OREGON’S CONTROVERSIAL “REVISED” PAIN PROPOSAL coming close to a final Vote by HERC

Two important meetings are on the horizon, let’s get this out of the way first;

The next meeting of the Value based Benefits Subcommittee (VbBS) will be on January 17, 2019. The VbBS is one of three subcommittees inside the Health Evidence Review Commission (or HERC for short). While both HERC and the VbBS will be meeting on January 17, only the VbBS will discuss the proposal submitted by the task force. The VbBS will be meeting from 8am-1pm and HERC in the afternoon 1:30pm — 4:30pm, but the HERC is not scheduled to discuss the proposal until their March meeting

VbBS January 17th from 8am-1:00pm PST.

Location: Wilsonville Holiday Inn, Dogwood Room 25425 SW 95th Ave, Wilsonville, Oregon 97070

Details are posted at least 28 days in advance of the meeting. Webinar Registration URL: https://attendee.gotowebinar.com/rt/7009899392791501315

And

HERC VOTE March 14th 1:30pm-4:30pm PST.

Location: Human Services Building, 500 Summer Street NE, Rooms 137A-D, Salem Oregon 9730

Details are posted at least 28 days in advance of the meeting.

Public listen-in only line: 1–888–204–5984, participant code 801373

Webinar Registration URL: https://attendee.gotowebinar.com/rt/4563145172385374211

The confirmed plan is for the Chronic Pain Task Force’s proposal to be presented to the VbBS for acceptance or non acceptance. (The revised proposal received strong objection from the community as well as esteemed experts around the Country. Regardless, it’s scheduled to move forward to the VbBS.) If the VbBS accepts the CPTF proposal as is, on January 17th it will go to the HERC for a vote, but they won’t address it until the March meeting.

HERC is set to vote March 14th 2019. If the VbBS does not accept the proposal as is, it is unclear what proceeds thereafter. Keep in mind, there are numbers of shared seats on both the VbBS and the CPTF, this is a concern. However, HERC’s deadline to vote is March, so they don’t seem to have the option to put it off. From everything we’ve been told, they will vote in March.

Since these meetings seem to leave little time for HERC to change or revise the proposal, we are confused about what to expect. Typically, the VbBS would accept a proposal and then deliver it to the HERC for vote on the same day leaving time for revisions, but in this case, the HERC has decided not to address the proposal until March. The HERC is not scheduled to receive the Chronic Pain Task Force proposal until the same day as the vote. What does this mean? This is not the normal process, so we can only speculate. March 14th in the afternoon the HERC will meet and vote. Similar to shared seats with the CPTF and the VBBS, please note shared seats with the HERC as well.

The revised proposal by the CPTF can be found in the links below.

Oregon’s unprecedented Medicaid proposal by the Health Evidence Review Commission and its ad hoc Chronic Pain Task Force posted online — its “revised” proposal one week before the last CPTF meeting December 5th 2018. The long awaited revised proposal was meet with criticism from the pain community and professionals alike. In the words of most pain patients, it was a token gesture. The policy still includes state mandated forced tapers to zero. If passed, certain conditions that move above the lines who previously had opioids covered will be without the ability to obtain their opioid medication, even if the caring physician disagrees.

Even though the policy still includes involuntary tapers to zero, the task force did change the language slightly regarding the timeframe. The Task Force added options for a taper to take longer than a year, this being the Patient / Doctor centered token gesture. However, they issue a recommendation of 10–5% a month. Some limited number of patients who meet strict criteria and have a covered conditions will be able to continue on some semblance of opioid therapy but only at a 50MME limit a day. And only if meeting a required 30% improvement. Furthermore the exclusion of centralized pain, which is confusing to doctors and to the task force who could not figure it out during their meeting because it’s more of a symptom than a diagnosis and could include almost all chronic pain conditions- since pain originates in the brain, was included as non-covered for opioid therapy, with fibromyalgia and other painful conditions that do in fact sometimes benefit from ongoing opioid therapy. The CPTF proclaimed opioids are harmful for conditions like fibromyalgia, moved fibromyalgia above the line for alternative services but removed coverage for opioids altogether. There is no good evidence that opioids are harmful for the conditions of fibromyalgia. Again, this is the human body and we are all unique. There is actually a study that they acknowledged during the last meeting that proves Tramadol (an opioid) is effective for fibromyalgia.

The task force contracted a review of their evidence from the OHSU, and the review came back showing their evidence rated as poor to very poor quality with some of the evidence noted as having a high risk of bias. In fact some of the studies they used actually supported the use of opioid therapy. It is my opinion, these are ideals of the task force members, that aligned with the ideals of the HERC and the OHA. The OHA’s Patrick Allen has not minced words about his ideals on this topic (please see the WSJ article “ Oregon’s Opioid Abuse Policy is the right one“) The title sums it up. For conditions that they move above the line, continuity of analgesic medications will be threatened. Stable patients who would not otherwise have their medication removed, would so under this blanket proposal.

The Oregon Medical Association attended the December 5th CPTF meeting and read a statement of concern, the OMA was not allowed to read the entire letter but was restricted to the allocated time of exactly 3 min to testify. 3 minutes for a caregiver who beautiful illustrated the drastic health coverage contrast of caring for two individuals with severe chronic illness, one on Medicaid and one on Medicare. The director of the HERC Darren Coffman an actuary, made sure to raise a sign when each speaker reached a 1 min mark, 2 min mark etc until time was up. There was so much confusion that we asked if we could ask questions during our testimony time, but our request was denied.

