Stacey St Amand

The Other Side of the Opioid Epidemic

The number of opioid prescriptions per person in the U.S. peaked in 2010. And it has dropped every year since through 2015. This sounds encouraging, but according to the Centers for Disease Control and Prevention (CDC), the level in 2015 was still three times higher than in 1999. And while the U.S. makes up 5% of the world’s population, we consume 80% of the opioid pain relievers manufactured.

So, prescribers are becoming more and more reluctant to write prescriptions for the drugs for fear of investigation, or worse, prosecution and prison. This after increasing attention on the opioid epidemic that has led to policies aimed at curbing prescriptions and dosages, as well as insurers limiting the number of pills they’ll authorize.

In March 2016, the CDC issued stricter guidelines for doctors who prescribe opioids. The guidelines urge doctors to use caution when prescribing opioids at any dosage, especially when increasing dosages, including justifying dosages greater than 90MME per day.

Is this a case of throwing the baby out with the bathwater?

What About Chronic Pain Sufferers?

What about the patients for whom pain is genuine, and often chronic (estimated to be between 25-100 million people in the U.S.)? What about those whose need for pain relief is real? Chronic pain is the primary reason people go on disability. And in addition to overall quality of life, chronic pain negatively effects work, family, and social networks. According to an article posted on the Psychology Today website (11/24/2015), the suicide rate among people with chronic pain is known to be roughly twice that for people without chronic pain.

Is there an epidemic of chronic pain that’s getting little attention in the face of the opioid epidemic?

Chronic pain sufferers are often dependent on opioids to function and live normal day-to-day lives. But being dependent (in order to function) is not the same as being addicted.

Patients who have legitimate needs for opioids are finding it increasingly difficult to get access to their prescriptions; they experience everything from having to drive long distances to find providers willing to prescribe, to having to sign contracts, to being urine tested, to being tapered to lower doses than they need.

What’s the Answer?

These patients, and their doctors, say that the answer to the opioid epidemic is not taking away the medication of every patient out there. It’s addiction treatment. They say there are those who legitimately need pain medication as well as the many options for chronic pain management available to providers. Appropriate use of the correct intervention at the right time must be part of the conversation.

In Idaho, where a “Don’t Punish Pain” rally was held in Boise in March 2018, attendees wanted to have chronic pain sufferers added to a list of cancer and hospice patients. This would enable them to get their pain prescriptions without limitations. Protesters hope that future legislation reflects their needs.

But providers in Idaho write higher than the national average number of opioid prescriptions. According to the National Institute on Drug Abuse, in 2015, Idaho providers wrote 76.4 opioid prescriptions per 100 people. That’s approximately 1.3 million prescriptions. In the same year, the average U.S. rate was 70 opioid prescriptions per 100 people. And in some Idaho counties the rate is even higher.

In an April 2018 interview with CNN, the head of the U.S. Food and Drug Administration, Dr. Scott Gottlieb, suggested mandatory training on pain management and opioid prescribing for the nation’s physicians. He said that current standards are based on outdated training, which is not mandatory and that we need to “re-educate a generation of physicians.”

Idaho is already making efforts in that arena with prescriber education via University of Idaho’s ECHO Program. ECHO uses a team of specialists in a learning and guided practice model – communicating through video conferencing technology to connect with providers throughout the state to conduct virtual clinics. Its first clinic (bi-monthly March through September 2018) is focusing on opioid addiction and treatment.

Chronic pain sufferers and the providers who treat them hope that the pendulum that has swung so far in one direction will come back toward center. They hope that with more research and increasing calls for mandatory education, not only in opioid prescribing but in pain management, the right balance of treating people who suffer from chronic pain will be achieved.

