Whatever happened to the opioid crisis? Before coronavirus disease 2019 (COVID-19) became the issue of import, it was nearly impossible to pick up a newspaper or read a journal without some mention of opioid abuse, whether prescription or otherwise. Clinical Orthopaedics and Related Research® has published several papers on how we might reduce opioid use in our surgical patients, the use of multimodal approaches to pain, and the effects of laws on prescribing [10, 14, 17, 21]. Unfortunately, cutting back on what’s prescribed by medical professionals is not enough to solve the opioid crisis. Although it may be true that, as leading economist John Kenneth Galbraith once observed, “Nothing is so admirable in politics as a short memory” , physicians do not have that luxury.
So, whatever happened to the opioid crisis? Well, it never left. In fact, the FDA recently released new data showing that US drug overdose deaths reached an all-time high in 2019, outpacing the previous peak recorded in 2017 . As we see in this month’s Editor’s Spotlight/Take 5 on “What Is the Financial Impact of Orthopaedic Sequelae of Intravenous Drug Use on Urban Tertiary-care Centers” by Dwivedi and colleagues , orthopaedic surgeons continue to confront problems in providing care to patients who use illicit opioids.
It’s worth reviewing the history of opioids in the United States over the last two decades, since nearly 450,000 people have died from overdoses involving any opioid, including prescription and illicit opioids, during that time period . According to the Centers for Disease Control & Prevention, the rise in opioid overdose deaths came in three distinct waves. The first began with increased prescribing of opioids in the 1990s, with overdose deaths involving prescription opioids (natural and semisynthetic opioids and methadone) increasing since at least 1999 . The second wave began in 2010, with rapid increases in overdose deaths involving heroin  and occurred despite significant efforts to change prescribing habits. The wave we are now riding began in 2013, with increases in overdose deaths involving synthetic opioids, particularly those involving illicitly manufactured fentanyl [8, 12, 13]. Of particular concern, fentanyl now can be combined with heroin, counterfeit pills, and controlled substances, resulting in particularly lethal end products .
As orthopaedic surgeons, we’re not involved in the management of acute overdoses, or in trying to get patients who use intravenous (IV) drugs to “get clean.” But, as Dwivedi and colleagues  show here, we spend a great deal of time addressing infection. This is not surprising. Street drugs (according to data from American Addiction Centers ) are mixed with any number of substances, including baking soda, sucrose, starch, powdered milk, or warfarin. Needless to say, the manufacturing processes leave much to be desired in terms of cleanliness, let alone sterility. And people who use IV drugs may not use clean needles. Although there is evidence that needle exchange programs can make a difference for motivated individuals who use intravenous drugs and who want to use clean needles [7, 11], even for that group, it seems incredibly difficult to do—the locations are few and far between, and the hours are limited. Even the most motivated person is going to have a tough time if the only exchange site is miles away, and only open from 9 AM to noon every other weekday.
The end result? A complicated set of patients, with potentially life-threatening medical issues. And as we see in the article in this month’s CORR , almost none have insurance that covers the cost of their care. As is often the case, government payers (Medicaid, in the case of almost all patients as Dwivedi and colleagues note), cover only a fraction of the cost—meaning that the remaining costs are either shifted onto other patients, or absorbed by the institution.
Although every hospital faces the challenges of providing care for patients who use opioids, the care of patients who use IV drugs is particularly difficult. As it happens, “safety net” hospitals are the most affected because they tend to serve patients who are often disadvantaged socioeconomically, and because the care provided is costly. In this month’s Editor’s Spotlight/Take 5, we explore the financial issues of care for those who use IV drugs at two such hospitals, one in Boston, MA, USA and one in Cleveland, OH, USA.
Join me now for a Take 5 interview with Paul Tornetta III MD, the senior author of “What Is the Financial Impact of Orthopaedic Sequelae of Intravenous Drug Use on Urban Tertiary-care Centers.”
Take Five Interview with Paul Tornetta III MD, senior author of “What Is the Financial Impact of Orthopaedic Sequelae of Intravenous Drug Use on Urban Tertiary-care Centers?”
Paul A. Manner MD:Congratulations on this provocative paper. We often see calls from providers at safety net hospitals calling for more money, with the warning that the hospitals will be unable to provide care otherwise. If I were a policymaker, my question would be two-fold: “Are patients truly unable to obtain access because of reimbursement? And if not, why take more money out of a finite pot, meaning the money available for health care, for this?” To put it bluntly, they may say that if providers at safety net hospitals are going to provide care whether or not you get paid, why would I pay them?
Paul Tornetta III MD: Thanks for the question. This is basic economics and fairness. We care for many patients with no insurance as well and these individuals were not included in this series. The simple answer to the question is that it is not a reasonable expectation for a health system to lose money when taking care of publicly insured patients. It simply is not sustainable. The system must be financially stable to provide the highest levels of care. At my institution (Boston Medical Center), there is an expressed mission to care for the most-vulnerable population of patients in addition to providing the highest tertiary level of care for all patients. But if publicly insured patients impose a predictable, consistent financial loss to the system, the system will eventually have to make cuts that will affect the level of care, or not be able to provide care at all.
