Medicare payments favor opioids over alternatives, and that’s a problem

By Angelarosa G. DiDonato

Our country in struggling with an opioid epidemic. An estimated two million Americans suffer from opioid use disorder, and opioid overdoses kill more than 130 Americans each day, on average.

Studies show that opioid addiction can occur from the very first exposure --- and sometimes, that first exposure may be during anesthesia for a necessary surgical procedure.

Certified Registered Nurse Anesthetists (CRNAs) operate in every setting where anesthesia is administered: hospital operating and delivery rooms; ambulatory surgical centers; the offices of dentists, podiatrists, ophthalmologists, and plastic surgeons; pain management centers and more. With such widespread influence among so many health-care settings, CRNAs play a major role in curtailing the opioid epidemic. We understand the risks and effects of the medications we administer, which is why we’re changing the way we operate. Nurse anesthetists today can manipulate their anesthetic to provide narcotic-sparing and often narcotic-free anesthesia. Our nation’s health programs should be doing the same. Unfortunately, federal regulations from the Centers for Medicare and Medicaid Services (CMS) fail to address a number of outdated regulations that put Pennsylvania’s pain patients in harm’s way. Over the last decade, many non-opioid pain treatment options have been developed, including single-dose injectables that release slowly over the course of up to 90 hours. For many patients, these promising alternative therapies can take the place of traditional more-addictive opioid painkillers. However, CMS rules fail to adequately cover the cost of administering these medications, leaving Pennsylvania’s more than 2.7 million Medicare beneficiaries without the option of affordable, non-addictive pain treatment. In a decade that saw drug overdose deaths skyrocket across the nation, Pennsylvania was among the worst in mortality increases, according to the U.S. Centers for Disease Control and Prevention. Last year, 4,125 Pennsylvanians died, according to the state Department of Health, and two-thirds of those deaths involved opioids. Recently, drug overdoses have spiked in Pennsylvania, with the rise coinciding with stay-at-home orders brought on by COVID-19. Treatment centers closed and counseling and support-group sessions went online. The stress and social isolation of being stuck at home also created a dangerous environment for those suffering from opioid use disorder. Beyond the human toll, the costs of opioid addiction are staggering. The CDC estimates the misuse of opioids costs our nation $78 billion annually in lost productivity, health-care services, addiction treatment, law and justice, and much more. Making alternative treatments more affordable and accessible can make a big difference. National studies suggest a 10 percent reduction in surgery-related opioid prescribing will result in 300,000 fewer people annually developing an opioid addiction, and keep over 330 million opioid pills out of American households, where they are often stolen or abused. These aren’t just numbers on a page --- they speak to lives saved, families preserved, and bright futures kept intact. Given the very real risks of opioid medications and the severity of Pennsylvania’s addiction crisis, we can’t wait to act. Antiquated federal regulations have helped to create our nation’s over-reliance on opioids, which remain the cheapest option for health-care providers because of how insurance payments are administered under the current Medicare reimbursement rule. The federal NOPAIN Act, which has bipartisan congressional support, would change that by requiring Medicare to cover non-opioid treatment alternatives for all Medicare recipients. It’s as simple as that. As a nurse anesthetist who specializes in anesthesiology and non-opioid therapies, I’m worried. I know all too well that legal opioid prescriptions and an over-reliance on pain management with narcotics too often can lead patients down a path of years-long addiction. There is only so much I can do in the operating room. We need help fixing laws that discourage alternatives to have a fighting chance. Passing the NOPAIN Act is a critical step in combatting the addiction epidemic nationwide and deserves our support. Angelarosa DiDonato, DNP, CRNA is president of the Pennsylvania Association of Nurse Anesthetists, online at https://www.pana.org.

PANA Supports Members’ PPE Needs by Purchasing Masks

Pittsburgh TV station WTAE-TV 4 (ABC) recently featured a piece about the Pennsylvania Association of Nurse Anesthetists (PANA) investing $40,000 to purchase 1,000 masks for certified registered nurse anesthetists (CRNAs) working on the frontline of the COVID-19 pandemic.