“The Brave New World of Patient-Centered Care”

– Dr. Susan Frampton’s Address to the Idaho Healthcare Summit

Dr. Susan Frampton opened her keynote address at this year’s Idaho Healthcare Summit with a tale of her bout with Lyme disease and how she was able to leverage technology on a Friday night to work with her primary care practitioner. She’d had the disease before, knew its symptoms, and wanted to start the prescription she knew she needed that weekend. Using the technology on her smartphone and a call with her physician’s nurse, she ultimately got the prescription called in within 12 hours of initiating the first contact. It was a story of patient-centered care.

This set the stage for the rest of her talk about keeping the patient at the center of care as the healthcare landscape changes. Her keynote address, “Brave New World of Patient-Centered Care: Trends in Policy, Practice, and Payment,” framed areas of opportunity in patient-centered care – where it’s going and what patients are asking to be delivered. She spoke at the fourth annual Idaho Healthcare Summit in Boise on May 17, 2018.

Healthcare Consumerism

 Dr. Frampton’s discussion focused on the rise in “consumerism” in healthcare: regulatory trends like direct access lab testing and direct to consumer advertising and genetic testing; patients turning to consumer-based rating services like Yelp to find doctors and hospitals; and Uber partnering with physician offices to transport patients. She said that virtual health (telemed services, texting, email) is becoming the 20th century house call and that payers are beginning to cover these services. She emphasized that meeting patients where they are is essential for the healthcare system to remain effective.

All these consumerism trends point to patients becoming more engaged in their own healthcare and seeking care at lower costs; which lead to better quality outcomes. A 2017 National Academy of Medicine publication on evidence connected better quality outcomes to engaged patients/consumers; she said it hasn’t yet led to lower costs but she sees that on the horizon.

But with the landscape changing so dramatically – financially and technologically – with programs like Doctor on Demand, do-it-yourself disease management phone apps, artificial intelligence, and personal wearable technology, she said, it’s important to keep healthcare where it needs to be – centered on the patient. It must be accountable to engaged patients, families, and consumers.

Policy Changes

And the landscape is also changing with respect to policy. In 2017, the National Academy of Medicine revised its definition of patient-centered care to read:

“care designed with patient involvement, to ensure timely, convenient, well-coordinated engagement of a person’s health and healthcare needs, preferences, and values: it includes explicit and partnered determination of patient goals and care options; and it requires ongoing assessment of the care match with patient goals…”

In addition, the CMS payment reform initiative on Alternative Payment Models (APM) now includes patient engagement criteria; shared decision-making is a ‘must pass’ criteria for PCMH certification; congress has taken steps to aid family caregivers; a public-private partnership funded by HHS to the tune of $1billion, Partnership for Patients (PfP), is working to improve the quality, safety, and affordability of health care for all Americans; and CMS is awarding funding to continue Hospital Improvement Innovation Networks (HIINs).

Idaho is participating in PfP with 29 hospitals (61%-80% of hospitals) enrolled for the state. The PfP vision for hospitals and other health care providers is to achieve quality and safety goals by:

  • fully engaging patients and their families,
  • determining what matters most to them in every situation,
  • and partnering with them to make improvements to all aspects of care.

Despite these trends, Dr. Frampton asked whether consumer-centric approaches to health care are a capability in the U.S. healthcare system? Her answer was no, not yet. In a recent study, 66% said consumerism is a priority but not a capability (16%). She said resistance to change, lack of urgency, competing priorities, and lack of clear evidence seem to be barriers to action.

Still, consumers want it quick and easy – this is what is means to be an engaged patient – and, she said, you lose business when you don’t deliver. So, the Centers for Medicare and Medicaid Services (CMS) has listed as its strategic goals:

  1. Empowering patients and doctors to make decisions about their health care.
  2. Ushering in a new era of state flexibility and local leadership.
  3. Supporting innovative approaches to improve quality, accessibility, and affordability.
  4. Improving the CMS customer experience.

