Oregon Health Commission

[jimmy johnson123]

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Can anyone tell me why there are 3 acupuncturists, 1 Chiropractor and only one "Anesthesiologist" involved with making "evidence based" decisions for the Medicaid Program?

Clearly there is zero evidence for acupuncture and Chiropractic "energy" or other quackery yet they are on the board.

After reading Dr. Russo's post about quackery in Oregon, I was curious to know why Pain Medicine is represented only by a "Dr Kevin Cuccaro"

He seems to offer nothing to patients outside of "stress relief" or some other nonsensical program and rejects anything conventional in medicine as being "wrong". He actually sells a "video program" that will solve "all pain" without medications, surgeries, injections, etc that are all "useless" for only 187 dollars per year.

According to his background, he isn't board certified in either Anesthesiology nor ABMS Pain Subspecialty. His only "contribution" to the field is that nothing in conventional medicine works and "acupuncture" causes "scar tissue to decrease" in his blogs.

Please tell me this isn't real?

 

[painfree23]

Wow.

 

[onewithpain]

Kevin used to contribute here but I don't remember his forum name. He did anesthesiology and a pain fellowship in Michigan and then had a Navy obligation. He started what I thought would be a great practice and then after about a year said that there was no evidence to support what we do. He said something about a non-compete keeping him from going back to gas.

The truth is that you can find "evidence" to support whatever you want, especially if you ignore the evidence that you don't like. But that is more of the law school approach in that you present your argument and make a point of not mentioning your opponent's argument. I always thought that in medicine it was our job to use the evidence to better define what can help our patients.

 

[drusso]

Can anyone tell me why there are 3 acupuncturists, 1 Chiropractor and only one "Anesthesiologist" involved with making "evidence based" decisions for the Medicaid Program?

Clearly there is zero evidence for acupuncture and Chiropractic "energy" or other quackery yet they are on the board.

After reading Dr. Russo's post about quackery in Oregon, I was curious to know why Pain Medicine is represented only by a "Dr Kevin Cuccaro"

He seems to offer nothing to patients outside of "stress relief" or some other nonsensical program and rejects anything conventional in medicine as being "wrong". He actually sells a "video program" that will solve "all pain" without medications, surgeries, injections, etc that are all "useless" for only 187 dollars per year.

According to his background, he isn't board certified in either Anesthesiology nor ABMS Pain Subspecialty. His only "contribution" to the field is that nothing in conventional medicine works and "acupuncture" causes "scar tissue to decrease" in his blogs.

Please tell me this isn't real?

You're conflating two groups:

1) The Oregon Pain Management Commission exists to provide guidance to the state legislature on matters related to pain management

Oregon Health Authority : Pain Management Commission Members : Oregon Pain Management Commission : State of Oregon

2) The Oregon Health Evidence Review Commission exists of members appointed by the Governor to review and approve clinical practice guidelines for the Oregon Medicaid Program

Oregon Health Authority : About Us : Health Evidence Review Commission : State of Oregon

The politics around pain in Oregon, as most places, are very complicated. There has been a push to adopt a population-based health orientation to the management of chronic pain without much consideration of whether or not pain is a population illness. This is the classic mis-application of knowledge from one domain to another: Maybe managing pain is like managing diabetes? Or, maybe managing pain is not a single bit like managing diabetes and mis-applying tools and knowledge from the domain of diabetes to pain is a fool's errand...in other words, "the map is not the territory."

Similarly, there is a misguided understanding about what happens when you expose a large population to opioids and then take them off. Going from "A" to "B" and back to "A" is not the same as never going from "A" to "B" in the first place. This is the classic "round trip fallacy." In this vein, Oregon has chronically underfunded mental health and addiction treatment for generations. The idea that a Government, by fiat, can taper off people who have been made opioid tolerant for years without a plan "B" for dealing with the consequences (like paying for more addiction treatment or mental health services) is nothing short of negligence and I wonder if the OHA might be unwittingly setting itself up for a large class-action law suit. I can see the late night commercials, "I was doing fine on my meds until Medicaid told my doctor to take them away..."

Finally, Oregon is the land of "circular firing squad." It loves "grand experiments" that often cost tax-payers hundreds of millions of dollars and yield pretty predictable results:

Oregon Medicaid health experiment - Wikipedia

 

[jimmy johnson123]

Why would they appoint a non boarded "pain physician" who is hostile to all of conventional medical practices coupled with 3 acupuncturists and a Chiropractor to determine the "best evidence based practices"?

Clearly there is no concern for "evidence" but some kind of weird liberal agenda out of Oregon.

 

[jimmy johnson123]

Kevin used to contribute here but I don't remember his forum name. He did anesthesiology and a pain fellowship in Michigan and then had a Navy obligation. He started what I thought would be a great practice and then after about a year said that there was no evidence to support what we do. He said something about a non-compete keeping him from going back to gas.

The truth is that you can find "evidence" to support whatever you want, especially if you ignore the evidence that you don't like. But that is more of the law school approach in that you present your argument and make a point of not mentioning your opponent's argument. I always thought that in medicine it was our job to use the evidence to better define what can help our patients.

