A well-managed pain management center is more than an economically successful pain clinic; it also provides high-quality multidisciplinary care that meets the changing needs of today’s health care environment. Health care is in the initial stages of what is likely to be unprecedented change induced by unsustainable health care inflation and the growing realization that this level of expenditure has not led to uniformly world-leading outcomes.1 The targeting of health care waste such as duplication of services; patient noncompliance; emphasis on doing, not preventing; and incentives that drive reactive care and utilization of services in an episodic manner are all mentioned as cost drivers. Just 1% of the U.S. population consumes 22% of health care expenditures. The magnitude for 5% and 10% of the U.S. population is also as striking.2 There is also a widespread notion that chronic diseases such as heart disease, diabetes, and cancer are examples of cost drivers. Yet as recognized by Gaskin and Richard, chronic pain’s cost exceeds the cost of heart disease, diabetes, and cancer combined.3 Yet chronic pain is rarely recognized by health care policy debates for the impact it has on expenditures overall. According to the Institute of Medicine report, there are 100 million Americans with chronic pain at a cost of $635 billion per year for treatment and lost productivity. Yet there is only one pain specialist per 33,000 patients.4 A forward-thinking pain management center that is prepared to deliver services in a timely, efficient manner and can provide high-quality services within the framework of rapidly changing delivery systems will have significant opportunities in this new era.
Earlier attempts at controlling the cost of health care using coordinated care models such as disease management programs did not work because of the cost needed to established and maintain these programs and the lack of coordination of care among specialties.5,6
For these changes to occur, a movement away from fee-for-service reimbursement schemes to a value-based reimbursement model needs to occur.7 The insurance industry has initially been slow to adopt these changes. This inertia is beginning to break.8 This transition period will be difficult for all practices but particularly for specialty practices such as pain management centers. More than ever, keeping track of outcomes and what value interventions bring to value-based care will be required for pain management programs.
Medical practices of all types will need to understand the implications of new types of organizations and payment models. The complexities of transitioning a practice from fee-for-service to these new care models will require in-depth planning and establishing new partnerships while closely tracking local trends and understanding the implications of regulatory implementation at a national level. Some of these new types of organizations and payment models include the following:
The patient-centered medical home (PCMH) is a care delivery system that seeks to enhance the communication between high-cost patients and their primary care providers. PCMH has been suggested for primary care practices as a vehicle to take advantage of value-based reimbursement. The potential value of a PCMH is to control costs by keeping patients out of the hospital by improvement in care coordination and improvement in the management of their chronic diseases. Some commercial insurers have been willing to pay an enhanced per-member, per-month, or care management fee per patient in these PCMH practices. Practices interested in this new care delivery system often become certified by the National Council for Quality Assurance (NCQA) to achieve this designation. The following checklist for primary care doctors considering a change of practice focus to patient-centered care model has been suggested and reviewed.9,10
Access to care
Access to patient records 24/7
Freedom of patients to select their own physicians
Secure e-mail for communication with patients
Web portal for patients to request prescription refills, laboratory results, schedule appointments, and so on
Policies and procedures to overcome patient’s barriers to care, such as transportation and cognitive barriers
Linguistically and culturally appropriate services
Engaging patients in decision making
Understanding patients’ health goals and priorities
Providing and reviewing with patients condition-specific decision aids
Understanding patient treatment preferences and ensuring follow-up of these
Practice supports patient self-management
Document patient and caregiver self-management abilities
Motivational coaching for patients
Engage family and caregivers in care plans
Offer health coach support
Assess and improve patient’s experience of care
Regular patient satisfaction surveys
Patient advisory panels to guide practice and quality improvement
Patient focus groups
Bundled payments is a concept that seeks to reimburse different providers with a single payment that traditionally has not been paid together or is usually paid through different payment methodologies. Examples include hospital services paid by diagnosis-related groups and physician-paid fee-for-service. Bundled payment programs may make one payment to a hospital, which is then responsible for distributing a portion of that to the physicians taking care of the patient in a single admission. This bundled payment approach provides full reimbursement for a single episode of care and all the services that are required for this hospital admission, including even postdischarge care related to the admission. Some programs retroactively include any charges for diagnostic testing that occurred even before the admission.
