Balancing Discrepant Goals in Pain Management

Balancing Discrepant Goals in Pain Management: Strategies for Balancing Patient, Physician and Other Stakeholder Needs Michael E. Schatman, Ph.D., CPE Executive Director Foundation for Ethics in Pain Care Bellevue, WA

Disclosure Nothing to Disclose

Learning Objectives Identify the conflicting stakeholders and their impact on pain care in the United States ď Ź Describe strategies for resurrecting interdisciplinary pain care ď Ź Explain how implementation of approaches to the insurance and hospital industries will further pain patient interests ď Ź

Crisis in Pain Medicine Decade of Pain Control and Research is over  The majority of chronic pain sufferers receive inadequate treatment 

The Mayday Fund. A Call to Revolutionize Chronic Pain Care in America: An Opportunity in Health Care Reform, 2009.

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No evidence of improvement in pain care, which may actually be deteriorating

Giordano J, Schatman ME. Pain Physician 2008;11:483-490.

Schatman ME. Pain Med. 2011;12:415-426.

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“…the silence…of caregivers to adequately address pain in the clinical setting has been deafening”

Rich BA. J Med Humanit. 1997;18:233-259.

Crisis in Pain Medicine ď Ź Why

are we in a crisis?

History of Profession of Medicine 

Earliest healers (witch doctors) were considered sorcerers and entertainers – supported by gifts from pleased spectators

Friedson E. Profession of Medicine: A Study of the Sociology of Applied Knowledge.

Chicago: University of Chicago Press, 1988.

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Code of Hammurabi (1750 BC) – While it questions whether physicians should be paid at all, it essentially laid out a fee structure

Warren T. Proc 12th Annu Hist Med Days 2003;12:192-198.

History of Profession of Medicine Ancient Greeks (e.g., Hippocrates, Sophocles, Aristotle, Plato) – questioned whether physicians should charge at all  If medicine is a craft (techne), then charging is okay  If it is an art, collecting fees would “be regarded as doing something typical of a hireling or slave” 

Aristotle. The Politics. Translated by Sinclair TA. New York: Penguin Group, 1981.

History of Profession of Medicine Galen (130-200 AD) – It is preferable to practice medicine for the love of humanity  Never requested fees, but would accept them if offered 

Kudlien F. J Hist Med Allied Sci 1976;31:448-459.

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Medieval Islamic physicians also questioned remuneration – “When doctors happen to make money in any way they turn to a life of ease”

Biesterfeldt HH. Bull Hist Med. 1984;58:16-27.

History of Profession of Medicine Hebrew scriptures – Humans could practice medicine, but ultimately, healing comes from God  Talmud – actually includes physician fee schedules 

Kottek SE. Isr J Med Sci. 1996;32:1147-1149.

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Medieval Europe – Physicians were either employed by royalty or paid by the church to treat parishioners

Sistrunk TG. J Hist Med Allied Sci. 1993;48:320-334.

Stakeholders 

United States – Physician fees first regulated in 1780 when the Boston Medical Society tried to prevent doctors from undercutting each other

Blumberg MS. J Hist Med Allied Sci. 1984;39:303-338.

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Massachusetts Health Insurance of Boston offered the first commercial health insurance policy in 1847

Edelberg C. Emerg Med Clin N Am 2004;22:131-151.

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This added a new stakeholder to the sacred dyad of patients and physicians

More Stakeholders 

1910-1915: A drive for national health insurance was squelched by medical societies

Light DW. J Health Soc Behav. 2004;45(Extra Issue):1-24.

1930’s: Physicians waged a fierce battle to ensure that national health insurance would not be included in the Social Security Act  1950’s: Efforts for national health insurance die due to Communist scare 

Quadagno A. J Health Soc Behav. 2004;45(Extra Issue):25-44.

• 2010’s???????????

More Stakeholders 1930: Veterans Administration created  1965: Medicare enacted  1966-1972: 49 of 50 states enact Medicaid  Federal and state governments become stakeholders  Will the role of the government as a stakeholder under the Affordable Care Act be altered? 

More Stakeholders Hospital industry in US – Pennsylvania Hospital in Philadelphia opens in 1751  For-profit hospitals – opened by physicians as extensions of their practices  By the 1920’s, 40% of our hospitals were for profit 

Gray BH. Introduction to the volume. In: BH Gray (ed.). For Profit Enterprise in Health Care, xvii-xxiii. Washington, DC: National Academy Press, 1986.

