maximize use of non-opioid therapies and consider initiating opioid therapy only if the expected benefits for pain and function are anticipated to outweigh the risks, Dowell and colleagues noted. When opioids are needed for chronic pain, clinicians should start at the lowest effective dose, evaluate benefits and risks before increasing dosage, and avoid raising dosage above levels likely to yield diminishing returns, they added.

“These principles do not imply that nonpharmacologic and non-opioid pharmacologic therapies must all be tried unsuccessfully in every patient before opioid therapy is offered,” Dowell and colleagues wrote. “Rather, expected benefits specific to the clinical context should be weighed against risks before therapy is initiated.”

The new guideline offers tips for tapering opioids when warranted, but is not intended to lead to rapid opioid tapering or discontinuation, Jones noted. The recommendations do not apply to sickle cell disease-related pain, cancer pain, and palliative or end-of-life care.

The 2022 document incorporated feedback from approximately 5,500 public comments since the new version was first proposed in February, including reactions from people who discussed their experiences with pain or opioid addiction and barriers to pain care. An independent federal advisory committee, four peer reviewers, and members of the public reviewed the draft version.

“The science on pain care has advanced over the past 6 years. During this time, CDC has also learned more from people living with pain, their caregivers, and their clinicians,” Dowell said in a statement. “We’ve been able to improve and expand our recommendations by incorporating new data with a better understanding of people’s lived experiences and the challenges they face when managing pain and pain care.”

The clinical practice guideline supports the HHS Overdose Prevention Strategy, the CDC said. The agency also is providing additional information associated with the guideline to clinicians and patients.

Filed under: General Problems | 5 Comments »

With inflation running 8% – CMS going to CUT physician reimbursement by 4.48%

Posted on November 2, 2022 by Pharmaciststeve

CMS releases final payment rules for 2023: 15 takeaways

https://www.beckershospitalreview.com/finance/cms-releases-final-payment-rules-for-2023-15-things-to-know.html

CMS has published its annual payment updates for physicians, the Medicare shared savings program and outpatient and home health services for 2023. 

Here are 15 takeaways from the final rules, published Oct. 31 and Nov. 1: 

Physician Fee Schedule rule

1. The conversion factor used to calculate physician reimbursement will decline by $1.55 to $33.06 in 2023, representing a 4.48 percent decrease. CMS said the conversion factor accounts for the expiration of the 3 percent increase in physician fee schedule payments for 2022 — as required by the Protecting Medicare and American Farmers From Sequester Cuts Act — and the budget neutrality adjustment for changes in relative value units.

2. The agency finalized several policies related to telehealth, including extending numerous temporarily available telehealth services during the public health emergency through at least 2023. CMS said this will provide more time to collect data that could support their inclusion as permanent additions to its telehealth services list. 

3. In response to the increasing demand for behavioral health services, CMS said it will allow these services to be provided under the supervision of a physician or nonphysician practitioner — rather than under direct supervision — when such services are provided by “auxiliary personnel,” such as licensed professional counselors or family and marriage therapists.

4. In an update to the Medicare Shared Savings Program, providers new to the initiative that are not renewing or reentering as an ACO and qualify as low revenue can receive a one-time payment of $250,000 and quarterly payments for the first two years of a five-year period. The advance payments would be recouped once an ACO begins generating shared savings in their current and next agreement periods. CMS said it will not move to recoup money from ACOs that do not generate savings, but those ACOs must remain in the program for the full five years.

Outpatient Prospective Payment System rule

5. CMS is increasing outpatient payment rates for hospitals that meet applicable quality reporting requirements by 3.8 percent. 

6. In line with the 2019 OPPS final rule — which finalized a proposal to apply the productivity-adjusted hospital market basket update to ASC payment rates through 2023 — CMS is also increasing pay rates by 3.8 percent for ASCs that meet applicable quality reporting requirements.

7. CMS is finalizing a general payment rate of average sale price plus 6 percent for drugs and biologicals acquired through the 340B drug pricing program.

8. The agency is finalizing separate payment in ASCs for five non-opioid pain management drugs that function as surgical supplies, including certain local anesthetics and ocular drugs.

Rural Emergency Hospitals rule

9. The agency established a new Medicare provider type called rural emergency hospitals, effective Jan. 1, to address concerns that rural and critical access hospital closures are reducing access to care for people in rural areas. 

10. The final rule broadly defines “REH services” to include all covered outpatient department services when provided by rural emergency hospitals, which will be paid for at a rate equal to the OPPS payment rate — for the equivalent covered outpatient department service — increased by 5 percent, according to the agency. Beneficiaries will not be charged coinsurance on the additional 5 percent payment. 

11. In 2023, rural emergency hospitals will receive a monthly facility payment that will increase in subsequent years by the hospital market basket percentage increase.

Home Health Prospective Payment System rule 

12. Home health agencies will receive a 0.7 percent Medicare payment boost, translating to an extra $125 million next year, according to the agency.

13. CMS said the increase reflects a 4 percent home health payment percentage, which will add $725 million, and a 0.2 percent increase because of an update to the fixed-dollar loss ratio used in calculating outlier payments, which will add $35 million. 

14. CMS payments to home health agencies will drop 3.5 percent next year after the agency found it has paid far more under the new patient-driven groupings model. An estimated $635 million will be docked from home health agency payments in 2023 and more cuts may be coming in the coming years. 

15. To make home health payments more predictable, the agency is finalizing a budget-neutral 5 percent cap on negative wage index changes for home health agencies to facilitate yearly changes in the pre-floor, pre-reclassified hospital wage index.

