time topic leads meeting materials participant list topic leads meeting materials ... 9:30 am low...

Smart Care California-AGENDA Tuesday, January 31, 2017

Inland Empire Health Plan (IEHP), 9 am 3:30 PM

Time Topic Leads Meeting Materials 9:00 AM Welcome and Introductions Lance Lang, MD, Covered California

Jennifer Sayles, MD, MPH, IEHP Participant List

9:15 AM Smart Care California Progress Updates New name, tag line, logo! Hospital Honor Roll for C-section Announced Consumer education resource on C-section update Opioid resources available on iha.org

Jennifer Wong, MPH, IHA Jeff Rideout, MD, IHA

Smart Care California Logo C-section Honor Roll: Press release and list of

Honor Roll Hospitals List of media stories on Honor Roll

9:30 AM Low Back Pain as a Priority for Smart Care California Richard Sun, MD, MPH, CalPERS Shari Little, CalPERS

9:45 AM Treatment Models for Low Back Pain Identification, Coordination, Evaluation (ICE): Eugene

Hsu, MD, MBA, Stanford Clinical Excellence ResearchCenter (CERC)

Total Pain Care Center of Excellence: Toby Moeller-Bertram, MD, PhD, MAS, Desert Clinic Pain Institute &Jennifer Sayles, MD, MPH, IEHP

Jennifer Wong, MPH, IHA

Reactors Jack Asher, MD, Anthem Mike Witte, MD, CPCA

Stanford CERC ICE Model for Spine Pain Care:Brief and Overview

IEHP Total Pain Care Center of ExcellenceProgram Guidelines

11:15 AM Low Back Pain Measures Jennifer Wong, MPH, IHA Overview of potential low back performancemeasures

11:45 AM Low Back Pain Resources by Target Audience Karen Shore, PhD, IHA Sample Low Back Pain Resources

12:15 PM Lunch

12:45 PM Opioids Priorities Payer levers to support change

o Health plan checklist and surveyo Health plan focus group

Provider strategy to support change Opioid Measures and Targets

Neal Kohatsu, MD, MPH, DHCS Kelly Pfeifer, MD, CHCF

Health Plan Checklist for Curbing the OpioidEpidemic

Opioid Measures One-Pager Opioid Resources to Enable Action Summary

2:15 PM C-Section Payment Creating a path forward Value-Based Payment Options for Maternity Care:

Diane Stewart, MBA, Pacific Business Group on Health Reducing Variation in Low-Risk, Primary C-Section

Rates Across BSC Providers: Joseph Safran, Blue Shieldof California

Lance Lang, MD, Covered California Stephanie Teleki, PhD, CHCF

Health Care Payment Learning and ActionNetwork (HCP LAN): Background slides, factsheet, and infographic

PBGH Value-Based Payment Maternity Menuof Options and Addenda

3:15 PM Next Steps and Action Items Lance Lang, MD, Covered California Jennifer Wong, MPH, IHA

Next meeting is Monday, June 5, inSacramento (location TBD)

3:30 PM Adjourn

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http://www.iha.org/our-work/insights/smart-care-californiahttp://www.chhs.ca.gov/Press%20Releases/CALIFORNIA%20HEALTH%20AND%20HUMAN%20SERVICES%20SECRETARY%20DIANA%20S.%20DOOLEY%20ANNOUNCES%20HOSPITAL%20HONOR%20ROLL%20FOR%20REDUCING%20C-SECTIONS.pdfhttp://www.iha.org/sites/default/files/files/page/hospital_award_winners_vfinal.pdfhttp://www.iha.org/sites/default/files/files/page/hospital_award_winners_vfinal.pdfhttp://www.desertclinics.com/center-of-excellence

Smart Care California Participant List

January 31, 2017

Parag Agnihotri, MD Medical Director, Continuum Care Sharp Rees-Stealy Medical Group Lisa Aliferis Senior Communications Officer California HealthCare Foundation Jacob Asher, MD Vice President and Chief Medical Officer Commercial Business Anthem Liana Bailey-Crimmins Interim Deputy Executive Officer CalPERS Chester Choi, MD, MHA, MACP California Service Chapter American College of Physicians Southern California Chapter Lead Claudia Crist, RN, FACHE Chief Deputy Director, Policy and Programs California Department of Public Health Peter Currie, PhD Senior Vice President, Program Strategy and Innovation California Health Care Foundation Stephanie Gampper, MBA Director, Clinical Transformation - Strategy Cedars-Sinai Health System Ruth Haskins, MD President California Medical Association Eugene Hsu, MD, MBA Adjunct Lecturer Stanford Clinical Excellence Research Center