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The distinction between not-for-profit and for-profit hospitals has clearly eroded

Potter SJ. J Health Soc Behav. 2001;42:17-44.

Carreyrou J, Martinez B. Nonprofit hospitals, once for the poor, strike it rich. The Wall Street Journal. April 4, 2008:1.

More Stakeholders 

Compensation for work-related injury dates back to Code of Hammurabi, and was also part of ancient Greek, Roman, Arab, and Chinese law

Geerts A, et al. Compensation for Bodily Harm. Brussels: Fernand Nathan, 1977.

1908: Federal WC law covers workers in interstate trade  1911: Wisconsin passes first state WC law  1948: Mississippi final state to pass WC law  Employers become stakeholders 

More Stakeholders 

Pharmaceutical industry – US prescription sales grew to $320 billion in 2011

Van Arnum P. PharmTech.com. Available at: http://www.pharmtech.com/pharmtech/News/US-Spending-on-Prescription-DrugsIncreased-Modera/ArticleStandard/Article/detail/768291

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Medical device industry – 2008 AdvaMed data indicated US sales of $188.8 billion

Rosen M. Medical devices on the firing line of healthcare reform. Wisconsin Technology Network News, Oct. 27, 2009.

Stakeholders in Pain Medicine Not just the patient and physician any more • Now threatening the sanctity of the physician-patient dyad are:  Government(s)  Employers  Pharmaceutical industry  Medical device manufacturers  Insurance industry  Hospital industry

Impact on Pain Medicine 

Dissonance between pain clinicians and the other supply-side stakeholders has impacted the scope and quality of care that can be provided to pain patients

Giordano J, Schatman ME, Hover G. Pain Physician 2009;12:E265-E275.

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Most distressing is the loss of access to interdisciplinary chronic pain management programs, which have the strongest evidence-basis

Schatman ME. Interdisciplinary chronic pain management: perspectives on history, current status, and future viability. In: Ballantyne JC, Rathmell JP, Fishman SM, eds.

Bonica’s Management of Pain, 4th edition. Philadelphia: Lippincott, Williams & Wilkins, 2010;1523-1532.

Efficacy and Cost-Efficiency of ICPM Turk & Swanson 2007 metaanalysis/systematic review: Compared MCPM to medications, spinal surgery, SCS, and IDDS ď Ź All of these approaches result in equal reductions in patient-reported pain ď Ź Only MCPM is essentially devoid of iatrogenic complications and adverse events

Efficacy and Cost-Efficiency of ICPM Turk and Swanson found that ICPM is:  Less expensive  Superior in terms of:  Functional improvements  Reducing health care utilization  RTW rates  Closure of disability claims Turk DC, Swanson K. Efficacy and cost-effectiveness treatment for chronic pain: an analysis and evidence-based synthesis. In: Schatman ME, Campbell A, eds. Chronic Pain Management: Guidelines for Multidisciplinary Program Development. New York: Informa Healthcare, 2007:15-38.

Biopsychosocial Interdisciplinary Programs 

1970s and 1980s - ICPM programs proliferated rapidly; described as “medicine’s new growth industry”

Leff DN. Management of chronic pain: medicine’s new growth industry. Med World News, Oct. 18, 1976:54.

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Programs holistically emphasized restoration of lifestyle rather than pain relief per se

Meldrum ML. Brief history of multidisciplinary management of chronic pain, 1900-2000.

In: Schatman ME, Campbell A (eds.). Chronic Pain Management: Guidelines for Multidisciplinary Program Development. New York: Informa Healthcare, 2007;1-13.

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Estimated number of clinics in US “over 1000” by late 1990s

Anooshian J, et al. Psychosomatics 1999;40:226-232.

Programs in US 

200, as of 2005 (latest data)

Interstitial Cystitis Association. Café ICA. 2005;5. Available at: http://www.ichelp.org/cafeica/Vol05No04.html.

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Impossible to ascertain current number, due to programs’ tendencies to falsely present themselves as “interdisciplinary” (only 7% advertised actually met criteria)

Castel LD, et al. Spine 2009;34:615-622.

100? 125?  1998: 210 CARF-accredited programs in US  2012: 59 CARF-accredited programs in US  30 out of 59 are in Texas 

Valenga K (CARF). Personal communication, June 21, 2012.

