Follow Us On
Contact Us
info@ampainsoc.org847.375.4715
American Pain Society
4700 W Lake Ave
Glenview, IL 60025
Robert J. Gatchel, PhD ABPP, and Akiko Okifuji, PhD
Editor’s note: In 2005, APS President Dennis Turk appointed Robert Gatchel, PhD ABPP, as the APS Task Force on Comprehensive Pain Rehabilitation Chair. This taskforce prepared the following summary, which outlines published results that support the clinical and cost-effectiveness of rehabilitation-oriented pain centers. The full document, Evidence-Based Scientific Data Documenting the Treatment- and Cost-Effectiveness of Comprehensive Pain Programs for Chronic Nonmalignant Pain, will be widely disseminated to third-party payers to alert them to the potential benefits of these programs.
Chronic pain is a ubiquitous medical condition. Traditionally, pain has been conceptualized as a symptom reflecting an underlying pathology. Many chronic pain cases, however, fail to fit into such a category, rather manifesting as multisystem illnesses that significantly compromise major parts of patients’ functional lives. For these cases, the standard medical approach or medication management does not seem to provide much relief. The only therapeutic approach that has shown efficacy and cost-effectiveness is a comprehensive pain program (CPP) with functional restoration as a primary goal.
The available literature documents that CPPs offer the most efficacious treatment for chronic pain patients. The growing number of randomized controlled trials from different clinical research centers in the United States and other countries provides unequivocal evidence for the effectiveness of CPPs. More evidence-based research documenting this effectiveness exists now than for any other medical treatment approach. Furthermore, CPPs have been shown to be more cost-effective than conventional medical interventions. When compared to a traditional medical intervention such as spine surgery, the long-term-treatment outcome results at 2-year follow-up are comparable, but CPPs demonstrate significantly reduced economic cost.
These results are particularly impressive given that many patients have undergone other treatments without achieving satisfactory outcomes and come to CPPs as the last resort. If those patients could be referred early or undergo preventive programs, the clinical efficacy and cost-effectiveness of CPPs would likely yield more improvement. The early intervention program (Gatchel et al., 2003) has clearly demonstrated striking therapeutic effect and cost-effectiveness outcomes for low-back-pain patients treated at the acute phase (i.e., less than 3 months since pain onset). CPPs offer a vital clinical option for persons with chronic, disabling pain problems.
Despite clear evidence of the significant long-term clinical and cost benefits of CPPs and the growing acknowledgment of the central role of outcomes in evidence-based medicine, third-party payers continue to resist reimbursing for the expenses of these rehabilitation programs. Furthermore, managed care organizations have been “carving out” portions of comprehensive, integrated programs (i.e., sending patients to different providers for their various needs outside of the CPPs), thus diluting the proven successful outcomes of such integrated programs in an effort to cut costs (Gatchel et al., 2001; Keel et al., 1998; Robbins et al., 2003). In the long run, however, the program that can help patients resume productive lives is much more cost effective in terms of healthcare, tax, legal, and general economic factors.
Indeed, a major obstacle to effective CPPs is the lack of understanding of third-party payers who refuse to cover such programs even though CPPs are known to be beneficial in significantly reducing pain and disability. Efforts of third-party payers to contain costs have paradoxically steered patients away from treatments that demonstrably reduce healthcare utilization and toward more expensive therapies with poorer outcomes. As noted by Turk (2004), “Greater collaboration is required among professional groups, consumers of healthcare services, governmental agencies, and third-party payers to ensure that the most clinically effective and cost-effective treatments are provided to all likely to benefit from them” (p. 13). This will be especially important in the immediate future with the “graying” of America. Indeed, persons 50 years and older are twice as likely to have been diagnosed with chronic pain. Epidemiologic projections suggest a chronic pain prevalence of at least 2% of the adult population (Verhaak, Kerssens, Dekker, Sorbi, & Bensing, 1998). By the year 2030, the U.S. Census Bureau (2001) has projected that about 20% of the population will be 65 years or older. Thus, the survival and continued growth of CPPs will be an important investment for health care in the future.
The misunderstanding of the cost-effectiveness of CPPs often leaves physicians in an impossible situation. Because of the multidimensional, multisystem presentation of chronic pain, they are compelled to become a comprehensive, multidisciplinary pain team by themselves. However, it is unrealistic to ask a single physician to have sufficient, detailed understanding of psychology, physical therapy, occupational therapy, and nursing to comprehensively assess and treat chronic pain. It is also not likely to be cost-effective practice. Consequently, inadequate treatment of persons with pain has been acknowledged to be an epidemic by several important organizations in the United States, resulting in the development of new standards for the evaluation and treatment of pain. The U.S. Veterans Administration and Joint Commission on Accreditation of Healthcare Organizations now require that pain be documented as the fifth vital sign (added to the other four of pulse, blood pressure, core temperature, and respiration). These organizations assert that patients have a “right” to have their pain adequately managed. In 2001, Congress passed and President Clinton signed into law a bill designating the period January 1, 2001, to December 30, 2010, as the “Decade of Pain Control and Research.” At this juncture in the decade, great advances have been made in pain management, especially in response to the cry by government and managed care officials for evidence-based data documenting the outcomes of pain management efficacy.
Gatchel, R. J., Noe, C., Gajraj, N., Vakharia, A., Polatin, P. B., Deschner, M., et al. (2001). The negative impact on an interdisciplinary pain management program of insurance “treatment carve out” practices. Journal of Workers Compensation, 10, 50–63.
Gatchel, R. J., Polatin, P. B., Noe, C. E., Gardea, M. A., Pulliam, C., & Thompson, J. (2003). Treatment- and cost-effectiveness of early intervention for acute low back pain patients: A one-year prospective study. Journal of Occupational Rehabilitation, 13, 1–9.
Keel, P., Wittig, R., Deutschman, R., Diethelm, U., Knusel, O., Loschmann, C., et al. (1998). Effectiveness of in-patient rehabilitation for sub-chronic and chronic low back pain by a integrative group treatment program. Scandinavian Journal of Rehabilitation Medicine, 30, 211–219.
Robbins, H., Gatchel, R. J., Noe, C., Gajraj, N., Polatin, P., Deschner, M., et al. (2003). A prospective one-year outcome study of interdisciplinary chronic pain management: Compromising its efficacy by managed care policies. Anesthesia & Analgesia, 97, 156–162.
Turk, D. C. (2004). Progress and directions for the agenda for pain management. American Pain Society Bulletin, 14(5), 3–13.
U.S. Census Bureau. (2001). The 65 years and over population: 2000. Washington, DC: Author.
Verhaak, P. F., Kerssens, J. J., Dekker, J., Sorbi, M. J., & Bensing, J. M. (1998). Prevalence of chronic benign pain disorder among adults: A review of the literature. Pain, 77(3), 231–239.
