Publications

APS Bulletin • Volume 8, Number 1, 1998

Pain Clinic Perspectives

Ronald Kulich, PhD, Department Editor

Managed Pain Care: The Dynamics of Pain Management

Stephen D. Lande, PhD; David Berger, MD; Bill McCarberg, MD

The challenge of treating pain under the cost-containment imperatives of managed care has had a profound impact on pain care. This has prompted the American Pain Society (APS) to form a managed care task force to seek a better understanding of the dynamics of managed care and to give pain specialists a greater opportunity to participate in the development of quality pain programs (Kulich & Lande, 1997).

To gain insight into the needs of managed care organizations (MCOs), the APS Managed Care Task Force recruited a faculty advisory board of 10 managed care physician executives and pain management experts, and conducted its first managed care executive roundtable symposium in San Francisco on September 14th and 15th of 1997. The objectives of the roundtable were to

  • examine current issues that influence the management of pain patients within the managed care industry
  • clarify the process that MCOs currently use to make referrals to pain specialists
  • understand how MCOs develop and implement care guidelines and treatment programs
  • identify approaches that APS and its members can use to demonstrate the value of pain treatments and programs and to favorably influence MCOs' medical policy

The purposes of this article are to summarize the results of the roundtable symposium, provide an understanding of the dynamics of pain management in today's managed care environment, and offer guidance to pain specialists to succeed in the managed care setting.

The problem of pain management

The roundtable focused on the perceptions, problems, and needs of MCOs that influence the provision of pain care to individual patients and the development of pain programs. Following are the roundtable's question and responses:

Question: Are pain patients overtreated or overlooked?

Responses:

  1. Pain patients receive far too much treatment over extended time periods without receiving clear benefit.
  2. Pain patients receive delayed and inadequate pain care, to the detriment of both patients and payers.

Problem areas identified:

  1. A lack of pain education received by primary care providers (PCPs) and medical directors. The faculty advisory board indicated that there is confusion about the basic nomenclature of pain, the multiple diagnoses in which pain is a primary symptom, the variety of specialists providing pain care, and the myriad of traditional and alternative pain treatments available in various regions of the country.
  2. PCPs experience a variety of problems that would prompt them to refer a pain patient to a pain specialist. One medical director indicated that “about a third of them have to do with opiate abuse, a third of them are categorized as driving the PCP crazy, and a third of them come from the PCP feeling they have nothing more to offer.” PCPs also complain that they receive too little feedback from pain clinicians and infrequently receive written care plans.
  3. Perceived abuse by pain providers. One executive said, “Being totally candid, there's a lot of suspicion among physician executives that there's chicanery in this field. We not long ago found that we were sending a patient to a pain center and he was getting magnet therapy. ” There was concern that too much testing and treatment would result in iatrogenic illness, thereby further increasing utilization and cost.
  4. The difficulty of measuring pain program outcomes. The faculty advisory board recognized the complexity of quantifying the outcome of pain programs and indicated the need to evaluate the cost, benefit, and quality improvement of any clinical program. One executive commented, “Every 3 years NCQA [National Commission for Quality Assurance] comes to the health plan and they want you to have programs that were successful at improving quality. If the [program] flops, you lose points. So you have to think very hard about where to put your resources."
  5. The lack of clear-cut clinical pain guidelines, particularly those based on outcomes research rather than “consensus” documents.

Current MCO pain programs

The faculty advisory board included representatives from the following types of managed care payer systems:

  • staff-model health maintenance organization (HMO)
  • network-model health maintenance organization
  • multispecialty medical group
  • integrated delivery system

In general, many staff-model HMOs claim to have formal pain programs, whereas multispecialty medical groups and independent provider associations (IPAs) rarely have pain programs, or refer outside the group or IPA for any treatment. However, they typically approve all referrals to pain specialists as long as the specialist is already a member of the group or IPA. In contrast, one physician executive from a multispecialty medical group indicated that he administers a comprehensive pain program with 10 treatment protocols for 10 separate pain diagnoses.

The mechanism used by most MCOs to identify patients in need of a pain program is the overuse of treatment resources. This means that patients with excessive urgent care visits, emergency room visits, drug use, and specialty consultations may be referred to a pain program. The faculty advisory board expressed the need for better methods of identifying patients at risk for excessively high levels of utilization.

