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American Pain Society
4700 W Lake Ave
Glenview, IL 60025
Patricia Robinson, PhD
The American Pain Society (APS) is providing members with a position statement, Pain Assessment and Treatment in the Managed Care Environment. (see APS Bulletin, March/April 2000). The statement is well developed, and most members will nod in agreement as they read it. Unfortunately, the activity stimulated in many members by the position statement may be limited to four or five head-nods when it could prompt much more.
The purpose of this article is to encourage APS members to go beyond their head-nodding response and work to create change. Members can use this statement to influence numerous aspects of the care process that most people in pain experience. Close to 90% of the pain patients in America receive care from some type of managed care organization. APS members can use the position statement to improve the quality of care for pain patients. The following potential change targets, along with a three-step action plan, are offered to members who are looking for ways to put the position statement to work.
Potential change targets include an array of measurement issues; program variety, accessibility, and interconnectedness; program and service evaluation protocols, and educational initiatives.
Numerous aspects of pain need to be measured consistently on an ongoing basis. Strong measurement protocols are the foundation for pain programs of varying levels of intensity that are capable of linking to provide more continuous and timely care.
If basic measurement problems concerning pain have not been addressed adequately in your system, use the position statement to generate interest in the development of a committee charged with addressing these critical questions. Answers to the following questions will provide a structure for program and guideline development efforts. Is pain measured in a consistent and quantifiable way? When it is measured? Is functional status measured when pain is the presenting problem? How? When does acute pain become chronic pain, according to measures in your system? Is chronic pain a diagnosis on treatment record forms in your system? Is an episode of care defined in your system? How?
Pain patients vary in their level of satisfaction with care. Do pain patients that you treat have an opportunity to report their satisfaction with care? In too many systems, satisfaction is not routinely measured. Chronic pain patients are often less satisfied with care than acute pain patients. If protocols for measuring patient satisfaction are in place, do these include patient input concerning more specific data for further refining assessment and treatment? Do you know what treatments in your system pain patients find most helpful? Do you know what frustrations pain patients encounter in your system?
As with patients, levels of satisfaction with treatment of pain patients varies among providers. More satisfied patients tend to be receiving care from more satisfied providers. Do you know which providers in your system see a higher proportion of pain patients? How do providers who see a lot of pain patients differ from providers who see fewer? Do some providers experience more satisfaction in working with pain patients than others do? If you are lacking information on patient and provider satisfaction, use the position statement to help you create instruments and protocols for obtaining this data. This will help you find out “what’s working and what’s not” and help you use limited resources most effectively in filling in the gaps.
Information concerning patterns of utilization can help create sponsorship for pain program initiatives. Do you have access to utilization information on subgroups of pain patients? For example, can you compare utilization and satisfaction data on cancer patients who receive group behavioral treatment with data on those who do not? Can you use utilization information on a group of chronic pain patients to assess the impact of implementing a narcotic contracting protocol in your system over a 5-year period? If not, find a starting point and develop a plan to obtain and use utilization data to improve treatment of pain. Perhaps you can plan a meeting with MCO representatives to discuss common objectives related to use of utilization data on pain patients.
Last, and certainly not least important, is the measurement of work and disability factors. Do providers routinely assess the impact of pain on work and family roles? Are there specific characteristics that providers use to identify patients at higher risk of disability? For a select group of patients, the disability mindset may set in within weeks of their initial injury. If we have methods for measuring work impact and disability risk status, we can work to create disability prevention programs. Use the APS position statement to start the process of developing basic measures that assess the presence of pain patients of all ages in your system and their response to care.
The position statement can help members assess program availability, variety, and integration issues. Programs include more traditional pain programs as well as primary care programs.
Begin with an assessment of strengths and weaknesses. What programs are available and what programs are needed? If there are a variety of programs available, are they accessible in a timely manner to patients? Are programs woven together by mutually agreed-upon pathways? Is there an element of “stepped care” in the design of pain programs so that program intensity is matched to patient need? Stepped care refers to the creation of a series of programs that are meaningfully connected to one another and that are ordered from least intensive to most intensive. The stepped care approach facilitates successful matching of patients to treatments. Use the APS position statement to evaluate these aspects of programmatic treatment of pain in your community.