The guy only practiced for 2 years in any attending position after fellowship and then just quit to make "pain" videos with no renewal of either his anesthesiology or pain boards whereby he charged $187/year on some weird quackery stuff.

That has got to be the strangest career in medicine I have ever seen. Why would he quit anesthesiology fully as well and only work for 2 years in conventional medicine to quit and just do some video stuff?

Also, the video nonsense he promotes appears to be just some random stress relief stuff but nothing ground breaking or substantive.

Also, how did he become the "expert" considering he isn't even boarded or have really much experience in any field of medicine. Are there not better candidates that are actually board certified with more than 2 years of experience as an Attending?

 

[onewithpain]

He is an expert because he says what the Oregon Health Authority wants to hear.

 

[jimmy johnson123]

He is an expert because he says what the Oregon Health Authority wants to hear.

Thats correct.

He actually says nothing when I look at his blog. He has some nonsense triangle thing about a fire and pain whereby he says "buy my video for 187 for a year" which states some gibberish about yoga.

Who quits anesthesiology and subspecialty medicine ENTIRELY to go make blogs about some triangle of "pain" and yoga nonsense?

I figure he wasn't very popular with patients and blamed other pain docs for being "unscrupulous" out of jealously and went on a warpath (not that there aren't dishonest pain docs out there making good money). His bizarre behavior doesn't make sense logically and there is more to his story.

Maybe pain docs can make an acupuncture mill now to cover Medicaid patient costs since that appears to be "evidence based" now lol

 

[Ducttape]

Similarly, there is a misguided understanding about what happens when you expose a large population to opioids and then take them off. Going from "A" to "B" and back to "A" is not the same as never going from "A" to "B" in the first place. This is the classic "round trip fallacy." In this vein, Oregon has chronically underfunded mental health and addiction treatment for generations. The idea that a Government, by fiat, can taper off people who have been made opioid tolerant for years without a plan "B" for dealing with the consequences (like paying for more addiction treatment or mental health services) is nothing short of negligence and I wonder if the OHA might be unwittingly setting itself up for a large class-action law suit. I can see the late night commercials, "I was doing fine on my meds until Medicaid told my doctor to take them away..."

so when these patients come to your office demanding that you prescribe their vicodin/oxycodone/oxycontin, by this default argument, you are forced to prescribe? it wasn't their fault, but they were put on it, and as a practicing physician, you are essentially required to keep them on what they want or get sued?

how does that not make you in to a drug dealer?

 

[onewithpain]

I don't think that an obligation to treat equates with an obligation to prescribe opioids. In my county the OHA provides PCPs with a long list of alternative treatment options. The only thing that is paid for is the list. The PCPs are supposed to educate themselves and their patients about available resources and then guide the patients through those resources. Simply put, it doesn't happen.

When I moved here 10 years ago Vicodin was OHA's #1 prescription expense. They wouldn't cover anything that I do then and won't now, except for the little tap dance I do while I apologize. They would pay for spine fusion for mechanical spine pain. Now they cover nothing except for experts like Dr Cuccaro to come and speak to us. If he were in my county I would happily refer to him.

 

[drusso]

so when these patients come to your office demanding that you prescribe their vicodin/oxycodone/oxycontin, by this default argument, you are forced to prescribe? it wasn't their fault, but they were put on it, and as a practicing physician, you are essentially required to keep them on what they want or get sued?

how does that not make you in to a drug dealer?

I want you to read what you wrote out loud and slowly...I don't want any unelected bureaucrat telling any doctor how to treat patients.

 

[jimmy johnson123]

I don't think that an obligation to treat equates with an obligation to prescribe opioids. In my county the OHA provides PCPs with a long list of alternative treatment options. The only thing that is paid for is the list. The PCPs are supposed to educate themselves and their patients about available resources and then guide the patients through those resources. Simply put, it doesn't happen.

When I moved here 10 years ago Vicodin was OHA's #1 prescription expense. They wouldn't cover anything that I do then and won't now, except for the little tap dance I do while I apologize. They would pay for spine fusion for mechanical spine pain. Now they cover nothing except for experts like Dr Cuccaro to come and speak to us. If he were in my county I would happily refer to him.

He doesn't see patients though lol

He just makes magical videos for a low price of 187 per year to solve all pain problems from vertebral fractures to spinal stenosis.

 

[Ducttape]

I want you to read what you wrote out loud and slowly...I don't want any unelected bureaucrat telling any doctor how to treat patients.

heres my source of confusion.

first, remind me which elected bureaucrats that tell doctors what to do.

let me list the unelected bureaucrats that do tell doctors what to do:
Secretary HHS
CMS directors
DEA directors
state DOH Commissioners
insurance company administrators
insurance company PA doctors
etc

second, my response was directed at the article (which I did read).

