Chronic Pain Programs: Can We Afford Not To?

Organizations struggle to effectively implement pain programs. Profitability challenges abound as this complex patient population requires substantial provider resource investment. Reimbursement for behavioral health lags despite the proven benefit of behavioral health services for the chronic pain population. Building the case for downstream revenue can be challenging, as many of these patients aren’t ultimately appropriate candidates for surgical intervention.

But the cost of doing nothing is high. This complex patient population can be a tremendous burden to primary care physicians (PCPs), requiring substantial medical management and time, limiting access for other patients to these providers. The US spends $560–$635 billion (an amount equal to about $2,000 per person in the US) to treat pain annually. Many PCPs feel uncomfortable prescribing and monitoring opioids that are often utilized in treating this patient population, and for good reason. Nearly 15,000 people die every year of overdoses involving prescription painkillers, and people addicted to opioid painkillers are 40 times more likely to be addicted to heroin, expanding our US pain epidemic to a heroin epidemic.

Start by Assessing Your Market
With competing priorities and resources, health care organizations considering chronic pain programs often are unsure where to begin. To develop successful programs, organizations must evaluate their markets’ chronic pain landscape. Understanding who in your community is treating chronic pain patients, where the gaps in care are, what procedures this population will require, and the future demand for these procedures is essential to drive your strategy.

Dean Health Re-envisioned Its Chronic Pain Services
Perhaps the best way to answer the question of “Where do I start?” is to learn from the experiences of Dean Health Systems in Madison, WI. Dean Health noted tremendous variability in care for the chronic pain patients it served. Its PCPs were overburdened treating these complex patients, with 15% of PCP office visits utilized to treat patients with chronic pain.

Because Dean Health has a 300,000-member health plan, the problem was even greater. Health plan members lacked the support they needed within the system for chronic pain treatment. Although one Dean Clinic physical medicine and rehab provider offered some pain management services, this single practice was not nearly sufficient to manage the needs of the entire member population. Due to this lack of resources, patients were seeking care through urgent and ED settings, resulting in significant costs to the system. There was also reliance on external provider referrals, a model which not only resulted in a lack of control over the quality of care provided, but also substantial cost liability to the system.

Dean Health considered this a call to action to develop chronic pain services within its system, which it addressed with a phased approach.

Keys to Success
Development of chronic pain programs requires efficient use of staff resources, streamlined triage and patient navigation processes, and strong leadership. Dean Health executed the following steps over 2 years to achieve its success.

  • Build an integrated solution that leverages existing and new resources to provide comprehensive care.
  • Balance appropriate procedural visits with E&M to maintain profitability.
  • Select a medical director to establish and champion the vision. Ensure this champion can dedicate the necessary time for program development.
  • Leverage advanced practitioners and establish an effective staffing model, attaining top-of-license practice for all team members.
  • Build scheduling templates, develop protocols and triage processes.
  • Support PCPs through a system-wide commitment to pain management that incorporates basic principles of pain assessment and treatment into daily practice, along with providing regular pain-related continuing medical education.
  • Establish the facility space, equipment and requisite IT infrastructure for triage, scheduling, documentation and billing.
  • In collaboration with the primary care leadership team, champion the development and system-wide launch of a controlled substance agreement to better manage long-term medical management of chronic pain.
  • Manage referrals to enable a controlled introduction to new services and manage expectations and wait times proactively.

Choose the Right Benchmarks to Evaluate and Refine Your Program
Dean Health also recognized that to be successful, its leaders had to agree on key metrics to measure success at both the department and system level.

Chronic Pain Program Metrics

System Level Department Level
Net system return Patient volumes
Decreased outmigration for pain services Fill rates
Referring provider satisfaction Access
Top-of-license practice Patient satisfaction scores
Percent of appropriate patients with controlled substance agreement in place Mix of procedural and E&M visits

Pain Program Led to Increased Volumes, Decreased Costs
The results of the program may be surprising to some that have gone down this path. Dean Health’s efforts to clearly understand opportunities and execute a diligent, phased approach to program development resulted in 11% clinic growth over 13 months, 10% contribution margin in years 2 and 3 of the program, and $160K in annual savings to its health plan.

Although this was a great starting place for Dean Health, it is continuing its journey to grow and refine the program by expanding its geographic reach through addition of physicians, advanced practitioners and other multidisciplinary team members. It continues to streamline operations and expand the scope of services to include inpatient, palliative care and complementary alternative medicine.

Sg2 projects a 20% increase in procedures to treat chronic pain over the next decade. The old adages of “We only take acute patients into our spine program,” and “We just don’t have the resources to manage chronic pain” may not support program viability in the future, as communities demand more comprehensive services in this era of population health. To get started with your own chronic pain program, evaluate the needs of your market and consider the key steps Dean Health took on its journey.

Sources: CDC. Today’s Heroin Epidemic. Updated July 7, 2015; CDC. Prescription Painkiller Overdoses. Accessed July 2015; The American Academy of Pain Medicine. AAPM Facts and Figures on Pain. Accessed July 2015; Sg2 Interviews With Dean Health, April 2015; Sg2 Analysis, 2015.

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As of February 11, 2016, Vizient, Inc. has completed its purchase of MedAssets Sg2 and spend and clinical resource management segments from Pamplona Capital Management, LLC. MedAssets revenue cycle business will continue to operate as a wholly-owned subsidiary of Pamplona Capital Management LLP.

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