All of which lead to what Dr. Frampton spoke directly to as the theme of this year’s summit, “Healthcare Solutions the Idaho Way.” Her address focused on policies and practices that align with Idaho’s efforts to transform healthcare and initiatives taking place around the state to keep the patient at the center of care. Her closing urged the audience to ‘Think Globally, and Act Locally,” and suggested:

  • Using technology more effectively to engage patients, families, and consumers.
  • Tying healthcare service quality improvements to consumer preferences and related emerging ‘personalized’ technologies.
  • Striving to meet and exceed patient and consumer expectations around cost, convenience, access, and quality.
  • Supporting patients and their families to play larger roles as members and captains of their own healthcare teams.

…it’s all about continuing the story of patient-centered care in Idaho.


Dr. Frampton is the president of Planetree International, a non-profit advocacy organization that works with a growing network of healthcare provider organizations across the continuum to implement comprehensive person-centered models of care. Dr. Frampton, a medical anthropologist, has authored numerous publications, including the three editions of Putting Patients First (Jossey-Bass 2004, 2008, 2013) and served as lead author on the National Academy of Medicine’s Harnessing Evidence and Experience to Change Culture, released in early 2017. In addition to speaking internationally on culture change, quality, safety, and the patient experience, she was honored in 2009, when she was named one of “20 People Who Make Healthcare Better,” by Health Leaders Magazine.

EHR Interoperability and Patient-Centered Care

Interoperability is defined by Merriam-Webster as “the ability of a system to work with or use the parts of another system.” It was unheard of in the healthcare field just a few years ago. Today it’s a touchstone in the field, functioning to modernize systems and help foster patient-centered care across the U.S.

In a recent article published by the Center for Healthcare Research & Transformation (CHRT) at the University of Michigan, the authors reported the results of a survey of primary care physicians in Michigan around the value of Electronic Health Record (EHR) interoperability to patient-centered care.


With the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009, Electronic Health Records (EHRs) – software systems that create a digital version of a patient’s medical record – came into widespread use among healthcare providers.

An unforeseen difficulty with the use of EHRs was the ability to exchange information among different proprietary EHRs. This exchange of information is known as interoperability. It’s important because it allows patients and providers increased access to their medical records, faster communication, and better quality of care. However, the issue was not considered when the legislation went into effect.

Now, eight years later, according to the authors, EHRs are used by more than 80 percent of providers and physicians who increasingly report that interoperability is important. Data from the CHRT Michigan Physician Survey show primary care physicians (PCPs) consider interoperability an important feature for providing patient-centered care.


The study showed that over a two-year period – from 2014 to 2016 – there was a significant change in PCPs’ perceptions of the value of EHR interoperability and the role it plays in patient care. The survey asked PCPs how important having an EHR with interoperability was to their ability to deliver patient-centered care.

“Significantly greater proportions of PCPs in 2016 said it was ‘very important’ to have EHRs that are interoperable between hospitals and practices, and practice to practice. There was no significant change in the proportion of physicians who saw just having an EHR in their own practice as ‘very important.’”

“While younger doctors are more likely to say EHRs are important, increasing numbers of doctors of all ages are embracing them. Regardless of how long they have been in practice, there was a substantial change in PCP views on the importance of interoperability from 2014 to 2016.”


Primary care physicians in Michigan have reported an increase in the value of interoperability over time. The study mirrors what is being seen in Idaho’s SHIP initiative. Almost all SHIP clinics in the state use an EHR. But as in Michigan, incompatibility among EHRs in Idaho is an issue. So too, is the problem of how healthcare data is described and recorded. There are nationwide initiatives underway, and in states like Idaho and Michigan, to improve interoperability. The long-term goal is a reliable tool that leads to coordinated care and delivery of quality, patient-centered healthcare.

To read the entire article, visit

A Report on Rural Family Physicians in PCMHs and Their Scopes of Practice

The post below is a summary of a study done by the Rural & Underserved Health Research Center at the University of Kentucky. The purpose of the study was to determine whether rural family physicians who work in PCMH practices have broader scopes of practice than those not in PCMH practices. The study used data from 18,846 family physicians nationally.


