Pain Medicine and Healthcare Reform

Daniel B. Carr, MD, DABPM, FFPMANZCA (Hon) opened the Thursday session of the American Academy of Pain Medicine’s 26th annual meeting with a frank discussion of healthcare reform and its expected effects on the practice of pain medicine, and his story began with a story, of a meeting of French and American pain management specialists.

The two groups were discussing the standard protocols for end of life care in each nation, and the French never really came to grips with his explanation that, in the United States, end of life care is largely dictated by a patient’s insurance. The French physicians assumed that the language barrier was preventing them from adequately understanding the explanation.

Unfortunately, the French had understood it all too well, which would explain the utter confusion. But this stems from what Carr claims is the nature of healthcare in the US. “The United States healthcare system is not even a system. It is a complex set of relationships influenced by many things. Common sense rarely explains what’s going on.”

But that is not to say that the system is entirely broken, says Carr, citing an article in the Wall Street Journal that found quite a few healthcare statistics of which the United States could be proud. Cancer, HIV/AIDS, hepatitis, and infant mortality rates, among others, are all down since the 1990s, all admirable achievements.

And yet, despite this, gaps remain. Rates of obesity and heart disease are nowhere near under control, teen pregnancy in on the rise, and tens of millions are without health insurance. So with the good comes the bad, and despite what you might infer from the acrimonious healthcare reform debate, there is consensus about certain things that need to be done to remedy these persistently negative American health issues.

On what do we agree?

1. Insurance needs to be regulated (though there is no consensus on the degree),
2. The Medicare doughnut hole needs to shrink,
3. Everyone should have insurance and people should keep the insurance that they receive through their employer.

Though that’s where the consensus largely ends, those are three major points on which to agree, and in the end, these points are really sub-agreements about a larger, shared goal: reducing the cost and increasing the effectiveness of healthcare delivery.

It’s a well-known fact that the United States is “an outlier in per-capita expenditures,” but does not produce outcomes commensurate with such a large expenditure. This reality is ineffective, and more importantly, unsustainable.

So how then is this to be fixed?

Coordination of care

Hussey et al. argue that the most effective means of controlling healthcare costs is to eschew the fee-for-service model for a “bundled payment” model. This, they said, offered the greatest promise, and is where the effects of healthcare reform will begin to affect the practice of pain management.

The other proposals that Hussey et al. considered in their analysis were expanding the role of nurse practitioners and physician’s assistants, implementing health IT, focusing on disease management, hospital rate regulation, retail clinics, benefit design, and the medical home.

When you consider each of these proposals together, they all seem to point toward a more proactive approach to both payment and care than is currently practiced. Carr says that the crux of an effort like this would center on the medical home, or as he termed it, the Accountable Care Organization (ACO) model.

This concept has a number of forms, but according to Carr, distilled they all basically integrate a primary care group, a specialty group (we’re talking pain specialists here), and the hospital. In such a model, a patient has a primary care physician orients care through parallel acute, chronic, and preventive care strategies. This is done through initiatives such as case management, planned visits, agreements with specialists, and providing enhanced access (not denying care on nights or weekends).

Anyone having dealt with the fragmented records of a patient’s care history can appreciate the ways in which this would eliminate the frustrations of guessing at knowledge gaps and being uninformed of another provider’s treatment goals.

The problem, though, becomes one of commission. Some of these ACO models include extensive use of health IT, bio-surveillance, public health databases, and evidence-based treatment models. For some specialists, such resources just wouldn’t be available and/or their cost would become increasingly prohibitive. However, the tools are there. It is merely a matter of figuring out what works within any given practice or practice area.

Pain Medicine’s Stake

Largely, Carr says, the pain community is on board with such a model and the healthcare debate “has produced a remarkable convergence of viewpoints in pain circles,” namely that:

1. Pain control is fundamental human right;
2. The community has recognized that acute, chronic, and cancer pain are widely prevalent and have substantial direct and indirect burdens;
3. Undertreated pain undermines a person’s quality of life;
4. Minorities have unequal access to care which affects them more because early preventive care eases subsequent pain control;
5. Pain “is disease per se,” and when treated in a fragmented manner, is both costly and ineffective;
6. The role of the primary care physician is hugely important;
7. Comprehensive pain care should be the medical standard.

Carr points to an emerging pyramidal treatment model that reflects this changing dynamic, one in which the foundation of pain treatment is the PCP, the center being shared management between PCPs and specialists, and at the top, the pain specialist who steps in when the PCP is unable to effectively manage a patient’s pain. The AOC model, Carr says, can accelerate this movement to the new pyramid model, while comparative effectiveness research can strengthen it through evidence-based medicine.

What more to do?

To further enhance the ability of the pain community to provide effective care, Carr believes in the importance of individualization of treatment and the need for pain specialists to unite with one voice behind causes in which it has a stake.

Otherwise, he emphasizes again that universal health coverage is an important issue, but less so than the impact of integration of care, which demonstrates the value of the practitioner and provides a research base for the interventions that pain specialists perform.