The 90-Day Prescription Isn’t for Everyone

As submitted to The Wall Street Journal in response to “The 90-Day Prescription Isn’t for Everyone”

February 19, 2020

To the Editors of the Wall Street Journal

Dr. Brian Barnett made an important point in his recent piece, (Feb. 6, 2020) “The 90 day prescription isn’t for everyone,” but the problem of matching treatment to patient is much larger than that, particularly in the issue of pain management, opioid prescription abuse and opioid addiction. As an orthopedic surgeon and possibly the only physician board certified in both orthopedic surgery and addiction medicine, I am on the front lines of advocating for major changes in treatment and payment methods.

In brief, treatment for abuse and addiction is stuck in the model of an initial, usually off-site, 28-day rehab period followed by a series of visits to health care providers. Providing care away from a patient’s everyday circumstances and subsequently returning the patient to those circumstances and expecting him or her to maintain the results of isolated treatment isn’t realistic. These patients are then required to attend additional medical appointments at a fee-per-visit rate, making each visit time consuming, expensive and difficult. Most patients don’t follow through.   

We have had great success by meeting patients close to home with an individualized treatment plan combining physical, biological, mental and pain management. Patients are able to attend the out-patient clinic for an entire year and make appointments at a time of day that works best for him or her, allowing patients to maintain their usual work and home schedule.  Instead of charging for each individual visit or treatment, we charge a capitated fee, that is, a per-person-per-year charge. Success, defined as freedom from abused substances 12 months after treatment, in traditional programs is a dismal eight to ten percent nationwide.  Without going into the detail about the medical complexities, in programs such as the one I describe, 100 percent of the initial group of patients were weaned off the dual use of central nervous system depressants and opioids and 100 percent successfully transitioned into a program where the medications they were using were below the Centers for Disease Control’s (CDC) recommended effective dosage. In this situation, “below” is where you want to be. That is, 100 percent of the pilot group were still considered a successful transition to lower or eliminated opioid use a year later.

Interestingly, Dr. Barnett identified insurance companies as the barriers to innovation. We have found the opposite. Some forward thinking insurers like Blue Cross/Blue Shield of Texas and Minnesota are supporting this new model. The national debate on opioid use and abuse and its tragic and widespread consequences seems stuck in “we need more money.”  Actually, because Congress has acted, lack of funds is not the problem. The problem is an unwillingness to embrace new treatment approaches. 

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