Transcript to view the presentation! - Pain Specialists of Greater Chicago

Interventional Pain Management and
ACOs- Reducing ER Visits,
Hospitalizations and Re-Admissions
Scott E. Glaser, MD, DABIPP
President, Pain Specialists of Greater Chicago
www.painchicago.com
Physician ChallengesThe Future is Now
• Medical landscape inalterably changed
by market forces and the ACA
• Physician independence (business and
clinical decision making) constrained
• Specialists selling practices to hospitals
or medical groups increasingly common
• 90% of residents expect to be employed
by hospital/medical group
Overarching Goals of ACA
through ACOs/Population Health
• Reduce costs for episodes of care and
treatment of medical conditions and
syndromes
• Incentivize providers and locations of
care to search for cost savings through
sharing in those savings
• Incenting doctors in this manner may
lead them to violate their credo to
promote access to appropriate care
Achieving Goals of ACOs
• “Low hanging fruit”-emphasis on
reducing care delivered in hospital (ER,
OR, and inpatient stays) through
strategically managed outpatient care
• Incentives and penalties- Carrots and
sticks, not a strategy, destined to fail
• Interventional Pain Management (IPM)
physicians working with ASCs uniquely
positioned to bend cost curve and
improve outcomes
Goals of This Presentation
• Highlight direct and indirect costs of
care for acute, subacute, recurrent, and
chronic pain, especially musculoskeletal
pain, especially spinal pain
• Review current paradigm and drivers of
poor outcomes, excessive costs, low
patient satisfaction
• Reveal new paradigm to improve
outcomes and patient satisfaction and
mitigate costs
Costs of Musculoskeletal Pain
• Bone, joint and muscle pain lead to 197
million visits to doctors’ offices, ERs, and
outpatient surgical facilities annually
• Musculoskeletal pain costs the US $254
billion per year
• One in 7 Americans (36.4 million people)
have musculoskeletal pain and impairment
that limits or decreases their ability to function
at home, work, or at play
• Two thirds of Workers Comp cases
involve painful conditions of the
musculoskeletal system
What is Musculoskeletal Pain?
• Pain can initially be from muscle,
ligament, tendon, joint, nerve
• Strains/sprains improve with time
• Persistent pain indicates joint or nerve
injury/inflammation
• Spine is most common location of
persistent pain
Costs of ER and Inpatient
Treatment of Lower Back Pain
• 9.4 billion dollars spent on inpatient
stays for lower back pain
• 7.3 million ER visits for lower back pain
• 2.3 million hospital inpatient stays
• 1993-2008 number of hospital stays for
lower back pain doubled
Costs of Other Sources of
Musculoskeletal Pain
• Neck pain, headaches, and other
musculoskeletal and chronic pain
conditions (diabetic neuropathy,
shingles, cancer pain) account for
billions more dollars
• Recent study- worker’s with recurrent
neck pain account for 40.4% of lost
work days
Other Costs of Treatment
• Musculoskeletal pain almost uniformly treated
with opioids (short term effectiveness
unquestioned) with tragic long term
consequences for individuals, families, society
• Over 95% of patients presenting to pain
management centers have been treated with
opioids by other providers
• Fact- no evidence of long term effectiveness
and well known risks associated with long term
use
Prescription Narcotic Epidemic
• Opioids prescribed for musculoskeletal
pain by multiple providers- ER
physicians, primary care, orthopedic, Oc
Med, PAs, NPs, pain doctors
• Patients inadequately educated
regarding safe usage and risks
• Risks include but not limited to abuse,
misuse, diversion, tolerance, physical
dependence, addiction, DUI, and.
most ominously, accidental poisoning
Unintended Consequences
and Costs of Treatment
• ER visits for abuse, misuse,
overdosage, lost productivity, and
treatment of substance abuse/addiction
• Cost of lost work days/decreased
productivity secondary to prescription
painkillers estimated to be >50 billion
• Mortality secondary to accidental
poisoning- 75-100 patients per day
Musculoskeletal Pain- Spine
• Spinal pain most common form of
musculoskeletal pain secondary to large
number of intervertebral joints that can be
sources of pain and proximity of spinal cord
and nerves
• Payors, patients, and most medical providers
have a significant knowledge deficit regarding
spinal pain, its causes, and effective treatment
• This deficit propels the current costly and
ineffective paradigm
Current Treatment Paradigm
for Spinal Pain
• Evaluation and symptom management by
primary care/OC med/orthopedic
doctors/chiropractors/company doctor
• Imaging- MRI, CT
• Referral for physical therapy
• Painful symptoms -improve and resolve,
improve and plateau, stay the same, or
worsen
• Unless it resolves, patient will continues to
search for relief of remaining symptoms
Current Treatment Paradigm
for Spinal Pain
• Without complete resolution of symptoms, the
next step is highly variable- This is the key
decision point which needs to change to
convert from old to new paradigm
• Most commonly, primary care/OC Med refer to
orthopedic doctor/neurologist/spine surgeon
• The patient begins to search for other options as
well including chiropractic tx, medications, and
other methods of symptom managementunaware of options for treating the specific cause
Orthopedic/Neurosurgeons
• Surgeons trained in surgical management of
orthopedic/neurologic diseases
• Surgeons not trained in algorithmic diagnosis
of treatment of spinal pain utilizing minimally
invasive procedures, conservative care,
symptom management
• Over 90% of spine surgery is truly elective
• Elective spine surgery should not be
performed unless clear indication and failure
of all other treatments secondary to
risk/benefit ratio- and patient fully informed
Spine Surgery
The rate of back surgery in the United
States was at least 40% higher than any
other country and was more than fivetimes those in England and Scotland.