Accountable care organizations (ACOs) is a term used to describe an organizational structure that allows health insurers to share some cost savings with primary care practices. Physicians are still paid for charges in the usual manner, bundled payment, and percent of global capitation, episode or care payments, or some form of payment plus bonus if cost saving targets are met. If a cost savings threshold is achieved, the practice will share a portion of this savings with an insurance company or Medicare. Virtually all ACOs have entered in some form of bundled payment program and have integrated into their practice measurement of outcomes such as quality performance, practice efficiencies, or patient satisfaction. ACOs usually have a PCMH approach as part of the practice. ACOs have rapidly increased in number.11 The primary reason for this has been demonstration of the bending the cost curve of care in dual eligible patients who are usually considered the most difficult patient populations for cost containment. These populations have a high incidence of emergent visits, controlled substance misuse, and problems with compliance and following through with treatment recommendations for their chronic diseases.
All of these new approaches have one thing in common: varying degrees of risk for outcomes are being shifted to providers. Yet patients with chronic diseases spend most of their time away from their doctor and health care systems, and most of our patients’ decisions affecting their health are made outside the doctor’s office away from physician’s watchful eyes.12
Improving patient satisfaction is another area of increasing importance for all health care providers. High-quality pain management is a very important component of patient satisfaction.13 Patients’ satisfaction with their health care has been identified as an important outcome measure by Centers for Medicare and Medicaid Services. Both the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) contain rules implementing health care consumer feedback. Results from this feedback will soon impact reimbursement for both inpatient and later outpatient visits.1,14,15
Pain management centers have had long-standing credibility issues with payers. Costs of care, narrowly focused specialty specific care, seemingly endless treatment without end points, and unsubstantiated subjective outcomes have resulted in chronic pain management programs being placed under increasing scrutiny.16,17 Meanwhile, numerous studies have documented that multidisciplinary pain management centers have better outcomes. These studies have shown that multidisciplinary pain management centers provide improved care, are cost-effective, and have improved long-term outcomes.18–20 Anesthesiology as a specialty is expanding beyond its traditional role in the operating room to provide leadership in the treatment of chronic pain.21 Anesthesiologists have an opportunity to participate in the development of and provide leadership in the development of multidisciplinary pain management centers of excellence. To succeed in this role, anesthesiologists must recognize the complexity of chronic pain.16,22,23
The successful treatment of chronic pain requires the understanding that chronic pain is a multifaceted problem. Chronic pain is not only a sensory complaint; it also has profound impacts on a patient’s affect, social circle, vocational pursuits, and cognitive abilities. Pain management centers of excellence understand the unique needs of each of their patients and provide cost-effective care based on those needs. A pain management center that seeks to develop its referral base to include ACOs and practices that support patient-centered care must have in place the resources and systems that will have the ability to provide expertise to treatment pain on site in the ACOs and efficiently accept patients that will underpin the goals of the practices.
The characteristics of a well-managed pain management center that is set up for success in this rapidly changing environment are:
The recognition that chronic pain is a multifactorial problem that requires specialized care delivered by a team of specialized providers with a full-time commitment to the treatment of chronic pain
The organization of the pain management center administration is set up to recognize that different patient groups are affected by chronic pain and understand new practice structures and their requirements for success
Specific emphasis on accessibility and customer-focused initiatives that enhance treatment outcomes improve customer service and facilitate referrals
Recognition and planning for outcome measures that understand and trace the specific outcome important to specific payer classes while also supporting local ACOs in their mission
Creation of a network of mutually beneficial relationships that sustain the center’s growth with the center’s various customers, including hospital administration and payers
Innovative products and services to help patients recover all aspects of their lives as part of a continuum of care
The commitment to increase the visibility and viability of pain management as a specialty, working within care teams supporting global payments and supporting an institution’s initiatives
Single-modality pain management centers that emphasize procedures and short-term relief that these blocks produce do not meet the previously mentioned objectives. An overemphasis on procedures for short-term relief serves only to enhance the perception of disability and does little for the long-term pain management problems that need to be solved for enhanced patient function. In addition, the economic viability of a single-modality approach is increasingly unlikely. Well-managed pain management centers are organizations that are equipped to manage all aspects of chronic patient disability. A broad focus such as this requires long-term commitments toward multidisciplinary team and program development.
Formulating a strategy is key for successful program development. Separating a multidisciplinary pain management center into smaller elements or key components can facilitate the developmental process. These elements are:
Organizational structure and administration
The medical treatment continuum
Trained interdisciplinary team
Key patient groups
Information and outcomes management
Fiscal management and business planning
KEY COMPONENTS OF A PAIN MANAGEMENT CENTER OF EXCELLENCE
In the following sections, each of these elements is examined; strategies are suggested that will lead an organization through the different stages of growth toward a pain management center of excellence.
