June 29, 2015
Better Outcomes for Chronic Pain
"Conservative care" needs to supplant opioids in the treatment of chronic pain -- premiums would plunge and workers would benefit.
The workers’ comp industry is burdened with perhaps 200,000 or more injured workers on long-term opioid treatment for chronic pain. Many more workers enter these ranks yearly. For 10 years, I have observed this awful misery slowly accumulate. But claims payers can do more to prevent new case and resolve “legacy” cases. It will require from them more commitment to best practice care and a lot more frank, open collaboration among themselves and with medical providers.
Conservative care is hugely under-exploited as an approach to prevent and resolve chronic pain among injured workers. Workers’ compensation claims payers would not have paid so much for opioid treatment, failed surgeries and claims settlements had they adopted conservative care decades ago, when research support for this approach was already pretty strong. The failure to promote this approach cost the policyholders perhaps $100 billion in higher premiums and cost injured workers years of disability and, in some cases, funerals.
By conservative care, I refer to functional restoration programs, which came into existence in the 1970s or earlier. Cognitive behavioral therapy became established in the 1980s. Coaching, as a non-medical method of helping persons in pain, has been around forever but recently gained visibility as a scalable form of intervention. There’s a lot of innovation going on, such as the PGAP program imported from Canada and a number of nerve-stimulation services such as Scrambler in New England.
Payers need to learn how to create conditions within which conservative care can prosper rather than repeatedly blossom only to die.
A friend prods me to use the term “evidence-based medicine.” But “conservative care” is my choice for an umbrella term because it is easy to remember, though inexact.
A few years ago, I talked by phone with a senior medical case manager at a claims payer in Kentucky, an epicenter of opioid prescribing excesses, who had never heard of functional restoration programs. This reminded me of the Harvard professor who spent a year in Munich without ever hearing about Oktoberfest.
The long history of insurers includes many instances where they brought risk management solutions like conservative care to the market. The first modern evidence of that goes all the way back to London fire insurers in the late 17th century. Mutual insurance companies played an essential role in introducing automatic fire-suppressing sprinkler systems to American factories in the late 19th century.
In my special report published by WorkCompCentral, “We’re Beating Back Opioids – Now What?”, I propose that claims payers and selected medical providers collaborate for the purpose of better success in treatment. This is particularly valuable for conservative care. The collaborations would allow each party to act on its own but to pool information. Periodically, analysts will dig into the database to report on the group’s experience on outcomes and costs.
The healthcare community, sometimes with the explicit support of health insurers, engages in collaborations to improve health outcomes. A Health Affairs article in 2011 is titled, “How a Regional Collaborative of Hospitals and Physicians in Michigan Cut Costs and Improved the Quality of Care.” The article addresses surgical collaborations, for instance:
- Michigan BCBS has been supporting since 2006 a bariatric surgery data-sharing project involving 27 hospitals and some 7,000 patients a year.
- Its major general and vascular surgery collaboration recorded 50,000 patients a year.
The article concludes that “results from the Michigan initiative suggest that hospitals participating in regional collaborative improvement programs improve far more quickly than they can on their own. Practice variation across hospitals and surgeons creates innumerable “natural experiments” for identifying what works and what doesn’t.
Elsewhere, collaborations among independent medical providers have been noted in asthma, diabetes, surgery and congestive heart failure.
Another analysis of collaborations commented that “real improvements [in treatment] are likely to occur if the range of professionals responsible for providing a particular service are brought together to share their different knowledge and experiences, agree what improvements they would like to see, test these in practice and jointly learn from their results.
Claims payers need to help this cross-fertilization happen. Hard as it may seem, they need to “own” the need to build conservative care resources in their markets. Physicians don’t understand conservative care; referral patterns are not set; and the providers of conservative care are often under-resourced. Claims payers need to step up.