Chronic pain is the black hole of medicine, wrenching energy from healing and drawing patients and physicians into a vortex of recrimination and paralyzing self-doubt. Ignorance, prejudice, grievance, fear, failure — troubles swirl around the chronic pain patient.
So most patients go undertreated for pain. They certainly aren't helped by their health plans. Most plans don't even identify their chronic pain patients, at least not until the dollars reach a critical mass, and then plans have little idea what to do.
"Managed care organizations have not focused on chronic pain, not the way they have on other high cost, easily identifiable chronic diseases," says Stephen Lande, PhD, former chairman of the managed care committee of the American Pain Society (APS). "They should make a commitment to understanding the medical and financial impact of chronic pain and its treatment on their members."
Behind the times
A survey of 118 health plan medical directors was conducted recently by researchers associated with Thomas Jefferson University in Philadelphia to determine the extent to which managed care organizations are managing chronic pain. The results were not heartening, and may, in fact, be worse than reported, according to some experts.
Fewer than half (42 percent) of the medical directors were willing to even hazard a guess as to how many of their patients suffered from chronic pain. Of those who said they did know or were willing to speculate, the majority said they believed fewer than 15 percent suffered from chronic pain. Most (40 percent) believed it was less than 5 percent.
Not surprising, then, only a third of the surveyed MCOs had some kind of formalized mechanism for identifying members with chronic pain and only 18 percent systematically used clinical practice guidelines for pain management. For the most part, health plans view pain management as pain medication management. (See "Plans Manage Pain Primarily Through Formularies," on page 22.)
Barrier to treatment
Further, in a 2000 study of pain treatment and third-party reimbursement in Connecticut, researchers identified inadequate insurance coverage as a barrier to adequate pain treatment, a perception shared by physicians and patients who participated in the study.
"Our interviews with representatives of Connecticut health care institutions, including nursing homes, hospice, home health, and pain centers, indicate that many institutions find reimbursement difficulties to be an obstacle to adequate pain management within their respective settings," says Diane Hoffmann, director of the University of Maryland Law School's Law and Health Program.
About half of the Connecticut physicians surveyed thought MCOs create obstacles when physicians try to refer patients for treatment of moderate or severe pain, and many physicians said they have been denied payment of, or approval for, pain management interventions, the study shows.
"These physicians identified MCOs as the third-party payer most likely to deny approval or reimbursement for pain treatments," Hoffmann says. The most common reasons given for denying approvals or payment were that the treatment was not covered by the patient's policy, the patient had exhausted his or her benefits, the treatment was unnecessary, or the treatment was not as efficient as other treatment methods, she says.
Untreated or undertreated chronic pain costs health plans and their purchasers a lot of money. It afflicts 40 million or more Americans, with a price tag of nearly $100 billion a year in direct medical costs and indirect costs, such as lost productivity and workers' compensation, according to the APS. Most primary care physicians are not adequately treating pain, primarily because they are not trained to do so and because they are afraid of litigation and regulatory restrictions.
"Fear is a big problem for physicians, fear of having licenses revoked, being pulled into something they can't handle," says Richard Payne, MD, chief of the pain and palliative care service in the department of neurology at the Memorial Sloan-Kettering Cancer Center in New York and an expert on pain management in palliative care. (See "Physicians Have Cause To Be Afraid," on page 24.)
"The problem for health plans seems to be lack of awareness of how bad the problem is of untreated pain," says Payne. "Physicians are not well trained; they need to be educated about how to treat pain, what remedies are available. That can be a role for health plans."
Managing pain and preventing chronically ill and dying persons from suffering needlessly is cost-effective, though relatively few health system medical directors appear to think so, says Sharon E. Melberg, assistant director of general nursing services at the University of California Davis Medical Center. She has studied and written about pain management in hospital settings.
For example, persons suffering unremitting pain commonly move about less, eat less, and breathe more shallowly than pain-free people, all of which contribute to the development of pneumonia. The cost of narcotics and provider supervision of their use is far less than that of an extended hospital stay, yet provisions for the routine dispensing of pain medication generally are not in place in health plans. "Untreated pain leads to increased lengths of stay, as well as an increased need for staff time," says Melberg. "The cheapest thing you can do is manage pain."
Managed care plans should treat chronic pain as a chronic disease, because that's what it is, say Lande and others. That means applying disease management principles.
"It used to be thought that everyone felt pain the same way," explains Bill McCarberg, MD, physician director of the Chronic Pain Management Program at Kaiser Permanente in San Diego, one of the first multidisciplinary pain clinics. "That it was purely a chemical electro-physiologic perception within the brain. But there is an emotional aspect to pain as well, and they cannot be separated."
