physician challenges- the future is now
TRANSCRIPT
5/21/2015
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Scott E. Glaser, MD, DABIPP President, Pain Specialists of Greater Chicagowww.painchicago.com
Physician Challenges-The 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
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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
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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
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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
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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 management-unaware of options for treating the specific cause
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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 five-times 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
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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
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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.
Musculoskeletal
Opiod Rx
95% of PMI
Social Consequences
Chronic
Use/Higher Risk
STEffectivenessis questionable
Seeks Information
Internet,
Social Media
Misinformation
Source of Pain not ID
Pt not treated
OTC med prolonged use
No Standards
Access Multiple MD
No Care Coordination
Inappropriate Access to care
Over prescribed Opioids
Greater risk of Addiction
Higher cost to
employer
Multiple Imaging
Patient In Pain
Outcome of Current Paradigm
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
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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, co-morbidities, 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
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New Paradigm-Diagnosis/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
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New Paradigm-Diagnosis/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
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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 Paradigm-Physical 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
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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
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
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
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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
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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
Mobile: 630 788-1355
Publications available at
www.painchicago.com