Back surgery rates increased almost
linearly with the per capita supply of
orthopedic and neurosurgeons in that
country. – Department of Health Services,
University of Washington
Current Treatment Paradigm
for Spinal Pain
This lack of information regarding the
minimally invasive treatment of the
sources of spinal pain leads to a delay in
appropriate diagnosis, desperation on
patient’s part, increased risk of ineffective
and dangerous (opioid) symptom
management, and an increased risk of
“elective” surgery- with its attendant risks
Outcomes of Current Paradigm
• Surgery for spinal pain is truly the
nuclear option because of both
perioperative risks and long term risks
of failure or worsening of pain
• Peri-operative complications occur 8%
of time according to most recent study
(IPM procedures risk <.001%)
• Leading cause of death after fusion
surgery- narcotic overdose
Outcomes of Current Paradigm
• Efficacy of surgery for spinal pain
extremely controversial
• Not amenable to scientific inquiry
(double blind placebo controlled study
impossible)
• Failed Back Surgery Syndrome an all
too common and life altering
consequence- especially post fusion
• Risk/benefit ratio unacceptable
Outcomes of Current Paradigm
• Surgery associated with prolonged
recovery, increased risks of drug
complications, lost work days, disability
• Epidural scar/fibrosis common and
causes pain and nerve root ischemia
• Facet/disc pain/sacroiliac pain from
adjacent spinal levels to fusion almost
inevitable and extremely difficult
to treat
Current Paradigm
• The outcome of the current paradigm is
obvious to any reasonable person who
studies it objectively- delay in diagnosis,
ineffective symptom management,
opioid use, surgery.
• This increases incidence of chronic pain
syndrome/lost work days/disability/ ER
visits/hospitalizations/redundant
imaging/elective surgery/drug
complications/litigation/etc.
Outcome of Current Paradigm
STEffectiveness
is questionable
Opiod Rx
Musculoskeletal
95% of PMI
Social
Consequences
Chronic
Use/Higher Risk
No Standards
Patient In
Pain
Seeks
Information
Internet,
Social Media
Misinformation
Source of Pain
not ID
Pt not treated
OTC med
prolonged use
Multiple Imaging
Access Multiple
MD
No Care
Coordination
Over prescribed
Opioids
Inappropriate
Access to care
Greater risk of
Addiction
Higher cost to
employer
Outcomes of Current Paradigm
• This approach has led to multiple doctors
and other care providers involved in
treatment without care coordination
• Unnecessary hospitalizations/ER visits/
unnecessary duplicative imaging/increase
in elective surgery
• More painkillers and increased risk of
abuse/misuse/addiction/overdosage
New Paradigm for Managing
Spinal Pain
• A new paradigm is required to reduce
costs and improve outcomes
• Care needs to be guideline and
algorithm driven by a physician with
expertise in all areas of conservative
and minimally invasive techniques
• Care needs to be patient focused and
responsive to changes in symptoms
New Paradigm- Early
Assessment by IPM Physician
• Assessment and treatment by a
qualified IPM physician at the onset of
pain or when symptoms persist during
conservative treatment in all cases
• Care needs to be tailored to the
individual, their pain levels, comorbidities, vocation, timelines
New Paradigm
• Care is based on three key concepts
• #1 identification/treatment of sources of
spinal pain through minimally invasive
procedures performed in an algorithm
• #2 appropriately managed symptoms
• #3 education/behavioral modification to
maximize function, prevent
recurrences
New ParadigmDiagnosis/Treatment
• Sources of spinal pain well known- facet
joints, disc joint, sacroiliac joints, and
nerve inflammation (sciatica, radicular
pain) secondary to proximity of nerve
roots to these spinal joints
• There are well-defined, published,
interventional treatment pathways for
each source of pain- National
Guideline Clearinghouse
New ParadigmDiagnosis/Treatment
• Well trained IPM doctor serves as
cardiologist of the spine- trained to
diagnose and treat the causes of spinal
pain minimally invasively
• Sources of pain- joints/nerves- can be
treated on a recurrent basis when
symptoms require it and relief from past
procedures documented
New Paradigm- Overview
• Spinal pain, like cardiovascular disease,
is managed with lifestyle adjustment,
behavioral modification, medication
management, utilizing minimally
invasive procedures to treat the sources
of pain to improve quality of life and
