Chronic pain costs the U.S. economy $635 billion annually in healthcare services and productivity loss. Severe daily pain is associated with a 20% reduction in full-time employment, moderate daily pain with a 10% reduction. When they remain at work, employees with severe pain exhibit markedly diminished productivity. The mirage solution, opioids, has turned into a nightmare, both human and financial, which is now universally recognized.
Are our health plans helping us get out of the hole or digging deeper?
Under the Affordable Care Act, as well as under most employer plans, there is coverage for pain medication (including opioids) and for “counseling” with physicians.
Good enough? Not really. In fact, that strategy usually makes for a deeper hole.
Consider that the opioid epidemic originated with well-meaning physicians and that the only real advantage that opioids have over alternative treatment models is not that they are more effective, but rather that they are cheap.
There are effective treatments for chronic pain, but they cost more, largely involve a non-medical approach, and are not generally funded by our health plans — or else the funding is so limited that patients cannot afford the out-or-pocket costs. Physicians are not well trained in managing chronic pain; they need to be educated about how to treat pain through means other than medication. Perhaps health plans could assist here.
While the current concern about opioid abuse is obviously warranted, the exclusive focus on opioids has an element of closing the barn door after the horse has left. People take opioids to deal with their pain. Choke the opioid pipeline, as we are now doing in some states, and — surprise — opioids abusers move to street-corner heroin. We need to go beyond opioid prescription management to the root cause, which is chronic pain.
Reversing the cycle
Chronic pain is different from acute pain. It’s not just that it lasts longer, but that the pain morphs into something different. Pain sufferers enter a chronic pain cycle where they cut back on activity, which leads to reduced stamina, then to depression from the more limited lifestyle, to depression-induced problems with sleep, appetite, libido and fatigue, and to an enhanced focus on the pain. Ultimately, the sequelae overshadow the initial physical pain, and “pain” becomes the patient’s sole focus and the heart of the problem.
Chronic pain is treatable. It’s really a matter of reversing the chronic pain cycle. That means not only getting addicted patients off the meds, but also addressing the depleted energy levels, increasing activity, combatting the depression, and getting back to healthier sleep and eating regimens. To address chronic pain you need to address the various pieces that have become the problem.
How well are our benefit plans doing that today?
From what I see as a clinician, most of the money is going to treating the worst symptom (the addiction) and very little is going to the root cause. I see employers willing to spend thousands of dollars on in-patient detox (with limited long-term benefits) but balking at spending hundreds on behavioral health interventions for chronic pain that, done right, could in turn save them thousands. It’s a new wrinkle on the old Ben Franklin adage about being penny wise and pound foolish.
So, what should health plans do to get us out of the hole? Loosen the mental health purse strings. And don’t be afraid to get a little innovative.
Reversing the chronic pain cycle can be accomplished via a multi-disciplinary approach. For example, it can be done in clinics which include physicians, psychologists, physical therapists, occupational therapists, nurses, etc., all working in a coordinated fashion. Unfortunately, this approach has proven difficult to maintain from a business perspective in an environment where reimbursements are largely provided on a “per procedure” basis
The alternative is usually to have the patient attend a number of different professionals: a physician to handle the medical diagnoses, a psychologist to provide cognitive-behavioral interventions, a physical therapist to enhance activity, etc. This smorgasbord can become a new lifestyle for some chronic pain sufferers. But there is an alternative.
Real world integration
We know what works. Our challenge is to find ways to deliver those active ingredients cost-effectively and to more chronic pain sufferers. In cases where the psychological co-morbidities are not at clinical levels, I have argued that an alternative — which deserves much more attention — is to integrate the treatment components into the real world of the patient’s life. This can be done by making use of “Swiss Army knife” generalist professionals who have both the knowledge and the relevant training. Nurses are the quintessential healthcare Swiss Army knives. They are versatile and eminently teachable.
Health plans typically assign nurses to members identified as at-risk or those who have evolved into a complex claim. Early identification of members at risk for chronic pain and / or addiction should be flagged for nurse management. When educated in cognitive-behavioral techniques studies have shown nurses to be as effective as mental health therapists in clinical settings, and they may also be able to prevent opioid addiction through collaboration with the treating provider.
Using trained nurse case managers instead of licensed mental health personnel would have the twin advantages of cutting down dramatically on the cost of service delivery and of broadening the range and the number of personnel who can deliver the treatment. This is no different from what has been happening in medicine over the last several decades, and which is now reaching full bloom under the Affordable Care Act, where the first and second levels of assessment and treatment are now typically provided by “physician extenders,” the nurses and physician assistants, with the physician coming in on the more difficult cases.
Can our health plans be modified to become more solution-focused? Isn’t well past time to start thinking outside of the box?