Bearing the Standard

An esteemed ethics colleague forwarded me a Washington Post column that raises an important, neglected aspect of the Choice program and other VA forms of purchased care: potentially unequal and uneven standards of care.¹ Congress authorized Choice to increase veterans’ ability to access needed clinical care in a timely and effective manner. The emphasis on access though may have inadvertently led to an equally serious gap in quality, especially for ethical standards of practice.

The Washington Post columnist Joe Davidson compares the often less demanding standard of opioid prescribing in the community with those of the VA and DoD. This difference in the monitoring of prescriptions the reporter suggests may be contributing to the epidemic of completed suicides—many by medication ingestion—and nonfatal but serious opioid overdoses. As Davidson writes, “The gap in coordination, adding to different clinical standards among VA and non-VA community providers, can be deadly. Health professionals outside the VA are not required to follow departmental guidelines.”¹

The VA and DOD are required to follow rigorous, evidence-based practices, documented in the VA/DoD Practice Guideline for Opioid Therapy for Chronic Pain revised and reissued in February 2017. In addition, VA has a comprehensive, systematic, and standardized program of education and monitoring its Opioid Safety Initiative (OSI). The OSI was launched to improve and rationalize opioid prescribing especially when opioids are combined with benzodiazepines, which increases the risk of lethal outcomes from overdoses.

It is not just journalists who have expressed concerns about this disparity in prescribing rigor: The VA Office of Inspector General and several veterans service organizations also have called attention to what is in effect a double standard in care.² All these entities have underscored another aspect of the Choice program that widens the quality and, hence, safety chasm—the fragmentation of clinical communication between community and VA providers. It is true that as of this writing, every state has passed prescription monitoring program (PMP) legislation. Prior to the change in federal regulation, VA was not permitted to release its controlled substance prescriptions to these pharmacy databases. But in the interest of patient safety, the privacy rules were modified to permit VA pharmacies to share records with the states. This has been a huge step forward in identifying patients who are receiving opioids, benzodiazepines, and stimulants, among other drugs, from a VAMC and 1 or more community prescribers.

Of course, it would be hubristic provincialism to think that there are not excellent clinicians and outstanding institutions in the community that equal or surpass the DoD/VA practice criteria. We are fortunate that because of Choice, veterans and service members now have available to them this level of expertise, which often is not present in smaller federal health care facilities. What is concerning, however, is those prescribers whose practice patterns are routinely and significantly below the bar and thereby place veterans in harms way.However, the efficacy of the PMPs to notify practitioners of prescribing patterns is dependent on the conscientiousness, given the death toll, even the conscience, of those who have prescribing privileges. I should emphasize that prescribing medications is a privilege and that states bestow this power only to those professionals who have met the stipulated education, training, credentialing, and licensing requirements. This professional preparation is crucial when there is not a shared medical record. Without the medical record, the practitioner, especiallyone who does not check the PMP or who does not have sufficient education and training in addiction and pain, is dependent on the history of the patient. The very substances being prescribed or sought may impair the ability of the patient to provide an accurate history due to ignorance, addiction, pain, or fear of losing pain relief.

There is a shortage of addiction and pain specialists in and outside the federal system.^3,4 Therefore, we need Choice in order to meet the needs of service members and veterans. Congress has authorized bureaucratic mechanisms and payment sources to enable veterans to receive treatment from community providers. But a regulatory means to ensure that those providers adhere to the same high standards of care as that of VA and DoD practitioners must be established.