For the past several years, our partners at the American Academy of Orthopaedic Surgeons (AAOS) have invited NAON leadership to participate in the National Orthopaedic Leadership Conference (NOLC) in Washington, D.C. A highlight of this event was joining colleagues from various orthopaedic-related organizations on visits to United States Senate and House of Representative offices to discuss concerns related to orthopaedic practice and patient care. The focus of these meetings with Congressional members and their staff centered on three core problems: opioid abuse, regulatory burdens impeding the provision of timely care, and the ability of providers to respond to emergency medical care needs during national disasters. Each of the issues addressed this year at NOLC is pertinent to NAON. They have bearing on both safety and access to care for orthopaedic patients.
The Centers for Disease Control and Prevention (CDC) recounts that between 2015 and 2016, opioids were involved in the deaths of more than 42,000 Americans (CDC, 2018). Opioid-involved deaths reached their highest rates in 2016 with sharp increases from 2014 through 2016 (Seth, Rudd, Noonan, & Haegerich, 2018). The persistent opioid epidemic has been declared a public health emergency. Pharmacy and payer dispensing constraints have been instituted. States have responded by imposing prescribing limits and national prescription limits are expected to be enacted in the future. Yet it is essential that national standards be developed with care. Pain management for acute musculoskeletal injuries and major surgical procedures requires a different approach than pain management for chronic conditions. A one-size-fits-all methodology is not appropriate.
Additional recommendations presented included the promotion of e-prescribing, improved care coordination platforms that enable physicians and pharmacists to see all prescriptions in all states in which a patient may have filled them, removing payer payment constraints that prevent the use of nonopioid multimodal pain management, additional research into new pain management therapies, meaningful education to patients and prescribers, care with mandatory pharmacy lock-in programs that may impede patient access to needed medication, and exploration of more effective take-back and disposal mechanisms (AAOS, 2018a).
The implications for orthopaedic nursing practice in alleviating the effects of the opioid crisis, while supporting the pain management needs of patients, are significant. As frontline care providers, orthopaedic nurses are acutely aware of the demands of effective pain management and realize that opioids are a necessary means to help alleviate discomfort. As pivotal members of the healthcare team, nurses' involvement in the development of evidence-based, standardized pain management protocols in our areas of practice is crucial. Assessment for potential opioid misuse is important in preoperative screening and optimization. Preprocedure opioid dependence has been shown to be correlated with increased inpatient mortality and morbidity. Complications encompass respiratory failure, altered mental status, surgical site infection, pneumonia, myocardial infarction, postoperative ileus, and postoperative mechanical ventilation required (Menendez et al., 2014). Screening patients for opioid abuse and postponing elective surgery until resolved should be advocated.
The orthopaedic nurse's role in patient education cannot be overemphasized. Educational efforts must take into account the challenges of patients challenged by basic health concepts and who are unable to make proper decisions about health-related activities. Low health literacy is correlated to opioid abuse in orthopaedic patients and 22% of orthopaedic patients may be affected by low health literacy, per responses to a standardized screening inquiry (Hadden, Princy, & Barnes, 2016). Difficulty grasping the concepts of how to take medications correctly elevates the hazard of opioid misuse. Patient education materials need to be easy to understand with clear directions on exactly how to administer, store, stop, and dispose of medications.
Another item for discussion, in the NOLC meetings, was the burden of healthcare regulation and the impact on provision and access to care. The Stark Law was enacted in 1989 as part of the Ethics in Patient Referrals Act. The original intent of the law was to prevent providers from referring patients to entities from whom they would benefit monetarily. This "antikickback" provision with removal of financial incentive seemed to be a straightforward method of protecting Medicare patients from unnecessary utilization and fraud. However, over the years, the Stark Law has become increasingly complex. With today's healthcare transformation from fee-for-service to outcome-based pay-for-performance and value-based reimbursement, the current law is obsolete. Coordination of care for orthopaedic patients should be driven by quality and the needs of patients, rather than hindered by this regulation.
Physicians, office staff, nurse navigators, case managers, surgical schedulers, and others involved in orthopaedic care settings are keenly aware of the time spent working to obtain insurance prior to authorizations for procedures, medications, equipment, and services for patients. The time spent in prior authorization activities could be better spent in patient care and may even delay the provision of needed care. Practices and standards vary among insurances and there is no uniformity for turnaround time on requests, submission methods, evidence-based criteria, or ways to appeal denials. The AAOS urges that requisites for automation of processes and standard specifications be enacted (AAOS, 2018b).
The third topic on the table was Legislation on the Good Samaritan Health Professionals Act (Good Sam HPA). This provision was introduced in 2017 and is slated for congressional action. The United States and territories have experienced a number of natural disasters and public health emergencies in the past year. In these events, a coordinated emergency response is well served by orthopaedic surgeons and licensed volunteers including nurses, emergency medical technicians, and paramedics with expertise in caring for musculoskeletal injuries. However, state and federal laws offer narrow liability protections for health professionals crossing state lines. Working in suboptimal conditions and triage decisions that patients may not understand, create potential for litigation, if outcomes are unfavorable. The Good Sam HPA will ensure that licensed healthcare professionals volunteering to provide medical services, during federally declared disaster events, will be covered by liability laws in the state in which they are providing care to disaster victims. The law would shield healthcare professionals from liability, as long as they are acting in good faith (Congress.Gov, 2018). This ruling will also help ensure that enough healthcare professionals volunteer in public health emergencies, rather than avoid serving those most vulnerable.
Stay tuned for new developments as discussions on these questions unfold on the national level. Opioid regulations are taking hold and will continue to influence our practice, perceptions, and experience of our patients. Regulatory constraints are recognized as needing reform: as of this writing, CMS has begun to seek broad input on how the revisions to the Stark Law would facilitate better care coordination, and CMS Administrator, Seema Verma, has stressed that innovative strategies are needed to make providers and patients the driving forces of care (Dyrda, 2018). The experience at NOLC offered a glimpse into decision making at the governmental level. It is evident that the experience of clinicians and the advocacy of professional healthcare organizations can work to influence public policy by communicating positions on current matters directly to members of Congress.
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