In general, there are fewer health care services provided in rural America than in urban America. But due to a lack of subspecialty care in rural areas, rural providers frequently deliver a broader range of services than their urban colleagues. The Patient-Centered Medical Home (PCMH) model of care provides a whole person-centered approach that delivers care coordination, improved accessibility, and higher quality care. Rural practices have shown a similar readiness to transform to the PCMH model compared to urban practices, but they frequently lack the financial and human resources to do so.

The purpose of the study was to determine whether rural family physicians already working in PCMH practices have a broader scope of practice than those not working in PCMH practices.

Scope of practice was defined as a family physician providing each of 21 clinical services, e.g., home visits, inpatient care, obstetrics, etc.; and scope of procedural services was defined as providing each of 18 procedural services, e.g., prenatal ultrasound, endoscopy, office skin procedures.

Rural practices were defined as follows:

Large rural           20,000-250,000

Small rural           2,500-19,999

Frontier                Less than 2,500


Using data from 18,846 family physicians nationally and an analytical sample of 3,121 rural family physicians, the study found that rural family physicians not only frequently have a broader scope of practice* than urban family physicians, it also found that rural family physicians working in PCMH practices “generally provide a wider scope of clinical and procedural services than those not working in PCMH practices.”

*defined as the range of clinical and procedural services they provide.

Within large and small rural areas, practicing in a PCMH was associated with delivering a wider scope of clinical services than non-PCMH practices. The study cited an example of 93.6% of physicians in PCMH practices and 86.7% of physicians in non-PCMH practices in large rural areas providing pediatric care (a statistically significant difference). In frontier areas, there were no significant differences in services provided except for chronic disease management and preventive services.

Differences in the percentages of physicians providing each clinical service between those practicing in PCMH and non-PCMH practices showed that the “largest differences were generally in large and small rural areas.” Services associated with preventive care (chronic disease management, preventive care), women’s health, newborn care, and coordination of care with surgeons (pre- and post-op care) were more commonly provided by family physicians in all rural PCMH practices than those in rural non-PCMH practices.

Policy and Healthcare Delivery Implications

The findings of the study suggest that the PCMH model is, for the most part, meeting the goals of providing more accessible, comprehensive, and coordinated health care in rural practices. It found that the model is associated with rural practitioners providing a higher number of clinical services and procedures than non-PCMH practices.

As the PCMH model seems to be “associated with an increased scope of health care services available to rural patients,” its policy implications suggest that:

  • Programs that support rural practice transformation to the PCMH model “may need to be investigated.”
  • “Financial payments that encourage family physicians to provide a broader scope of practice within a PCMH may be beneficial.”

This study reinforces the practice transformation being undertaken by the SHIP initiative. With many areas of Idaho being rural and frontier with serious provider shortages, the patient centered medical home model can increase the access patients have through their medical homes. The addition of virtualizing care through the use of Community Health Workers, Community Health EMS teams, and the use of Telehealth are additional aspects of the SHIP currently being evaluated by the Boise State University State Evaluation Team.


For more information or to read the entire article, please visit

To read more articles about PCMH transformation, click here.

Connecting to Idaho’s Medical-Health Neighborhood

Ever heard of a medical-health neighborhood? Have you ever needed services provided by the medical-health neighborhood? Even if you answered no, chances are you’ve used the services of the medical-health neighborhood without really knowing it.

According to the Patient-Centered Primary Care Collaborative, the medical-health neighborhood is defined as “A clinical-community partnership that includes the medical and social supports necessary to enhance health, with the PCMH serving as the patient’s primary “hub” and coordinator of healthcare delivery.” It includes specialists, hospitals, long-term care providers, community centers, faith-based organizations, schools, employers, and public health agencies. The medical-health neighborhood is based on relationships and the coordination of health care and information within the patient’s community.

In Idaho, there are several organizations you can turn to that both provide information and connect you to the hundreds of community and social service organizations and direct healthcare providers across the state. One of these is phone-based and one is a website; both help you navigate the hundreds of resources available to you:

Live Better Idaho

Live Better Idaho is an organization whose mission is to connect people to services to help them live better lives. It’s a website that’s a collaboration among multiple groups including government agencies, non-profits, faith-based organizations, and other community services working throughout the state to bring available services to Idahoans.

