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The Opioid Epidemic and the ACA

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Benjamin Kalinkowitz
August 29, 2017

This month, the Trump Administration announced two new health care initiatives: a “prosecution first” approach to the American Opioid Epidemic, and the winding down the bundled payment pilot to hospitals. These two seemingly separate measures will work together to undermine health care advancements of the past eight years, and ultimately will make it more difficult to treat the victims of the Opioid Epidemic.

health-care-checklist-600 304 - BrantleyThe bundled payment pilot builds on an earlier Obama Administration measure which directed Medicare to reduce payments to hospitals based if patients had to be readmitted to the hospital for five preventable conditions. While initially decried by the industry, the measure reduced readmissions while improving overall outcomes. Bundled payments would direct Medicare to pay hospitals a set amount for certain procedures, with the goal of reducing costs while not worsening outcomes. Early data on bundled payments demonstrated costs could be reduced without sacrificing patient outcomes. Had the Trump Administration chosen to expand this program, it could have led to real cost reductions in the largest non-defense federal expenditure.

While pain management was not yet to be added to the bundled payment program, some of the factors which led to opioid over-prescription mirror larger trends in the unsustainable growth of health care costs. The fee-for-service model in use now encourages providers to do more: more tests, more pharmaceuticals and more surgery. Without an incentive to focus on long term outcomes, it is easy for providers to rack up huge bills doing procedures. And research on long term outcomes shows common surgeries for back pain and meniscus tears aren’t necessarily beneficial. On the other hand, research has found early physical therapy improve back pain symptoms and reduces use of medical imaging, other medical follow up and surgery. If American health care would undertake an outcomes-based payment system it would incentivize the free market to find cheaper and effective solutions.

Outcome based health care models have already proven to work for difficult problems like chronic pain and opioid addiction in the Department of Veterans Affairs. For five years, I worked at a VA hospital which dealt with their own chronic pain and opioid issues with a novel approach: coordinated multidisciplinary treatment. Under the lead of a pain psychologist, a team of physicians, pharmacists, physical therapists, dieticians and veterans suffering with chronic pain, worked together to find an individualized treatment plan for each veteran. With an outcomes based directive, we were able to use each health care service to its fullest potential and dramatically reduce not only opioid prescriptions, but reported pain levels and quality of life.

Federal health policy should strive to lower costs and improve outcomes. Rather than harm patients, outcomes based payment has proven to do both of these. Regardless of whether the political class choose to repeal, replace or repair the ACA; the next iteration of federal health care policy should build on previous successes, not make the underlying problem worse.


Author: Benjamin Kalinkowitz, PT, DPT, MPA is a recent graduate of the Masters of Public Administration program at the University of Nebraska at Omaha. He is also a practicing physical therapist in New Jersey. All views expressed are the author’s alone and do not necessarily represent a view of the Department of Veterans Affairs or any federal agency of the United States.

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