If treatment of chronic pain followed disease management protocols — treating the patient in an integrated, progressive fashion rather than symptomatically — it would reduce overall health care costs and reduce suffering, say experts. So why isn't it happening? Why aren't doctors treating chronic pain aggressively? Why aren't the health plans that pay the bills helping them, and how does a good program work?
The first problem faced by plans is identifying patients. That's hard because no definitive biological markers of chronic pain exist, and the most accurate evidence of pain comes from patients' descriptions. The lack of objective measurement instills suspicion in providers, and MCOs need referrals from physicians to make their pain programs work.
"The root cause of difficulty of appropriately managing chronic pain stems from the complexity of the disease itself," says Lande, who is also executive vice president of Interactive Forums, a health care consulting company. "The underlying pathophysiology is difficult to measure objectively. For example, a patient with severe low back pain may or may not have disk herniation, and there may or may not be any clear-cut radiographic findings. Physical, psychological, legal, social, economic, all these factors are implicated in the treatment of chronic pain."
A second problem is that physicians are afraid of being prosecuted if they treat chronic pain aggressively with opioids, which are controlled by the Drug Enforcement Administration. Therefore, providing accurate information on the proper use of pain medications is an important part of any managed care pain program. Misinformation about opioids flies in the face of recent research that's shows opioids can be a highly cost-effective means of controlling pain, with a minimal risk of addiction in the large majority of chronic pain sufferers.
"They have reason to be afraid," says Mary Baluss, a lawyer and director of the Pain Law Initiative. "State boards like to make examples of physicians, and prove to prosecutors they are able to control the problem."
She says a lot of physicians don't know what they are allowed to do in treating pain. Plans could enhance the quality of care by creating hot lines that inform doctors about appropriate treatments and dosages. "That would be a cost-effective way to make sure people were receiving the help they need from their own doctors and staying out of emergency rooms for their pain," she says. "It would make physicians feel supported, because they are scared to go it alone."
A third problem is that treatment can be expensive — many medical directors believe treatment is too expensive to be cost-effective. A multidisciplinary pain program that lasts from two to ten weeks can cost more than $15,000, according to McCarberg. Compared with the expense of other chronic conditions, the annual costs associated with chronic pain exceed even those related to heart disease, hypertension, and respiratory disease, he says.
But untreated chronic pain is more expensive, say McCarberg and others, because it leads to a significantly increased level of utilization. Those with chronic pain are five times as likely to utilize health care services, and 58 percent of them experience symptoms of depression or anxiety, comorbidities that increase the utilization of health care resources.
The average patient with chronic pain has had symptoms for seven years, has undergone three major medical procedures, and has generated medical bills between $50,000 and $100,000, McCarberg and others have found.
Managed chronic pain would not eliminate all those costs, of course, but an effective pain management program is, by definition, cost-effective, says Marilee Donovan, PhD, manager of the Kaiser Permanente Northwest Regional Pain Management Clinic. "We totally integrate our program with primary care physicians," she says. The program has three components:
- An education program directed at physicians that provides the information needed to identify patients suffering from chronic pain, and provides a mechanism to report those patients to the health plan.
- Pain management groups for patients, offered throughout the region. Patients attend for seven weeks, two hours a week. They are taught self-management techniques, including cognitive therapy and biofeedback, and are given information on the appropriate use of medications and treatment alternatives.
- A consultation with a pain specialist, with a detailed report to the PCP.
The program has been very effective in physician education, says Donovan. When she started the program in 1996, all her patients said that they had been referred to the program "because their doctor told them the pain was in their head; their doctor just didn't believe them. Today, we hardly ever hear that."
Programs like Donovan's are successful because they begin with patient identification. "That must be the first step for MCOs to address this issue in any kind of serious way," says Russell Portenoy, MD, chairman of the department of pain medicine and palliative care at Beth Israel Medical Center in New York.
Lande agrees. He sees managed care implementation of pain management as a five-step process:
- A commitment of resources to the problem of chronic pain as a disease management problem.
- Identification of chronic pain patients, who are often high-end users of resources.
- Development of proper assessment mechanisms.
- The availability of a multidisciplinary treatment team, including an anesthesiologist specializing in pain medicine, a behavioral medicine specialist, such as a psychiatrist or psychologist, a physical therapist, a rehabilitation medicine specialist, and a case manager.
- The development of protocols that integrate behavioral, medical, and pharmaceutical care.
A recent analysis demonstrated that the Kaiser NW program saves the plan about $1,000 per patient. "Managing pain effectively reduces utilization," says Donovan. "It's that simple."