 

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The Opioid Crisis Is Still a National Threat

Posted on October 31, 2022 by Pharmaciststeve

Once again Congress is GIVEN A PASS over their contributions to the opiate crisis in the early 2000’s.  In 1999-2000 Congress passed the DECADE OF PAIN LAW… and The Joint Commission (JC) got involved and declared that pain was THE FIFTH VITAL SIGN – on par with the importance of  a pt’s Body Temperature, Pulse Rate, Respiration Rate, Blood Pressure.  JC made adequate pain management a MAJOR STANDARD for hospital to meet in order to attain certification by the JC.  Pt surveys given to pts on being discharged from the hospital were required to have questions about how their pain was treated while in the hospital. When the Decade of Pain Law expired, the politically party in the majority of Congress had FLIPPED and refused to renew the law.  Once that law was not renewed, JC disavowed any ownership of the 5th vital sign and pain was no longer a major standard for hospitals to meet when pts were in the hospital.  I guess that is no small coincidence that the number of opiate Rxs peaked a couple of years after the Decade of pain law expired and have continued to drop annual ever since.  Currently about 60% less from the earlier peak. While OD/poisoning from illegal fentanyl has increased around FOUR TIMES in a similar time frame. 

The Opioid Crisis Is Still a National Threat

https://www.medpagetoday.com/opinion/focusonpolicy/101502

Its shape is changing slightly, but we must continue to battle this scourge

Midterm election madness is in full swing and the incipient cold/flu/COVID season is looming. Our national opioid epidemic has largely disappeared from the headlines with the exception of local coverage when drugs are associated with a crime.

How are we faring in this longstanding battle?

First, a brief recap of what brought us to this point. Beginning in the late 1990s, pharmaceutical company misinformation about the addictive properties of opioid pain medications led providers to prescribe them at higher rates. This precipitated an alarming increase in the use and misuse of these highly addictive medications and, in 2017, prompted the Department of Health and Human Services to declare a public health emergency.

Since then, a great deal of effort and financial capital has gone into understanding the “upstream” conditions that fueled the crisis, and implementing interventions to resolve problems. However, the challenges are formidable; for instance –

  • Addressing social determinants such as poverty, joblessness, disparities, and crime
  • Changing long-established provider prescribing practices
  • Disrupting the supply chain for illegal manufacture and distribution of deadly opioid and synthetic preparations on a nationwide basis

On the “downstream” side, some interventions have been effective in preventing deaths and reducing recidivism. Consider the relative speed with which opioid antagonists (i.e., naloxone and naltrexone) have become an integral part of training for many police officers, emergency medical technicians, and non-emergency first responders. In fact, most states now permit people who are at risk — or who know someone at risk for an opioid overdose — to be trained in administering naloxone. There has also been a sizable uptick in the availability of mental health support services and medication assisted treatment options for people who have experienced a non-fatal opioid overdose.

So, back to my original question: are we any closer to winning the battle?

A quick scan of recent national statistics suggests that, rather than abating, the crisis may be undergoing a subtle transformation. A Substance Abuse and Mental Health Services Administration survey estimates that 9.5 million Americans age 12 and over misused opioids in 2020, down from 10.1 million the previous year. While this is encouraging, the survey data also show a disturbing increase in heroin use.

National hospitalization and mortality data provide a more robust assessment of the situation. From 2010-2018, opioid-involved overdose deaths rose from 21,088 to 46,802 in the U.S. Recent statistics paint an increasingly bleak picture. During the first year of the COVID pandemic, there was an increase of 30.6% in 12 months (68,630 overdose deaths through 2020). The increase was not confined to a few hot spots; statistically significant increases in drug overdose death rates were reported in 40 states.

Homing in on a specific locale, the Pennsylvania Health Care Cost Containment Council recently released its report on opioid overdose hospitalization trends in the state. In addition to differentiating between pain medication and heroin overdose hospitalizations, the report highlights trends across race/ethnicity and poverty levels from 2016 to 2021.

Over the 6-year period, there are indications that the crisis as we know it might be waning. For example, there was a 27% decrease in hospitalizations for opioid overdose (from 3,342 in 2016 to 2,429 in 2021), and the percentage of overdose hospitalizations associated with heroin also declined (from 47% of cases in 2016 to 30% of cases in 2021).

Analysis of demographic data suggests a worsening of “upstream” conditions. While hospitalization rates for opioid overdose decreased in the white, non-Hispanic population, they increased for both Black and Hispanic residents. Similarly, increased rates over time were observed for residents living in high-poverty areas (i.e., areas with a poverty rate >25%).

The statistics I find most alarming in this report relate to the drug fentanyl, a powerful and highly addictive synthetic opioid. In 2021, approximately 18% of all opioid overdose hospitalizations were for fentanyl overdose; and, of all opioid overdose hospitalizations that ended in death, 34% were for fentanyl overdose. National data reinforce these concerns; the CDC reports that overdose deaths from synthetic opioids (primarily fentanyl), psychostimulants (such as methamphetamine), and cocaine continued to increase in 2021 compared to 2020.

Inevitably, there is no simple answer to the question I raised. Although national- and state-level reports show hopeful declines in death rates from prescription opioids, the crisis appears to be evolving. We now face the prospect of rising deaths from fentanyl and other addictive substances.

The message is clear. Substance misuse is now –- and will likely remain — a serious threat to national and local population health. We cannot afford to avert our eyes!

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If you sit on the sidelines… sitting on your hands… if nothing changes… if you are not part of the solution… you may be part of the problem

Posted on October 31, 2022 by Pharmaciststeve

Filed under: General Problems | 2 Comments »

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