Reason for Demise of Interdisciplinary Chronic Pain Programs in the US

Responsible Stakeholders 

Physicians – Some guilty of “nickel and diming” – adding on unnecessary services to increase remuneration and taking on patients irrespective of prognosis

Giordano J, Schatman ME. Pain Physician 2009;12:E265-E275.

Patients – Expectations of being passive recipients of pain tx are unrealistic  Pharma and Implantable Device industries – Market passive approaches  Insurance industry  Hospital industry 

Insurance Industry and ICPM Initially enthusiastic about ICPM  Became skeptical over time 

Aronoff GM. Where have we been? Where are we now? Where are we going? Clin J Pain, 1997;13:3-5.

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Became seen as “too expensive and not proven” Loeser JD. The decade of pain control and research. APS Bulletin 2003;3.

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The insurance industry made a conscious decision to ignore the prodigious evidence-basis of ICPM

Insurance Industry and ICPM Insurance carriers arbitrarily began not to pay for ICPM based on their “policies”  The ethical implications of basing a “policy” on something other than evidencebasis has been aggressively criticized 

Schatman ME. The demise of multidisciplinary pain management clinics? Practical Pain Manag. 2006;6:30-41.

Schatman ME. The demise of the multidisciplinary chronic pain management clinic: bioethical perspectives on providing optimal treatment when ethical principles collide.

In: Schatman ME, ed. Ethical Issues in Chronic Pain Management. New York: Informa Healthcare, 2007;43-62.

Diverging Ethics Physicians – Expected to operate under biomedical principles such as beneficence and nonmaleficence, with the goal of ameliorating suffering  Insurance and hospital industries – Operate under the “business ethic” of costcontainment and profitability  E.g., insurance companies have a fiduciary obligation to their share-holders, not to their enrollees 

Lo B. Resolving Ethical Dilemmas: A Guidebook for Clinicians (4th ed.); 2009.

Schatman ME. Pain Med. 2012;12:415-426.

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“There is sufficient evidence that multidisciplinary pain treatment clinics/centers are effective for the management of appropriately selected patients with chronic non-malignant pain. Studies have shown that chronic pain patients who have completed these programs have lasting reductions in pain and psychological distress. These studies have demonstrated improvements both in subjective ratings of pain and in objective measures such as reduced use of narcotic pain medications, increased rates of returnto-work, and decreased utilization of the health care system.”

Aetna. Clinical Policy Bulletin: Chronic Pain Programs. Available at: http://www.aetna.com/cpb/medical/data/200_299/0237.html. Accessed on July 3, 2012.

Hospital Industry ICPM will never be a “cash cow” due to labor intensity  Hospitals tend to terminate services that are not profitable 

Iezzoni LI. Med Care 2009;47:269-271.

Burns LR, et al. Popul Health Manage. 2011;14:69-77.

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Example of UW – the “cradle” of ICPM 

“For large American hospitals, especially those associated with a medical school, revenue generation is the major determinant of what services the institution will offer. [ICPM] is not seen as a value compared to cosmetic surgery”

Loeser JD. Foreword. In: Schatman ME, Campbell A. Chronic Pain Management: Guidelines for Multidisciplinary Program Development. New York: Informa Healthcare, 2007:v-vi.

The “Fix” - Specious Measures 

National Pain Care Policy Act (H.R. 1020) (2003) – called for:  Adequate treatment  Research  Education  Development of 6 regional pain treatment/research centers

National Pain Care Policy Act Good news: “Champions of pain” are becoming politically active  Bad news: By the time these centers would have been developed, more than 6 of the existing centers have closed down  More bad news: The bill ultimately became subsumed under the Health Care Reform Act – something had to be cut…. 

Specious Measures Congressional declaration of the last decade as the “Decade of Pain Control and Research”  There is no evidence that pain management improved during this period  Many posit that the quality of pain treatment has actually deteriorated 

Schatman ME, Sullivan J. Psychological Injury and Law, 2010;3:182-202.

Aronoff GM. Pain Pract. 2011;12:326-330.

Kulich R, Loeser JD. Pain Med. 2011;12:1063-1075.

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There is evidence that the availability of ICPM has decreased

Should We Give Up?

Strategies for Resurrection 

Pain practitioner advocacy/political & social activism

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AMA Code of Ethics (2001): “…enjoins physicians to be invested in political action that will influence policy that undermines good medical practice” American Medical Association. Principles of Medical Ethics, June 2001. Available at: www.amaassn.org/ama/pub/category/2512.html.

