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APS Bulletin • Volume 17, Number 3, 2007
Pain Clinic Perspectives
Steven Stanos, DO, Department Editor
Financial Rehab for Interdisciplinary Programs
Jane Martinsons, Staff Writer
| “My perception is that third-party payors could benefit from a greater understanding of what interdisciplinary care is about,” says Jeff Livovich, MD, medical director at Aetna |  |
Interdisciplinary pain rehabilitation programs (IPRPs) may pride themselves on bringing together under one roof multiple disciplines to treat pain, but they are leaving a key player out in the cold: the insurer, the one out there wearing the well-padded jacket with purse strings. To thrive, some say to survive, IPRPs must learn to communicate better with thirdparty payors and even partner with them.
For IPRPs, that means starting with the basics and simply introducing themselves to payors who may be unfamiliar with interdisciplinary care. “My perception is that third-party payors could benefit from a greater understanding of what interdisciplinary care is about,” says Jeff Livovich, MD, medical director at Aetna, one of the only insurance companies to have a publicly available interdisciplinary care policy on its Web site. “They don’t know about outcomes that actually support treating people in this fashion. With the emphasis on evidence-based medicine, it is critical that they have access to this information to guide their coverage decisions.”
Dennis Turk, PhD, of the University of Washington in Seattle agrees, saying that “when third-party payors hear the word multidisciplinary they think that implies multiple disciplines that each need to get paid, and is therefore expensive.” That’s why it’s so vital for IPRPs to share with payors their outcomes data and actual costs of care.
“We’ve got to clarify what the costs are,” Turk says. “There’s a lack of dissemination of information to decision makers to help them understand the relative costs” of treatment, which he estimates at about $14,000 for rehabilitation compared to up to $50,000 for back surgery and $40,000 for spinal-cord stimulators or implantable devices. “We need to get published journals into the hands of decision makers and those who are paying the bills,” he says. “Evidence-based medicine dictates that you should pay for the things that are cheap and work. That evidence [exists] for rehabilitation programs and yet they’re getting little attention. Obviously, we are not communicating very effectively with third-party payors.”
There are several ways that IPRPs can improve their relationship with insurers and stay financially sound, say several pain experts who recently spoke with APS Bulletin. But interdisciplinary programs face unique challenges, says Steven Stanos, DO, medical director of the Chronic Pain Center at the Rehabilitation Institute of Chicago.
First patients in these programs are known as big spenders in healthcare, having racked up years’ of bills trying, unsuccessfully, to alleviate their chronic pain through chiropractics, acupuncture, epidural injections, and other treatments. Likewise, patients who attend these programs often view 3–4 weeks of intensive pain care at an IPRP as a last-ditch effort to regain some semblance of a life they believe has been overrun by uncontrollable pain.
Another big challenge is in defining the goal of the program. Depending on whom you ask—insurers, patients, providers, workers’ compensation people—a goal may be one or a combination of getting patients back to work, closing their disability claims, decreasing their pain, or improving their quality of life.
At the very least, it’s about “getting these people out of a previously ineffective cycle of mostly passive based treatment approaches. With most of these patients, such an approach hasn’t helped them to improve their function or offer them any significant pain relief,” Stanos says. He notes that third-party payors frequently overlook the goal of increasing patients’ physical function and subsequent sense of well-being, focusing too often on significant quantifiable reduction in patients’ self-reported pain scores. They’re also not seeing the whole picture: The same patients who report only a 1-point reduction on their verbal analogue pain scale are many times also thanking the team for helping give them their life back. They are reporting returning to previously cherished leisure activity, coping better at home with their families, or more successfully managing stress in the workplace. Turk concurs that whereas pain reduction is of number-one importance to patients and providers, third-party payors focus primarily on healthcare utilization, and workers’ compensation people focus on the return to work. It’s a reason why IPRPs must make sure that data is distributed and disseminated to the people who are paying the bills. He suggests IPRPs gather both pre- and post-treatment information to show third-party payors that they are both cost and clinically effective. “Is, in fact, the patient using less healthcare? Are they being hospitalized less frequently? Are they using fewer medications? Are they using fewer kinds of services, such as emergency room services?”