Howard Kahn, MD Emeritus LA Care Health Plan Neal Kohatsu, MD,MPH (CO-CHAIR) Medical Director CA Department of Health Care Services Marshall Kubota, MD Medical Director Partnership Health Plan Lance Lang, MD (CO-CHAIR) Chief Medical Officer Covered California Ryan Lawton, MS Chief of Staff to Marcus Thygeson, MD, Chief Health Officer (Interim) Blue Shield of California James Leo, MD Medical Director of Best Practice and Clinical Outcomes MemorialCare Health System Shari Little Chief, Health Policy and Research CalPERS David Lown, MD Chief Medical Officer Safety Net Institute Gregg Miller, MD Chief Medical Officer CEP America Tobias Moeller- Bertram, MD, PhD, MAS Director of Medical Affairs and Clinical Research Desert Clinic Pain Institute

Smart Care California Participant List

January 31, 2017

David Perrott, MD,DDS Senior Vice President & Chief Medical Officer California Hospital Association Lindsay Petersen, MS Senior Quality Analyst Covered California Kelly Pfeifer, MD Director, High-Value Care California Health Care Foundation Jeff Rideout, MD President and CEO Integrated Healthcare Association Beccah Rothschild, MPA Senior Outreach Leader Consumer Reports Ashley Ruby Executive Director California Service Chapter American College of Physicians Joseph Safran Senior Network Manager PPO Professional, Ancillary and Specialty Networks Blue Shield of California Shirley Sanematsu, JD Senior Attorney Western Center on Law & Poverty Jennifer Sayles, MD,MPH Chief Medical Officer Inland Empire Health Plan Jean Shahdadpuri, MD, MBA Regional Medical Director Health Net Karen Shore, PhD Consultant Golden State Health Policy

Julia Slininger, RN, BS, CPHQ VP, Regional Quality Network Hospital Quality Institute Stephanie Spoerl, MPH Senior Clinical Project Advisor Cedars-Sinai Health System Steven Steinberg,MD Family Medicine Physician Kaiser SCPMG Diane Stewart, MBA Senior Director Pacific Business Group on Health Richard Sun, MD, MPH (CO-CHAIR) Chief Medical Officer CalPERS Stephanie Teleki, PhD Senior Program Officer, High-Value Care California HealthCare Foundation Barbara Wentworth, PhD Senior Quality Improvement Specialist Health Net Mike Witte, MD Chief Medical Officer California Primary Care Association Jennifer Wong, MPH Project Manager Integrated Healthcare Association

JERRY BROWN GOVERNOR

State of California HEALTH AND HUMAN SERVICES AGENCY

DIANA S. DOOLEY SECRETARY

Aging

Child Support Services

Community Services and Development

Developmental Services

Emergency Medical Services Authority

Health Care Services

Managed Health Care

Public Health

Rehabilitation

Social Services

State Hospitals

Statewide Health Planning and Development

FOR IMMEDIATE RELEASE Contact: Scott Murray October 26, 2016 (916) 654-3304

CALIFORNIA HEALTH AND HUMAN SERVICES SECRETARY DIANA S. DOOLEY ANNOUNCES HOSPITAL HONOR ROLL FOR REDUCING C-SECTIONS

Award recognizes hospitals meeting national goal for low-risk, first-birth C-sections

SACRAMENTO California Health and Human Services Secretary Diana Dooley today recognized 104 hospitals that have met or surpassed a federal goal aimed at reducing Cesarean births (C-sections) for first-time moms with low-risk pregnancies. Secretary Dooley announced achievement awards to the hospitals on behalf of Smart Care California, a coalition of public and private health care purchasers that collectively cover more than 16 million people statewide or 40 percent of all Californians.

One of the most important things we can do to make Californias health care system smarter is to help hospitals, physicians and nurses ensure that C-sections are only performed when medically necessary, Dooley said. Todays award recipients represent an honor roll of California hospitals and their clinicians who are leading the way toward safer births and healthier babies and mothers.

Between 1997 and 2015, California's overall C-section rates increased sharply, from 1 in 5 births (21%) to nearly 1 in 3 (32.2%). During that same period, low-risk, first-birth C-sections increased from 19 percent to 25.6 percent. While potentially life-saving in certain circumstances, unnecessary C-sections can pose serious health risks for babies and mothers. C-sections also cost on average 50 percent more than vaginal deliveries, burdening patients and the health care system as a whole with unnecessary costs.