According to Greg Kunz, Deputy Administrator of Live Better Idaho, the organization set out to create a website that would be easy to use. With that in mind, it’s designed to be user-friendly – so that people can find the services they need within three clicks…even if they aren’t sure what they’re looking for. Live Better Idaho is free to users.

Click here for more information about Live Better Idaho.

2-1-1 Idaho Care Line

The Idaho Care Line is a program of the Idaho Department of Health and Welfare. It’s a free, statewide information and referral service. It uses a comprehensive database of programs that offers free or low-cost health and human services. By dialing 2-1-1 from anywhere in the state, you’ll be connected to a live information specialist who can refer you to health and human services available right in your own medical-health neighborhood.

For more information about Idaho’s Care Line, dial 2-1-1 or click here to visit their website.

Click here to read more articles about PCMH transformation.

Dementia Caregivers – A New Training Curriculum

Back in September, on World Alzheimer’s Day, we addressed some general knowledge about Alzheimer’s and related dementias. We also talked about the number of people in Idaho suffering from the disease, the outlook, and some of the things being done about it.

Today 24,000 people in Idaho aged 65 and older have Alzheimer’s; in just eight years, that number is expected to climb to 33,000. It’s the sixth leading cause of death in Idaho. The Medicaid costs of caring for Alzheimer’s and dementia patients in Idaho in 2015 was $125 million; that number is expected to increase by 60% to $200 million by 2025.

Recently, the Health Resources & Services Administration (HRSA), which supports the training of health professionals in the United States, came out with some new training modules that focus on Alzheimer’s and related dementias. These are in addition to their basic dementia training curriculum and specifically address caregivers of People Living with Dementia (PLwD). According to their website, currently more than five million Americans live with Alzheimer’s disease. And ultimately, one out of every three Americans will die from Alzheimer’s disease or another dementia.

The 11 supplemental training modules are designed to help providers understand the needs of caregivers of PLwD (four modules) and to directly assist family and other caregivers take care of themselves and cope with the challenges of caring for PLwD (seven modules).

Modules for Providers:

Module 1: Providers and Caregivers as Allies

Module 2: The Provider’s Role in Shared Decision-Making with Caregivers, Families, and Persons Living with Dementia

Module 3: How Clinicians Can Interact Effectively with Caregivers

Module 4: Taking Care of Those Caring for Persons Living with Dementia


Modules for Caregivers:

Module 1: Caregiving for Persons Living with Dementia (Faculty Guide)

Module 2: The Caregiver Role in Shared Decision-Making with Persons Living with Dementia (Faculty Guide)

Module 2a: Assisted Living Facility Considerations (Faculty Guide)

Module 2b: What to Consider When Choosing a Nursing Home (Faculty Guide)

Module 3: Working with the Healthcare Team (Faculty Guide)

Module 4: Caregiver Self-Care (Faculty Guide)

Module 5: Addressing Behaviors in Dementia (Faculty Guide)


To access the learning modules, visit the HRSA website at 

To read more General Health articles, click here.

ParkRx and the Eco-Therapy Movement

You’ve probably heard of psychotherapy, equine therapy, and group therapy, but what about ecotherapy? Ecotherapy is a nationwide trend that’s working to add one more tool to the array healthcare providers use to integrate care across the medical health neighborhood. The philosophy behind the trend is that prescribing specific interactions with nature like walking and exploring local parks will benefit patients with chronic conditions such as depression, diabetes, obesity, high blood pressure, and ADHD. It’s gaining acceptance in mainstream medicine and carrying more weight with patients when prescribed by a doctor.