Dr. Manner:Following up on this, many of the facilities that now are safety net hospitals began as charity hospitals for indigent people, and they have had the specific mission of providing care to underserved patients. When Boston City Hospital (the precursor to Boston Medical Center) was founded 160 years ago, it “[… was] intended for the use and comfort of poor patients, to whom medical care will be provided at the expense of the city, and ... to provide accommodations and medical treatment to others, who do not wish to be regarded as dependent on public charity”. Is it possible to continue that tradition, while accepting that this care will not be lucrative?
Dr. Tornetta III: We do that now, and with great pride. Our hospital, from the C-suite to the medical campus, embraces our service to those who have less. Indeed, it is part of our mission, to make Boston the healthiest urban population. The question is not whether this care should be lucrative. It will never be that. It does, however, have to be compensated at a rate that allows for the institution to continue its mission. Additionally, our study only examined hospital finances, specifically excluding professional fees for all physicians involved in the patients’ care. Professional fees would be an additional stress on the system, considering that for many of the Medicaid products, the fees paid to the physicians are not enough to support their practice expenses. It is common to have physicians receive no money even if the hospital is paid something. With very low physician fee schedules, it will be harder to get physicians to care for these patients unless the hospital or system supplements their income, further stressing hospitals with a high proportion of Medicaid patients for whom they are already not fairly compensated. This, too, is a real problem in systems that require revenue to cover expenses, as our system does. Boston Medical Center and Cleveland Metro are quite lucky in having dedicated faculty who accept this and still provide the highest levels of care. This does not mean that it will always be the case. Ideally, systems should provide fair compensation to safety net hospitals and physicians working there. Anything else serves to create a substantial disincentive for all involved to work at these hospitals. Hospitals, I would add, that most need the highest quality physicians and staff.
Dr. Manner:The concept of a Medicaid Accountable Care Organization is a good one—consolidate care under one virtual roof, provide a dependable portal, and save money by reducing waste from duplication or loss of care. But they don’t seem to do very well in real life [9, 16, 20]. Should we look at other care models? Since we have finite resources, are there other ways to provide care that is equitable and fair, but which doesn’t sacrifice quality and innovation?
Dr. Tornetta III: I generally agree with your opening line. The concept is a good one if the funding is fair and reasonable. My belief is that failures in these environments are multifactorial and exceedingly complex. In my experience, most costs incurred for caring for a population are spent on around 5% of any captured group. The issue then becomes dropping costs for about 5% to 15% of the population in order to make ends meet, so to speak. We have some very bright people working in population health and some innovative practices in this arena. One example is the use of care managers for the highest health utilizers. They attempt to prevent hospitalizations and help patients maintain health rather than provide episodic relief of conditions that often are neglected. There is a real attempt to teach better health literacy and support better preventive health measures. This program has tremendous potential, but it cannot care for the needs of all patients. In particular, patients who are addicted to IV drugs frequently are not domiciled and are not necessarily able to take advantage of these programs. We do have a large addiction center with people working on this problem, but solutions won’t come quickly, or easily. Efforts to defeat addiction must be supported if safety net hospitals are to be financially viable.
Dr. Manner:The idea of an outpatient wound clinic is intriguing. During my training, we had a leg ulcer clinic that was staffed by residents, but really run by an old-school nurse. It seemed to work, in that it provided good care to the patients who attended but I do not know how it did financially, or how one might apply a model like that for those who use IV drugs. If you were given reasonably free rein, how would you do this?
Dr. Tornetta III: We do a fair amount of this now. There are several areas in the hospital where emergency department physicians and staff see patients with these problems. I would say that we are reasonably successful in this. However, regulations now preclude “resident” clinics. All patients must be seen by an attending physician or other licensed provider in the outpatient and inpatient setting. That said, we had success during the COVID-19 surge in Boston running a wound clinic in our department, and the emergency department in theirs. I believe that this is a part of the solution. It does not, however, speak to the failure of reimbursement what we found in our study as no outpatients were included in the study. We likely treat many more patients who use intravenous drugs and who have cellulitis and abscesses as outpatients in the manner you refer to than we do as inpatients. The problem is the inpatient population as the actual cost of care is not covered (as we detailed in our study ).
Dr. Manner:Although your study was conducted at urban safety net facilities, you made the case that, "The high proportions of under- and uninsured patients within the IVDU patient population are challenges likely faced by a broad range of medical centers throughout the country" . What mechanisms do you believe would be most helpful for smaller/rural centers dealing with this issue?
Dr. Tornetta III: I think this is something that other centers do face, but with smaller numbers. Ideally, centers set up to handle these problems should probably be the center of care, and be reimbursed at a reasonable rate to do that. Alternately, the solution for all centers would be for public insurance to cover the costs of care as private commercial insurers do. We, as a society, want everyone to have coverage, but coverage that does not actually support care is not going to be sustainable. I believe that if everyone had “universal coverage” or “indigent care coverage” the system would fail, and I don’t think most taxpayers or voters realize it. The main purpose of our paper was to raise this discussion. Don’t get me wrong, there are no simple solutions, and drug addiction is a horrible problem that likely will never go away. However, we must remain vigilant in looking for solutions to the addiction, and the cost of care for those who are addicted. Our hope is that this paper  shows that even looking only at the orthopaedic manifestations of this problem, the cost of care is not covered by public insurance.
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