POSTED: August 19th, 2018
POSTED IN: EPIC - The Official Newsletter of MOCEP, July/August 2018,
As many of you may know in March, the Department of Health and Senior Services (DHHS) and Department of Mental Health (DMH) announced a new program, the Opioid Prescribing Intervention (OPI). The plan was to send letters to physicians if a prescription they wrote was flagged due to violating 1 of 12 quality indicators for prescribing opioids and benzodiazepines. In actuality, the program was not new. The state had previously been sending letters due to concerning prescriptions, but you were free to either never read them or just throw them away. What was new was that they required a response within 20 days of receiving the letter or they could refer you to the Board of Healing Arts (BHA) or the Bureau of Narcotics and Dangerous Drugs (BNDD).
Understandably, this caused a lot of anxiety and confusion. In actuality, the goal of the program was just to clarify the reason for the prescription and confirm that it was written appropriately. Additionally, DMH and DHHS also wanted to offer peer physician support if the prescribing physician thought it could help them better manage the patient’s condition. The state admits that ninety something percent of the prescriptions are reasonable and that most physicians are doing the right thing. Per them, their goal was really to help and not just make life harder for well-meaning physicians.
Of course, that was their expectation. Most physicians would feel uneasy about the potential of being referred to the BHA. Additionally privileging bodies (such as the hospital) may ask if you have been referred to the BHA before credentialing you.
Well, hopefully I can provide you an update and some good news. First and foremost, the program is suspended for the next 6 months. During this time, DHHS and DMH are going to refine this program. The state still feels that the letters are a good idea but are listening to outside opinions on how they can improve the program. As part of that, they have formed an Opioid Advisory Committee which I have been asked to sit on. I can’t promise that they’ll listen to my suggestions but at least I can ensure Emergency Physicians (EPs) have a voice. There is more good news. BNDD has not started a single investigation because of the letters and no one was referred to the state licensing board because of the letters. Also they are replacing the term ‘referred’ with a different term to make it clear that these inquiries are not the same thing as being referred to the Board for disciplinary reasons. Their goal is not for you to have to mark that you were referred to the state licensing board every time you are credentialed or renew your license. So if you did receive a letter, please take a deep breath as nothing bad should happen because of it at this time…outside of I’m sure a lot of unfortunate trepidation and anxiety that you’ve already felt.
There is other good news for EPs. The program is not really directed at them! The state realizes that Eps are not writing the majority of these prescriptions. The state is working to change the filters that the computerized system uses so that EPs do not get flagged. They are also modifying the filters so oncologists, hematologists, and palliative care providers do not get flagged and so do not stop writing reasonable prescriptions for populations that may benefit from opioids.
It is also worth stating that many of the 12 quality indicators do not pertain to EPs. For instance, it is hard to imagine the scenario where we’d write someone a 4 month prescription for an opioid from the emergency department (ED). What is possible is that a patient may come to the ED and receive a prescription for 6 tabs of hydrocodone, but unbeknownst to you, they have also been receiving opioids from another provider for the last 4 months. In this situation, you could still get flagged under the old system for violating a quality indicator even though you really didn’t; you just happened to write a prescription for a patient whose other physician did something to get flagged by the system. Good news is if this happened to you, all you need to do is send back a letter stating that you are an ED physician and only wrote a one-time prescription for a few pills and that should be the end of it. Additionally, the state is also reviewing the indicators to make sure that they are helpful and appropriate. This means that whenever the OPI program does return, it may look quite different. Hopefully, these changes will also decrease the odds of any EP receiving a letter.
Now if you have already received a letter, you should still respond. If not, someone from MO HealthNet may try to contact you to ask about the letter. Once again if you just tell them that you are an EP and wrote a short prescription for acute pain that should be the end of it. Additionally for those that are worried that you may have missed the letter, MO HealthNet is working to make the letters better standout (e.g., change the color of the envelope) so that you are less likely to miss or ignore them.
It is worth noting that there is another state organization that will still be sending out informational letters. To repeat, these letters will be for informational purposes only, and from my understanding, do not require a response. Now the OPI program will return either late this year or early next. As mentioned, the program should be improved, look very different, and it should be even less likely that an EP will receive one of the OPI letters. In the meantime if you have thoughts about how to improve or modify the program, please let us know. You can also email MMAC.OPICompliance@dss.mo.gov or go to https://dss.mo.gov/mhd/providers/opi-program.htm for more information about the program and any updates.
Evan Schwarz, MD, FACEP, FACMT