This proposal by the Chronic Pain Task Force in Oregon is also incredibly unethical. The reasons are simple. There is no evidence that forced opioid tapers—particularly a forced taper to zero opioids—is of any benefit for chronic pain patients, but there is considerable anecdotal evidence of potential harms, up to and including suicide. Indeed, Department of Veterans Affairs data suggests that opioid discontinuation is not associated with overdose mortality but is associated with increased suicide mortality.

in essence doctors cannot force tapers, so are forced to keep patients on their opioids.

 

[lobelsteve]

heres my source of confusion.

first, remind me which elected bureaucrats that tell doctors what to do.

let me list the unelected bureaucrats that do tell doctors what to do:
Secretary HHS
CMS directors
DEA directors
state DOH Commissioners
insurance company administrators
insurance company PA doctors
etc

second, my response was directed at the article (which I did read).
in essence doctors cannot force tapers, so are forced to keep patients on their opioids.

Doctors can and do force tapers. And doctors can abandon opiates without abandoning their patients.

 

[TheLoneWolf]

U Michigan for pain and U Chicago for anesthesia. Great credentials. Unusual career path. Not unlike a few attendings I trained with who ultimately left pain back to the OR. Doing procedures all day sounds like a sweet deal but many cant stomach the population and business aspects. Academia where I trained for residency was coddling eggshell soft egos. Some huge names behaved more like every tiny thing was a weiner measuring contest.

Also, could be someone who ultimately holds to their erroneous convictions. Met one dude like that, slick anesthesiologist who stopped doing procedures then stopped med prescribing, recommended exercise PT and diet. Now, back to the OR.

 

[SeniorWrangler]

Don't know the man personally, but he wouldn't be the only pain doc to become skeptical about some pain treatments after being in practice for a while...

 

[drusso]

heres my source of confusion.

first, remind me which elected bureaucrats that tell doctors what to do.

let me list the unelected bureaucrats that do tell doctors what to do:
Secretary HHS
CMS directors
DEA directors
state DOH Commissioners
insurance company administrators
insurance company PA doctors
etc

second, my response was directed at the article (which I did read).
in essence doctors cannot force tapers, so are forced to keep patients on their opioids.

There are plenty of examples where locally-elected bureaucrats govern health care delivery. The beauty is that if these bureaucrats don't deliver results for their communities, then doctors and patients can vote them out on their asses. Representative Democracy in action.

For example, in jurisdictions that have formed county hospital districts/authorities with taxing authority, locally-elected Directors are accountable for the financial stewardship of their hospitals. If they want to subsidize insurance for poor people, they locally determine the level of the benefit package and have a third-party administrator administer it. They hire their own administrators. If they need to buy a new ambulance, then they can organize a bake sale (or raise taxes). The CEO, administrators, managers, etc are directly report to a locally-elected board. The financial reporting is transparent and conforms to GAAP.

For example:

Board of Directors

This one even has a pain doctor on it's Board of Managers...(an SDN alumni who used to post here years ago)

Board of Managers | JPS Health Network

This is not how things get done in Oregon on a state-wide basis. Medicaid was expanded by fiat through an unusual "public-private" consortium of intermediaries really as a grab for Federal dollars. The end result is that it has burdened the state budget: You can have great schools, great infrastructure, cushy pensions for public employees, or free health care for poor people but not all of the above. The entire Medicaid contracting process is opaque. The rate-setting process is closely guarded as "trade secrets" and carried out behind closed doors as there is virtually no direct public vetting of benefit packages, etc. If you're taking public money, this is not a good way to maintain the public trust.

Now, the opioid policy specifically: This is just dog$hit public policy. Raise your hand if you're worked for months or years to taper patients? It can be a slow, laborious process that requires frequent follow-up, trust, and RESOURCES (like integrated behavioral health) to be successful. We all recognize that some proportion of patients will never come off opioids or MAT. Those are the legacy patients; that's the travesty of opioid epidemic. But, instead of seeing that as a "failure" or the lack of achievement of a a quality metric, it should just recognized for what it is...some people get started on opioids and can't or won't come off. "Fixing" the opioid epidemic is more like rebuilding Berlin after WWII than it is like eradicating polio.

If the mandatory tapering policy is approved (and I think it will be), it will functionally have the same effect as the DEA coming in and shutting down a pill-mill without some boots-on-the-ground coordination with local medical providers. It will displace pain-addicts into more expensive and/or more dangerous (the street) venues to manage their symptoms.

How about this: Before setting "a national example" and "embarking on a grand new experiment," why not take the time and build-up a ROBUST, PROVEN infrastructure of coordinated mental health/addiction/pain treatment centers that are adequately resourced and paid to the work that is required of them. Then, institute the mandatory taper opioid policy.

Cart<----->Horse<----->Cart

 

[Ducttape]

Good points but it is very hard to ignore the time constraints. To organize a council to evaluate and coordinate is much more time consuming and cuts into economic mics.

Factoring into this also is the lack of resources currently allocated for mental health and addiction resources and even the negative social connotations associated addiction services.

So do we wait? Business as usual is not appropriate...

FWIW: Around me, I find essentially no one that will prescribe suboxone without the classic definition for opiate use disorder - no one interested in prescribing suboxone for patients on high dose opioids who should be tapered.