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Idaho’s 2018 State of the State Address – Healthcare Recap

Governor C.L. “Butch” Otter gave his final State of the State and Budget Address on Monday, January 8, 2018. Below is a recap of the healthcare portion of his address which focused in large part on affordability and accessibility:

The governor opened his healthcare remarks by declaring that Idaho’s healthcare sector has led the state’s employment growth during his 12 years in office, adding more than 26,300 jobs since 2007. Healthcare accounted for 46 percent of the state’s overall job growth and 13 percent of total employment. He said that this raises two public policy debates for the coming decades: how do we make healthcare more accessible and affordable, and how do we ensure employers have enough skilled workers to meet Idaho’s needs, especially in healthcare and other STEM (Science, Technology, Engineering, Mathematics) fields.

The governor also talked about the need for predictability in planning. But, he said, “When it comes to healthcare, the federal government seems to be going the extra mile to ensure that Idaho and other states have no certainty at all about what the future holds.” After many proposals for making healthcare in Idaho more accessible and coverage more affordable, the governor said he was making one last try.

The Idaho Health Care Plan

The governor will be putting forth for the legislature’s consideration, the Idaho Health Care Plan – a proposal that he said, “Would stabilize Idaho’s healthcare insurance market and give more working Idaho families the ability to purchase affordable coverage.” The plan enables people with the more costly and complex medical conditions to move their coverage to Medicaid. This will allow insurance companies to reduce premium rates for most people who remain in the individual marketplace. The governor was quick to point out that this plan is not an expansion of Medicaid. Rather, it’s a way to provide Idaho’s working families who have modest incomes a more affordable way to get the coverage they need. The plan calls for $17.4 million from the General Fund and another $11.4 million from the Millennium Fund.

Seeing affordability and accessibility as among the central public policy challenges of our time, the governor also addressed Idaho’s last-in-the-nation ranking in the number of primary care physicians per capita, especially in the rural parts of our state. He addressed the opening of Idaho’s first medical school – the Idaho College of Osteopathic Medicine (ICOM). The school, which is working with Idaho State University and other stakeholders, is committed to bringing more physician-residency opportunities to Idaho. His budget also contains a request for funding for 11 new residencies at Eastern Idaho Regional Medical Center in Idaho Falls and Bingham Memorial Hospital in Blackfoot. This is in addition to efforts since 2013 to fund medical school seats for Idaho students through the regional WWAMI program where there are currently 40 seats dedicated to Idaho students – twice as many as when the governor took office.

Behavioral Health

The governor thanked the legislature for their support of the creation of behavioral health crisis centers in Coeur d’Alene, Idaho Falls, Twin Falls, and Boise. His budget asks for $2.6 million to create additional crisis centers in Lewiston, Nampa-Caldwell, and Pocatello that will help alleviate the costly use of emergency rooms and jail cells to address behavioral health challenges.

The governor concluded the healthcare portion of his address by affirming that having healthcare professionals in a community is “one of the factors that can determine a community’s success in developing its local economy by attracting and growing businesses that provide good-paying jobs.”

A complete transcript of the governor’s 2018 State of the State and Budget Address can be found here.

Influenza Immunization: Continuing Education Credit Opportunity

The National Foundation for Infectious Diseases (NFID) has partnered with mdBriefCase Group Inc. to offer a complimentary online Continuing Medical Education (CME) activity offering strategies to help prevent influenza in patients age 65 years and older. This on-demand program provides a framework for counseling adults age 65 years and older on the importance of annual influenza vaccination through case-based scenarios and can benefit all providers in all task areas.

Upon completion of this activity, participants will be able to:

  • Describe the benefit of influenza vaccination in adults age 65 years and older
  • List the vaccine options available for seasonal influenza vaccination of adults age 65 years and older
  • Differentiate vaccine products approved for seasonal influenza in adults age 65 years and older
  • Effectively counsel older adult patients about the importance of seasonal influenza vaccination
  • Please note that participants will be required to create an mdBriefCase account to access the online program, but there is no fee to participate in this activity.

If interested, the program can be accessed at Influenza Prevention Strategies.

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