Fighting for Change Groups calling for obligatory social and political activism in order to help patients:  Medicine  Psychology  PT  OT  Nursing  Biofeedback

Fighting for Change Groups calling for obligatory social and political activism in order to help patients:  Medicine  Psychology  PT  OT  Nursing  Biofeedback

The Practical Solution

ď Ź

Rapprochement (n., Fr.) – to bring together, as in a reconciliation of divergent perspectives and/or values

The Necessity of Change 

Gatchel and colleagues – demonstrated that insurance practices of “carving out” adversely affects outcomes

Gatchel RJ, et al. J Work Compens. 2001;10:50-63.

Robbins H, et al. Anesth Analg. 2003; 97:156-162.

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Insurers “desire predictability and uniformity with respect to treatment services”

Kulich RJ, Adolph M. Multidisciplinary chronic pain treatment: Minimizing financial risk. In: Schatman ME, Campbell A, eds. Chronic Pain Management: Guidelines for Multidisciplinary Program Development. New York: Informa Healthcare, 2007:241-262.

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More specificity of interdisciplinary tx elements is necessary if these programs are to make a comeback

Giordano J, Schatman ME. Pain Physician 2008;11:775-784.

Change We Can Believe In? ď Ź

The plight of the chronic pain sufferer was gaining national attention as the social implications of chronic pain were becoming more explicit

Manchikanti L, et al. Pain Physician 2008;11:271-289.

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President Obama’s wider efforts at health care reform are potentially putting attention to the improvement of pain care on the back burner

We are Responsible for Change 

Despite our frustrations as clinicians, we must bear in mind (and reinforce) the role that clinicians play in the conduct, tenor, scope, and enactment of pain care — as both an individual and public “good”

Giordano J. Pain, the patient and the physician: philosophy and virtue ethics in pain medicine. In: Schatman ME (ed.). Ethical Issues in Chronic Pain Management. NY: Informa Healthcare, 2007:1-18.

Giordano J, Schatman ME. Pain Physician 2009;12:E265-E275.

• Even well-intentioned physicians may contribute to the problem by failing to practice from an evidence-basis Schatman ME. Pain Med. 2012;13:[epub ahead of print].

A New Model A paradigmatic revision emphasizing translation of pain management research to practice guidelines is necessary, and would hopefully be embraced by the insurance industry as viable means of disease management as well as costcontainment ď Ź The body of research supporting ICPM is copious and consistent! ď Ź

A New Model 

“…self-management education for chronic illness may soon become an integral part of high-quality …care”

Bodenheimer T, et al. JAMA 2002; 288:2469-2475.

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Patient engagement and participation in care has been shown to produce superior health care outcomes, including less reported pain and cost-efficiency

Von Korff M, et al. Ann Intern Med. 1997;127:1097-1102.

Von Korff M, et al. Spine 1998;23:2608-2615.

Lorig K, et al. Med Care 1999;37:5-14.

A New Model 

A strength of the Affordable Care Act is its emphasis on cost-efficiency

Hall M, et al. Ann Fam Med. 2010;8:569-569.

Buntin MB, et al. Health Aff. 2011;30:464-471.

Boninger JW, et al. Arch Phys Med Rehabil. 2012;93:929-934.

• Not only is our health care system the most inefficient in the world, but our pain care system is extremely inefficient due to the current model of fragmented care Dubois MY, et al. Pain Med. 2009;10:972-1000.

• Will the government ultimate mandate provision of interdisciplinary treatment?

Strategies for Resurrection Working with individual health care insurance plans  Actuarial concerns, not clinical outcomes, drive insurance company decisions 

Kulich RJ, Adolph M. Multidisciplinary chronic pain treatment: minimizing financial risk. In: Schatman ME, Campbell A, eds. Chronic Pain Management: Guidelines for Multidisciplinary Program Development. New York: Informa Healthcare, 2007:241-262.

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In negotiating, emphasize cost-savings to insurers

Working with Insurance Plans Present outcomes data to an insurance plan consistent with its specific needs  e.g., only workers comp will be concerned with return-to-work rates  Present data on multiple financial indicators: 

 Program

cost per patient  Program cost per patient by diagnostic code  Reduction in pharmacy costs  Reduction in inpatient hospitalization costs  Reduction in medical system utilization

Working with Insurance Plans Present program as “disease management”  Insurance carriers recognize costeffectiveness of such approaches 

Krause DS. Economic effectiveness of disease management programs: a metaanalysis. Dis Manag. 2005;3:114-134.