Targeting MCOs for pain program development

A proposal for developing an MCO pain program should make good, solid business sense. One faculty advisory board member said, “We've got a lot of solutions running around, but the question is, What is the size of the problem? How do you define it? What are the potential benefits [of offering a pain program]?” The MCO requires a projection of the return-on-investment for putting significant resources into any new program.

Proposal development

The proposal should recognize the needs and incentives of each of the program's customers: the MCO (payer), the employer (purchaser), the PCP, and the patient. The proposal must demonstrate added value for the MCO, and should include the following features:

  1. Delineate different types of pain disorders and provide clinical guidelines for each disorder. The use of evidence-based guidelines are clearly preferred over consensus-based guidelines.
  2. Include screening protocols to identify patients at risk for high levels of healthcare resource utilization. PCPs need help identifying patients who are at a point in treatment at which referral to a pain program is appropriate (the “red flag moment"). The philosophy is to quickly put "the patient in the hands of the expert that knows how to best manage this patient."
  3. Use less costly, time-limited treatments. A number of faculty advisory board members shared a preference to “shift [treatment programs] away from a procedural orientation to a behavioral...orientation," and to include a mechanism for establishing the endpoint of treatment.
  4. Specify which providers are required to treat which disorders. Establish a method of credentialing the providers. The advisory board recognized that pain is a multidimensional problem requiring a multidisciplinary treatment team. One faculty advisory board member said, “It's not just about physicians. A lot of it is about other providers on the healthcare team."
  5. Provide a mechanism for tracking outcome. The outcome measures most often used by MCOs are utilization costs, patient satisfaction, and functional improvement. The MCO also would benefit from a continuous quality improvement component that would help the plan meet NCQA requirements.
  6. Develop an educational plan both for PCPs and patients. One faculty advisory board member commented, “You're going to convince the primary care physician groups that you have a valuable program not by showing them how you save money, but by showing them how you can make it easier to manage these patients that are tremendous headaches to them."

Financial contracting

Contracting with the MCO payer may take a number of forms:

  • discounted fee-for-service
  • case rate (i.e., a global fee for a specified period of treatment)
  • capitation (i.e., a fee per member per month for all patients in a specified population)

The faculty advisory board recommended shifting the risk for treating pain patients from the payers to the pain program providers. Although several pain programs use case rate contracts, the faculty advisory board was not aware of any pain programs that are currently under a capitated contract.

Future MCTF programs

The managed care task force's strategic plan for future programs includes a series of regional managed care executive roundtables. The goal of the regional roundtable series is to examine regional and individual MCO differences that might influence guidelines for pain care and the development of a pain program. APS hopes to form ongoing relationships with MCO executives in each region, with the aim of improving the quality of pain care, education, and research at MCOs.

Managed pain care handbooks series

APS is planning a managed pain care handbook to help pain specialists provide pain care services and develop pain programs in managed care settings. In response to the faculty advisory board's suggestion that managed care medical directors, as well as pain patients, would benefit from further education about pain disorders and treatment, we are considering two other handbooks.

The MCTF is planning a professional development course as well as additional APS Bulletin articles on managed care topics. We welcome your comments, suggestions, and contributions to this important effort.

Authors' note: For a review of managed care terms and financing mechanisms, see The Managed Health Care Handbook(3rded.), (1996). Chicago: American Medical Association.

Reference

Kulich, R., & Lande, S. (1997). Managed care: The past and future of pain treatment. APS Bulletin,7(4), 1.

Acknowledgment

The managed care executive roundtable was supported by an unrestricted grant from Ortho-McNeil Pharmaceuticals.

Stephen Lande is executive director of Biohealth Pain Center in Bala Cynwyd, PA, and clinical assistant professor of psychiatry at Allegheny University of the Health Sciences in Philadelphia. He is also founding president of the Greater Philadelphia Pain Society. David Berger is a clinical associate professor of anesthesiology at Stanford University in Stanford, CA. Bill McCarberg is physician-in-charge of the Chronic Pain Management Program and is coordinator of pain services at Kaiser Permanente in San Diego.

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