In short, the controversial portion of the plan forced opioid tapering is unchanged. The relevance of it being a year, two years, three months is not the issue. The issue is forcing stable patients whose doctors have medically justified the use of these medications for their patient, will be instructed to force their patients either down or off all analgesics, based on nothing more than blanket policy for all on Medicaid that is not supported by one piece of good evidence. An approach not supported by data, not supported by CDC Guideline, by Canadian Guideline, and not even by the fairly aggressive VA/DoD Guideline. The proposal will have a disproportionate negative impact on patients with severe disabilities in economic hardship. It is not the responsibility of these medically fragile Medicaid patients to bear the weight, of a flawed and dangerous policy that in large part intends to use it to reduce prescribing rate in the state.

The back and neck lines, phase one that began in 2016 and did allow exceptions have not been thoroughly studies for harms. There is a study being conducted presently by PCORI. Cat Livingston a HERC voting member is one of the lead scientists on this study. Cat Livingston is able to vote on a state policy and also study its affects. Please keep this in mind, when looking over this study in the links bellow. She is one of the members who is completely content with passing the proposal with poor to very poor possibly bias evidence. In fact no one on the task forced raised any objection to passing the proposal without good evidence.

Oregon has many onion layers, the deeper one goes the more questions arise. There is great concern with oversight and accountability in this health organization by those who reside in Oregon and experts. It is critical that bias and agenda does not influence the health care of millions of Oregonians. Aside from the CPTF, Oregon has other high influencers in making pain policy that have raised ongoing concern. Some include the Oregon Health Authorities Pain Management Commission, Oregon Pain Guidance and its OrCRM, the PDMP Advisory Commission and its subcommittee. Advocates and experts will continue to investigate bias agenda and conflict of interest in the state of Oregon regarding pain care. These lives are as important as all others. These lives deserve respect and dignity like any other group of people with health challenges, disabilities or economic challenges.

Oregon currently has the reputation for being the worst state for chronic pain care nationally, if this Medicaid proposal passes it will be the nail in the coffin for thousands. Many cannot afford to flee the state, many will be left to suffer in agony. Families will be destabilized and many vulnerable innocent people will fall through cracks of the system. If we have an overwhelming number of experts warning the task force of harms this policy will create and yet the task force proceeds, then the state and Governor should do an extensive external and internal investigation of these institutions. Given it has already gotten to the point it has, should warrant an investigation immediately.

Task Force Members include:

  • Task Force Leader; Ariel Smits MD (VbBS lead staff)
  • Laura Ocker, Acupuncture (State lobbyist for Acupuncture, instrumental in getting acupuncture services reimbursement from state and federal/ OHP)
  • David Eisen, Acupuncture
  • Ben Marx, Acupuncture (instrumental in getting acupuncture services reimbursement from state and federal/ OHP)
  • Mitch Haas, Chiropractor
  • Holly Jo Hodges, Osteopath (Voting member of HERC and member of the VbBS)
  • Nora Stern, Physical Therapist (Lead staff of the OHA Oregon Pain Management Commission)
  • Andrew Gibler, Pharmacist
  • Tracy Muday MD
  • Amber Rose Dullea (“pain patient representative”) pain couch, operates web site called thriving with pain.
  • David Sibell MD
  • Jim Shames MD (Founder Oregon Pain Guidance)
  • Cat Buist, PhD (Former Lead staff of the OHA Oregon Pain Management Commission)

New Members added for only September CPTF meeting, did not attend the December 5th meeting:

  • Amanda Risser MD (with addiction specialty)
  • Jessica Gregg MD (with addiction specialty)

Keep in mind, the policy proposal must pass two phases, acceptance by the VbBS and a vote by HERC.

Members of the CPTF who also sit on the VBBS; Ariel Smits MD is the lead staff of the VbBS. Holly Jo Hodges MD.

Member of the CPTF who also sit on the HERC board with voting privileges; Holly Jo Hodges MD. Kevin Cuccaro was recently added as Staff of HERC it is unclear if he has voting privileges.

Amara

Co Founder Oregon Pain Action Group. Senior Patient Advocate, Oregon Legislative Coordinator for The Alliance for the Treatment of Intractable Pain

Please watch the in depth presentation by filmmaker, investigative reporter and pain patient advocate Caylee Cresta. Part one of an ongoing series about Oregon’s Pain Crisis.


For further information or to join the fight for ethical medical pain care in Oregon free of corruption, visit the Oregon Pain Action Group on facebook:

https://www.facebook.com/groups/oregonpainactiongroup/about/



Voting member of HERC Cat Livingston MD: https://www.youtube.com/watch?v=u8-tct6xNzI

Study on OR Medicaid Lynn Debar PhD and Cat Livingston MD https://www.pcori.org/research-results/2017/testing-one-states-effort-prevent-unsafe-treatments-patients-back-pain

https://www.statnews.com/2018/12/06/overzealous-use-cdc-opioid-prescribing-guideline/

http://nationalpainreport.com/opinion-open-season-on-the-poor-and-medicaid-population-in-oregon-8836804.html

Oregon Advocate Youtube links to meeting audio recordings of the CPTF: https://www.youtube.com/channel/UCwwRwdzNuyp5I_TN2gQZ33w