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The demise of ICPM may relate to a move from “pain management” (based on operant conditioning) to expensive “pain amelioration” programs (based on interventional “advances”) Kulich RJ, Adolph M, 2007.

Working with Insurance Plans Develop a broad list of admission criteria and present it to the plan  Assures the plan that only “best fit” patients will be considered  Develop a rigorous outcomes measurement/quality assurance program and present it to the plan 

Working with Insurance Plans 

Be honest with insurers!!!!!  “Two wrongs don’t make a right”  Provide the services you purport to provide  Discharge early for noncompliance  Do not extend treatment to work on characterologically-based emotional problems  However, do not become prostitutive  Example

of Washington and Workers’ Comp

Working with Insurance Plans 

Be effective!!!!  Use the available literature to start, use your own data to continue  Publish your outcomes data  Good outcomes translate to carriers referring to you – which beats fighting with them  Present yourself as “cleaners”

Working with Insurance Plans Novel approach with Managed Care Organizations:  Approach them as a consultant proposing to help develop their own in-house ICPM program  Be armed with data  Convince them that only your expertise will allow for the development of a costefficient program 

Working with Hospitals If any steps toward reconciliation are to be realistic, it is critical to question the focus and direction of hospitals’ fiduciary obligation with regard to chronic pain care  “…matters of hospital management do not figure prominently on the medical ethics agenda” 

Biller-Andorno N, et al. J Med Ethics 2004;30:136-140.

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Hospital ethics committees are more concerned with avoiding litigation than with actual ethical dilemmas

Annas G. Hastings Cent Rep. 1991;21:18-21.

Working with Hospitals Large hospitals may be good settings for ICPM programs  Significant financial resources  Instant referral base  Large hospitals may be bad settings for ICPM programs  Profit-driven  ICPM programs will never be “cash-cows” 

Working with Hospitals Market your program as a depository for difficult patients, and thereby an indirect benefit for the “cash cows”  Discuss opportunities for cross-referral  Discuss opportunities for grant-writing to supplement income  Identify a powerful ally on the hospital board 

 DON

is a good place to start

Rapprochement in Praxis By definition, rapprochement entails:  Reflective appraisement of perspectives  How differing types of information has contributed to such perspectives  How information can be exchanged and shared so as to allow compromise and intersection of values hierarchies between the parties 

Rapprochement in Praxis Focusing on the evidence-basis of ICPM grounds rapprochement to the philosophical basis and ethical framework of pain care  ICPM’s evidence-basis sustains it as a powerful tool that can benefit all stakeholders – to some extent – in our efforts to allocate limited medical (and financial) resources critical to pain care 

Giordano J, Schatman ME, Benedikter R. Pract Pain Manag. 2008;8:65-69

Toward Rapprochement Rapprochement requires:  Educating all stakeholders  Rejecting existing prejudices  Emphasizing collaboration  Helping non-medical stakeholders understand the potential long-term implications of not providing appropriate treatment on both individual and social levels 

Toward Rapprochement ď Ź

Physicians bear a major responsibility to shape the organizational cultures that support the fiduciary and professionalism of medicine, including pain medicine

Chervenak F, McCullough L. Am J Obstet Gynecol. 2001;184:875-879.

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Let us, as advocates for ICPM, lead by example

Closing Thoughts Wide-spread change in payment for pain management is not occurring in the near future  Would pain care improve if the government controlled medicine?  Clearly open to debate 

 Example

of Washington and Workers’ Comp

Schatman ME. Workers’ compensation and Its potential for perpetuation of disability. In: Gatchel RJ, Schultz I, (eds.). Handbook of Occupational Health and Wellness. New York: Springer, 2012:in press.

Closing Thoughts We don’t have to like the insurance and hospital industries  We have to find a way to work with them  Failure to do so will result in a situation tantamount to the partisan bickering in government  Just like our citizens suffering globally due to partisan politics, pain patients will continue to suffer if we cannot all learn to play in the same sandbox 

Closing Thoughts 

Activism by health care providers is perhaps the highest form of advocacy

Mahlin M. Nurs Ethics 2010;17:247-254

However, it will take us only so far in regard to helping ameliorate human suffering  Ultimately, rapprochement will be imperative if we are to truly be “champions of pain” 

Thank You