Pain Medicine Slowly Making Progress in Value-Based Care System

The advent of accountable care organizations, bundled payments, and other reforms under the Affordable Care Act has steered the focus of health care delivery from quantity to quality, but where exactly do pain medicine providers fit into the new value-based care model, and how can it benefit their patients? Those are the questions Ajay D. Wasan, MD, MSc, of Harvard Medical School, in Boston, MA, will explore in an afternoon session at the 2013 American Academy of Pain Medicine annual meeting.

While moderating the “Value-Based Care for Pain Medicine” session on April 12, Wasan will present findings from his systematic review of more than 2,000 prospective studies that tracked both the clinical outcomes and costs of an integrated, multidisciplinary approach to treating pain, though he said the most emphasis will be placed on managing chronic lower back pain.

“When someone presents their initial back pain, there are good value-based care studies on stratifying (that person) into high-risk, medium-risk and low-risk groups for outcome, and what those studies have found is if you stratify them into good and poor risk outcome groups, and you target resources to those at a high risk, then you show an improvement in value,” Wasan said. “Overall, we found that for multidisciplinary chronic pain care—that means seeing a provider using multiple modalities, whether it’s medications, procedures, physical rehab, psychiatric care— when providers integrated those kinds of treatments, patients did better and overall cost was cheaper.”

Though his evidence suggests an integrated health care structure will help pain medicine providers achieve the goals of the Affordable Care Act, Wasan noted “no one knows exactly what a value-based system is going to look like, because it doesn’t really exist.”

“It’s more about trying to make health care policy decisions with some sort of value calculations in mind … but even for Medicare, what’s really out there is not able to track the change in outcome divided by the change in costs, and it’s really only tracking progress measures by asking, ‘Was this collected? Was that recollected?’ For pain management, the questions are, ‘Were certain pain scores and functional scores collected?’” Wasan said. “That doesn’t exactly hold providers accountable to provide value, because right now — specifically in pain— we have some tools that do it, but nothing that’s really available on a widespread basis that’s feasible and that can go on an electronic form to collect and track clinical outcomes and costs simultaneously.”

In addition to technology for monitoring patients’ diagnosis and billing information, Wasan said pain medicine providers need cooperation from their hospital or clinical systems to commit to common goals, which he said is “where the win-win comes in” for value-based care, though he noted “that’s kind of missing in pain.”

Still, Wasan said many issues in today’s pain medicine practices — specifically regarding opioid prescriptions — could be more effectively examined from a value-based standpoint than the current system.

“A lot of criticism gets leveled at opioids, but that really kind of is a very broad brush because pain providers know there are many patients who do great on opioids, and there are some who do very poorly on opioids, and this is where a value-based system can help. Where you can show some patients do have an improvement in pain and function with relatively modest doses of opioids with low complications and very little costs, versus groups who do poorly on opioids where clearly they’re a poor choice from a value-based perspective,” Wasan said. “The opioid debate would be much clearer if there was actually a value-based approach to it, but we struggle with that for a variety of reasons.”

While it may not matter to a pain medicine physician how that data gets collected, Wasan said utilizing electronic tools is the best method to show payers, hospital administrators, and other members of accountable care organizations evidence of the value attained by delivering the most “economical and sustainable and overall beneficial care for patients.”

“You can do them by hand using paper measures because these are all standardized measures, but if you really want to demonstrate value for the care of thousands of patients, you have to capture it electronically,” Wasan said. “It’s really the only way to do it.”