The APS position statement makes numerous recommendations concerning primary care treatment of pain. Do programs in your community address primary care treatment of pain? How do specialists from mental health, anesthesiology, rehabilitation, neurosurgery, physical therapy, pharmacy, and alternative care connect with primary care? If the connection is somewhat weak or haphazard, use the position statement to begin discussions about strengthening the link. Numerous programs may help you reach this goal. The availability of phone and e-mail consultation with specialists may help primary care providers to become more consistent in their methods of treating pain patients and to experience more satisfaction in treating more complex pain patients. You might propose a pilot of a multidisciplinary team that travels to primary care clinics to provide consultation services to more complex pain patients. Certainly, an easy first step in this critical area is to e-mail a copy of the APS position statement to pain treatment providers who share your interest in creating an array of interconnecting pain programs. Propose a brown bag picnic among this group to make a plan to improve pain programs in your area.
Use the position statement to strengthen efforts to evaluate pain services and programs. How are programs evaluated at present in your community? How? Who evaluates them? Who reads the evaluations? How is a treatment failure defined? What cost and clinical measures are used to evaluate pain services and programs? Useful program evaluations include multiple dimensions (physical, functional, utilization, disability, and satisfaction). Improved clinical outcomes may be associated with increased costs (Von Korff et al., 1998), and, in this case, the pertinent measure is that of value rather than cost per se. Use the APS position statement to create interest in systematic evaluation and ongoing refinement of pain services and programs.
The position statement can help members initiate educational programs to further awareness of pain evaluation and management. MCOs are going to become more interested in pain services and programs as measurement efforts bring this large group onto the MCO radar screen. APS members can also accelerate this process by meeting with MCO representatives to share facts related to the size and costs of pain in America. With more education, MCOs will be interested in cooperative development of measures that better define the group of pain patients and of programs that improve quality of care.
A related educational opportunity concerns training of primary care providers. These providers play a central role in today’s healthcare environment. They will welcome presentations that help them define pathways for treating pain patients. APS members affiliated with medical schools will also want to share the position statement with appropriate faculty members.
What do you as a pain clinician, researcher, or educator care about most? Action energized by values has more power. If your concern is with development of a multidisciplinary chronic pain treatment program, plan a meeting of key players in your area and discuss the position statement and how it can be used to fuel a chronic pain initiative in your community. If your concern is with development of empirically based guidelines for treatment of pain, initiate a discussion with an MCO concerning a pilot research project on this topic. Send the guideline to the MCO representative before your first meeting. If your proclivity is for teaching, offer to make a lunch hour presentation on the APS position statement to a local primary care clinic.
Whether you practice in primary care or specialty care, conduct research studies in an MCO, or provide training for those who treat pain patients, you are a busy person. Dozens of pain patients cross your threshold on a daily basis. As the position statement points out, pain is the most common symptom that prompts people to seek care. Regardless of your challenge (assess and treat versus study versus teach), you need to make a plan about how you will influence the process of care for pain patients. The best plans often include an assessment of needs and a mission statement that is written and shared with the larger group. Strong plans also require identification of sponsors at multiple levels.
However you decide to use the APS position statement, you are to be commended for going beyond the head-nod reaction. Go forward and implement your plan. Keep notes. Next month, evaluate it. What impact did you have? What’s going to be your next step? Stay proactive and grow in your ability to collaborate with MCO representatives to improve care to pain patients. Finally, report the results of your efforts to APS Bulletin. Help keep the APS position statement alive and living up to its potential as a catalyst for positive change.
Von Korff, M., Eaton, W., Bush, T., Lin, E., Simon, G.E., Saunders, K., Ludman, E., Walker, E., & Unutzer, J. (1998). Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression. Psychosomatic Medicine, 60, 143149.