maintain function
• IPM physicians are uniquely
qualified to manage care of spinal
pain
New Paradigm- Education
• Patient needs to be educated regarding
the causes of their pain and their
diagnostic findings to reduce
fear/avoidance behavior
• 90% of 50 yr olds have bulging or
herniated discs, 10-14% have pain
• Important message- You can work and
function with disc abnormalities if your
pain is managed properly
New Paradigm- Symptom
Management
• Medications, especially narcotic pain
killers, used judiciously by doctors
trained in their usage and risks and
patients monitored closely
• Emphasis on minimizing opioid risks
through adjuvant meds, modalities, but
most importantly, treating the source of
pain whenever feasible
New ParadigmPhysical Therapy
• Physical therapy by specially trained
therapists who understand the spine,
the causes of pain, and emphasize
education of the patient is integral
• PT and physician must share open and
frequent communications to avoid
prolonged ineffective treatment and
reduce risk of chronic pain and
disability
New Paradigm- Goals
• Goals of new paradigm- reduced ER
visits, reduction in unnecessary
diagnostic testing, reduced surgical
rates, reduced hospitalizations and
rehospitalizations- reduced costs
• Other goals- reducing sequelae of
opioid use- lost work days, disability, ER
visits, overdosage and death through
carefully monitored narcotic use, early
treatment of substance abuse
New Paradigm- Care Directed
by IPM Physician
• This approach to musculoskeletal pain
relies on expertise in diagnosing and
treating painful disorders minimally
invasively to treat the cause of the
symptoms and educate the patient
• It relies on expertise and special training
in interventional treatment and in the
therapeutic use and management of
opioids and potential complications
Family
Practice,
Internal Med.,
Orthopedic
Lawyers,
Case Mgrs,
Oc. Med.
Friends,
Family,
Neighbors,
Co-Workers,
Associates
Internet,
Social Media,
Lay Press
Chiropractic,
Acupuncturist,
Holistic,
Naprapath
Symptomatic Non-Specific Treatments
Physical Therapy (core strengthening)
Medication Mgt (NSAIDs, Opioids, Muscle Relaxants)
Acupuncture, TENS unit, Inversion Tables
Salves, Patches, Ice, Heat Rest
Activity Adjustments/Restrictions
Interventional Pain Mgt Specific Treatment of Pain Source(s)
Facet/Disc/SI Joint Nerve Root Inflammation
Joint Injections, Nerve Blocks, RF Rhizotomy
Caudal/Interlaminary/Transforaminal Epidurals
Percutaneous Disc Decompression
Annular Treatments, Adhesiolysis
Spinal Cord/Peripheral Nerve Stimulation
New Paradigm in Action
• We are committed to the cost effective,
outpatient, treatment of the specific
structures causing pain through minimally
invasive treatments
• Symptom control with judicious and safe
medication management/other modalities
• Reducing the risk of future exacerbations
of symptoms through education, lifestyle
adjustments, and behavioral modifications
New Paradigm in Action
• This goal is accomplished through early
recognition, timely pathway guided
interventions, accessibility, and
responsiveness to exacerbations or lack
of improvement
• We function as a subacute care
provider, counseling/adjusting
medications for patients with physician
extenders and seeing patient in 1-2
days for acute exacerbations
Recap- Current Paradigm
• Current lack of a treatment paradigm for
musculoskeletal pain, esp. spinal pain,
is costly, ineffective, and inefficient
• Costs are direct (treatment costs) and
indirect (lost work days, disability)
• Other indirect costs are associated with
prescription drug abuse and misuse and
its consequences and treatment
Recap- Current Paradigm
• Drivers of excessive costs can be
identified: fractured, redundant, and
ineffective care and ignorance of
specific causes and treatment options
• Surgery clearly not a cost effective
option and one that often leads to
greater pain and disability
• Treatment with opioids has led to
drastic unintended consequences
and has not improved outcomes
Recap- New Paradigm
• A new paradigm led by well trained,
board certified, motivated, and accessible
interventional pain management
physicians can reduce costs and improve
outcomes
• This is achieved via taking responsibility
for the continuum of conservative and
minimally invasive care and symptom
management
Please feel free to contact me at any time
Scott E. Glaser, MD, DABIPP
[email protected]
Mobile: 630 788-1355
Publications available at
www.painchicago.com