More than ever, chronic pain management centers are under constant pressure to improve performance and integrate their unique specialized knowledge into developing multidisciplinary episodes of care, overcoming the image of procedural-based service that is viewed by many skeptical payer organizations as a large financial burden without appropriate returns. Chronic pain remains one of this country’s primary public health problems. Centers of excellence provide the leadership and advocacy necessary to influence the attitudes of the local community about pain management services.
This component recognizes that the organizational foundation of a pain management practice is important to achieve these objectives. These objectives are achieved through the following:
Mission statement developed by the interdisciplinary team
Showing a complete commitment to the discipline of pain management with full-time staff and board certification such as the added qualifications in pain offered by the American Board of Anesthesiology and the American Academy of Pain Medicine
Developing key relationships with affiliated institutions and working toward complete integration of pain management services in all aspects of health care
Development of a governing body that includes members from various interest groups that are representative of patient groups treated by the pain center
Formation of a dedicated organization providing the foundation from which a pain management center can build
The pain management center must initially make the needed alliances to ensure that the appropriate resources are available. This can be in the form of informal professional contacts forming actual contractual links with pertinent organizations such as drug addiction treatment centers or vocational rehabilitation organizations. Developing an appropriate continuum of care requires not only considerable effort to identify appropriate personnel who have an interest in treating chronic pain; it also requires ongoing interactions with referral sources and payers to determine the necessary resources required to fund a treatment continuum. Determining the type of treatment to be included in the treatment continuum requires an understanding of the needs of the referral sources as well as the patients. Understanding this requires the tracking of referral sources, treatment outcomes, and patient satisfaction along with the demographics of all patients seen.
Intensive training in advances in pain management and allied interests, such as enhancing return-to-work rates, keeping patients out of emergency rooms (ER), strategies to identify patients early at risk for developing chronic pain, and research on adaptive appliances for disability, must be ongoing. This training also lends itself to team building, which is a vital component of a multidisciplinary center. The synergism that occurs during team building will improve outcomes and enhance customer satisfaction. Developing a pain management center of excellence requires a substantial investment in time and personnel to develop the needed resources as previously described to treat chronic pain.
Processes of care for chronic pain require team interactions. The physical facility should be developed to enhance interdisciplinary team interaction. In addition, as the practice grows, the facility must have enough space that can be allocated to facilitate the integration of medical management services, various psychotherapies, and individual and group as well as rehabilitative therapies in one contiguous building. This integration of services or interdisciplinary treatment approach will have a positive impact on patient outcomes. Tight coordination will exist among the disciplines for patient conferences and team interaction. The facility should be designed to enhance patient comfort and confidentiality as well as convenient access for patients with disabilities. The physical facility should have enough space for family conferences so that family members can also participate in the rehabilitation process. Although a pain management program must have a home base, provision for outreach programs is increasingly important. Having only one central location can become a barrier to PCMH initiatives. Advanced planning is required to ensure that outreach programs are economically viable.
As the pain management center grows, clinical problems tend to increase in complexity. There becomes a need to customize a treatment plan for each patient. Rational customizing of treatment plans requires a framework to classify patients into similar groups and develop an understanding of their unique needs. The emphasis on treatment being both cost-effective and efficient must lead to an understanding of how to optimize the treatment to these groups of patients.24 Treatment of chronic pain requires a triad of therapies: medical management, behavioral intervention, and physical rehabilitation. The assessment of a chronic pain patient must lead to an understanding of the patient’s needs in each of these areas. This assessment could then lead to the classification of the pain syndrome using a combination of various tools available today. The International Association for the Study of Pain (IASP) taxonomy of pain provides both an axis tool and a list of chronic pain diagnoses that can provide a framework for the optimization of treatment plans. Because psychological factors often figure prominently in chronic pain diagnosis, additional understanding of patient subgroups requires a means of stratifying the IASP diagnostic groups. Many different evaluation tools exist that can quantify the impact of disease on the patient’s physical and psychological functioning. Using this multidimensional approach allows further subclassification of patients.25 The data collected allow efficient customization of an individual patient plan, as well as the accumulation of data along with outcome data that facilitates quality-improvement activities.