How can programs become financially sound? Experts have some advice.
Market Yourself to Payors
Sell yourself to insurance companies by providing them with good outcomes, documentation, and a willingness to review cases frequently, says Edward C. Covington, MD, of the Cleveland Clinic Foundation in Cleveland, OH. Officials there not only talk on a weekly basis to insurers about patients, but their discharge reports include patients’ efforts to rehabilitate, patients’ current functional capacity, and recommendations for further treatment.
IPRPs must keep in mind that to payors “these are expensive cases, and costly treatment already has proven futile or harmful,” Covington says. “It’s not unusual for them to have already funded blocks, radio frequency ablation, and a fusion and a spinal-cord stimulator for these patients, so they’re entitled to ongoing evidence that you’re not another bottomless pit.”
Covington also warns IPRPs to expect an uphill struggle when marketing to payors, patients, and referral sources. “Ours is a high-tech, you-fix-me healthcare system,” he says. “We need to better define necessary and sufficient treatment components. What is the minimal effective level of care? Who is and who is not likely to benefit from these programs?”
A strong marketing push is needed. Livovich suggests that IPRPs “evangelize” their message of holistic, biopsychosocial care to insurers and learn to advertise to consumers as effectively as unimodel treatment programs. “People who work in IPRPs don’t realize how unique and rare they are,” he says. “For now when people think of pain medicine they think of interventional techniques.”
Hold Patients Accountable
Discharge patients when necessary, says Covington. Programs can discharge patients for nonattendance, inability to maintain sobriety or lack of work, and even for failure on the part of family members to attend the program.
| Stanos says that third-party payors often overlook the goal of increasing patients’ physical function and sense of well-being. |  |
Likewise, Stanos says that patients at the Rehabilitation Institute of Chicago are closely monitored informally and formally through weekly team conferences and can be discharged early from a formal treatment program for reasons such as treatment noncompliance, failure to grasp and comply with its biopsychosocial approach to care, or for refusing to apply learned coping and functioning techniques in their lives outside the program.
“There’s a lot of supportive handholding, and time spent counseling and trying to push these patients to change some very ingrained and maladaptive thoughts and behaviors. The treatment team tries to remain persistent, but many times patients aren’t willing to change significantly,” Stanos says. “We’re working with a very difficult and challenging group of patients. Their pain condition is complicated by high levels of depression, catastrophic thinking, deconditioning, and operant factors. Our goal is to help patients unlearn bad behaviors and change their focus to self-management and independence. Still, many patients are open to this biopsychosocial approach; unfortunately it just hadn’t been offered to them in an organized fashion in the past.”
Educate Insurance Companies
Programs need to educate the payor, and direct some of that education to the actual patient management areas of the company, Livovich says. “It’s important that multidisciplinary programs really partner with insurers, particularly since a central credentialing program doesn’t exist,” Livovich says, adding that some but certainly not all IPRPs choose to seek accreditation from the Commission on Accreditation of Rehabilitation Facilities. He calls for individual programs, as well as professional pain societies like APS, to develop agreed-upon criteria on what constitutes a true IPRP. “This would be helpful to both IPRPs and insurers,” he says.
Stanos says to educate case managers and third-party payors on an ongoing basis through ongoing report sharing and by continually updating them on patients’ outcomes and treatment. “Many times the insurance providers approve a program, but then get no feedback on what’s going on,” he says. This can be remedied by providing insurers with continual clinical feedback through, for example, team conference notes, progress notes, and pre- and post-psychometric testing on patients. Over time “you create a much better educated and informed stakeholder,” he says.