Personal protective equipment (PPE) is crucial for CRNAs, and the shortage of some material has been alarming. CRNAs often work with patients’ airways and perform intubations and other procedures. COVID-19 is a respiratory pandemic that is spread through coughing or sneezing, so our members are up close and at great risk.

To protect its members, the PANA board voted in March to have masks made for members who need them, or for those who may have been working in facilities where PPE was limited or quantities were diminishing. The focus was on those in hospitals in direct response and others in high-need areas.

All of this came after guidance came from the federal government that during shortages, any facial covering, even a bandanna, would be better than nothing.

At first, PANA allocated $20,000 for a first run of 500 masks. That first run was nearly accounted for in 48 hours. (CRNAs were made aware of the masks via email.) The board then allocated another $20,000 for 500 masks. All told, PANA is investing $40,000 for 1,000 masks.

These are not basic cloth masks, but rather advanced prototypes. The masks have been innovatively designed after extensive review of a variety of mask prototypes used by healthcare professionals. The masks are reusable and feature a filter, with three replacements.

The manufacturing is being done through a vendor from Evans City --- Ifft Enterprises, LLC, in Evans City in western Pennsylvania. Among the first order, and this is a large order, about 61 percent of the masks were manufactured in Evans City; the balance were made in Michigan by a subcontractor Ifft Enterprises works with during periods of high demand.

Each CRNA must request the mask individually. The manufacturer then ships the masks directly to the CRNA. But PANA is underwriting the full cost --- both manufacturing and shipping.

We are proud of the work CRNAs are doing to respond to this crisis and remain committed to doing all we can as an association to keep our CRNAs healthy and safe so they in turn can keep patients healthy and safe.

CRNAs Respond to COVID-19 Pandemic

As our country and the commonwealth continue their aggressive measures to stem the spread of the coronavirus (COVID-19), Pennsylvania’s certified registered nurse anesthetists (CRNAs) are taking action to ensure public health and safety.

As the hands-on providers of anesthesia care, operating safely in every setting where anesthesia is administered, CRNAs, like so many other health-care professionals, are on the frontline. That makes the profession a critical part of the national response.

“CRNAs hold leadership positions in their institutions of care and help to create policy about how best to protect fellow providers and patients,” said Angelarosa G. DiDonato, DNP, CRNA, president of the Pennsylvania Association of Nurse Anesthetists (PANA). “Our top priority is always public health and safety.”

As a precaution, many Pennsylvania hospitals are choosing to cancel elective cases requiring anesthesia, except where a condition is emergent or urgent and essential to the health of the patient. All decisions are made in consultation and coordination with patients and surgical teams.

CRNAs also are changing the way they work with patient airways, as COVID-19 is a respiratory illness that is characterized by mild to severe symptoms, including fever, cough, shortness of breath, and breathing difficulties.

The American Association of Nurse Anesthetists (AANA) is providing resources to support CRNAs as they develop strategic steps for managing patients with expected or confirmed infection. These tips go beyond meticulous hygiene and strict environmental cleaning and disinfection procedures to intubation and aerosolization techniques.

Excellence in care, safety, and continuous improvement of care are hallmarks of the anesthesia profession.

In Pennsylvania, the Department of Health is reporting new cases daily, which means everyone has a role to play. Remember these simple tips to protect yourself, your family and your community:

• Wash your hands often with soap and water for at least 20 seconds.

• Clean and disinfect frequently touched objects and surfaces.

• Avoid touching your eyes, nose and mouth.

• Avoid crowds and stay home, even when no exhibiting signs and symptoms.

• If you must work or be in public, follow guidelines for social distancing (stay six feet others).

Thank you for all you do always, but especially in times of crisis like we face together today. Be smart and be safe. Don’t hesitate to contact PANA with questions.