Bring Payors into the Process
“Include insurance companies so that they are part of the process and don’t feel they’re just being flooded with bills, one after another,” says Turk. “Instead of being adversarial, try to help third-party payors become our allies.” This includes providing them with criteria that specify which patients are appropriate for treatment. Insurers need to know that “we don’t just take anybody into these programs to make money,” he says, “but that we actually have criteria to help us make decisions, [select] people we think are most likely to have good outcomes, and hold down costs.”
Also invite case managers to attend patient evaluations, formal recommendation meetings where the assessing team—including the pain physician, pain psychologist, and vocational therapist—review recommendations and devise a treatment plan. Not all patients are recommended for formal treatment in the program. Like other programs, the Rehabilitation Institute of Chicago invites case managers to attend weekly patient team conferences where the treating staff reviews patient’s progress across multiple disciplines.
We’re helping to educate the insurance company case managers and adjustors on an ongoing basis by having them directly involved in monitoring progress,” Stanos says. “Educating them is key. Many people at the insurance level don’t fully understand the complexities of chronic pain, and have had little if any training. This is an opportunity to educate them about all disciplines, from medications to physical therapy, occupational therapy, and psychology. Without proper education, they may wrongly see it as just another failed cost burden. We are also helping them move patients closer to case closure and getting patients out of the treatment cycle conundrum and on with their lives.”
Consider Package Pricing
There also are issues with contracting, Livovich says. “IPRPs want to keep the treatment team together. One of ways to accomplish this is to contract a case rate for your programs. Do a detailed financial analysis on what you bill, what you do, and what the relative costs are. Figure out a medium price for all patients and then present that as a strategy for contracting.” Also remember the bottom line. “If you’re going to contract with a provider, make sure that all the providers within your treatment center are contracted. Discounts that are offered can often be made up through the growing patient base that contracting can provide.”
Covington, meanwhile, warns IPRPs to be careful about pricing by service because it invites payors to negotiate over every service you provide. A daily price permits service allocation based on need rather than reimbursement and facilitates billing, bookkeeping, and documentation.
“Much of what helps patients recover can be called ‘psychoeducation.’ A lot of things are either reimbursed poorly or, in the case of biofeedback, are not reimbursed at all, [while] reimbursement for physical therapy and occupational therapy can be quite good,” Covington says. ‘If the program bills a package price, the well reimbursed care can support the poorly reimbursed, and patients get both, which they need for recovery.”
Share Risk with Insurers
Insurers “are skeptical about what we’re doing and we’re worried about whether they’re going to pay, so let’s cut a deal,” Turk says. “Let’s say to the insurer, ‘For the next 6 months or year, we’ll contract with you and give you a reduced cost on a hundred patients and you will be involved with us in evaluating the outcomes. If, in fact, the outcomes are as good as we hope, you’ll make us a preferred provider for patients in the future.’ If it doesn’t work, then [it doesn’t work].”
Selectively Determine Patients
Avoid patients who will be quick to blame the project for poor results—they can demoralize peers and staff—and be mindful about taking on patients with pending litigation or disability claims or who show sociopathic tendencies. To help you cover the cost of patients, be sure to have a good mix of patients on workers’ compensation and those covered by public and private insurance.
Be Indispensable to Key Program Supporters
Supporters include orthopedists and anesthesiologists, Covington says. These are their nightmare patients who return week after week complaining that they’re not getting better and possibly even worse.
Consider More Flexible Programs
“These patients are very complex and not every chronic pain patient needs the same type of pain program,” Stanos says. “It’s pretty tough getting someone out of work for a 4-week, 8-hour-a-day program. We need to really focus on what patients need and have flexibility.” It will lead to better outcomes and get patients in and out of treatment faster, he says.
Meanwhile, Turk calls for more research to assess current IPRP structure and treatment modalities. He says that questions that need addressing include the following: Are 3–4 week programs necessary for all patients? Is an 8-hour-a-day program necessarily more effective than a half-day treatment? Do a combination of treatments—say, drugs, rehabilitation and exercise—lead to better outcomes? How do we get patients with a long history of pain into these programs earlier and how does that affect outcomes, cost, and clinical efficacy?