Evidence suggests that a womans chance of having a C-section depends in large part on where she delivers and the practice pattern of her physician. Even for low-risk, first-birth pregnancies, there is huge variation in California hospital C-section rates, which range from less than 15 percent to more than 60 percent.

To respond to the rapid rise in unnecessary C-sections, the U.S. Department of Health and Human Services set a Healthy People 2020 goal of reducing nationwide C-section rates for low-risk, first-births to 23.9 percent. Todays awards, which will be given annually, acknowledge California hospitals that have achieved and in many cases gone beyond that goal.

We are extremely proud of the hospitals that have earned this award, said Julie Morath, President and CEO of the Hospital Quality Institute. Reducing C-section rates requires hospitals, physicians, and nurses to think differently and to change their policies and practice patterns. The patient care team must also ensure that they inform expectant mothers of the risks and rewards of their child birth options. Hospitals throughout California are committed to meeting this goal.

Hospitals now have more incentive and more support than ever to bring down their C-section rates. Last spring, with funding from the California Health Care Foundation, the California Maternal Quality Care Collaborative (CMQCC) produced a toolkit to help hospital care teams to better support vaginal delivery. Over the next year, more than 90 California hospitals are expected to receive formal training and mentoring to implement the toolkit. In addition,

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http://www.iha.org/sites/default/files/files/page/Hospital_Award_Winners_vFINAL.pdfhttps://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectiveshttps://www.cmqcc.org/VBirthToolkitResource

Covered California also a member of Smart Care California recently announced that under its new contract, insurers on its exchange would require that contracted providers meet standards on a number of quality measures, including C-section rates.

"These award winners include different types of hospitals serving a diverse population of patients from all over the state, and each is dedicated to providing the best care possible," said Dr. Lance Lang, Chief Medical Officer for Covered California and a Co-Chair of Smart Care California. "Collectively, we expect that all 244 maternity hospitals in the state will achieve the same goal of 23.9 percent or lower thus improving quality, safety, and value of health care across California."

Achieving this C-section goal of 23.9 percent is the right thing to do for patient safety and health, added David Lansky, President and CEO of the Pacific Business Group on Health. Its also where the market is heading.

Learn more about C-sections.

View the full list of hospitals receiving this award.

View the latest quality data for all California hospitals at www.CalHospitalCompare.org.

About Smart Care California

Smart Care California is a public-private partnership working to promote safe, affordable health care in California. The group is currently focused on three issues: Cesarean sections, opioid prescriptions, and low back pain. Collectively, Smart Care California participants purchase or manage care for more than 16 million Californians or 40 percent of the state. Smart Care California is co-chaired by the states leading health care purchasers: California Department of Health Care Services, Covered California, and CalPERS. The Integrated Healthcare Association convenes and coordinates the partnership with funding from the California Health Care Foundation. Learn more about Smart Care California.

# # #

1600 Ninth Street Room 460 Sacramento, CA 95814 Telephone (916) 654-3454 Fax (916) 654-3343

Internet Address: www.chhs.ca.gov

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http://www.iha.org/sites/default/files/files/page/C-Section_Fact_Sheet_vFINAL.pdfhttp://www.iha.org/sites/default/files/files/page/Hospital_Award_Winners_vFINAL.pdfhttp://www.iha.org/our-work/insights/smart-care-california

2016 HOSPITAL C-SECTION HONOR ROLL

HOSPITAL NAME LOCATION

Alameda Health System-Highland Hospital Oakland

Alta Bates Summit Medical Center-Alta Bates Campus Berkeley

Bakersfield Memorial Hospital Bakersfield

Barstow Community Hospital Barstow

Barton Memorial Hospital South Lake Tahoe

California Hospital Medical Center Los Angeles

California Pacific Medical Center-California Campus San Francisco

Community Memorial Hospital Ventura

Community Regional Medical Center Fresno

Desert Regional Medical Center Palm Springs

Desert Valley Hospital Victorville

Dominican Hospital Santa Cruz

Eden Medical Center Castro Valley

El Camino Hospital-Los Gatos Los Gatos

Emanuel Hospital Turlock

Enloe Medical Center Chico

Feather River Hospital Paradise

George L. Mee Memorial Hospital King City

Henry Mayo Newhall Hospital Valencia

Hi-Desert Medical Center Joshua Tree

John Muir Medical Center Walnut Creek

Kaiser Permanente-Anaheim Anaheim

Kaiser Permanente-Antioch Antioch

Kaiser Permanente-Downey Downey

Kaiser Permanente-Fontana Fontana

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Kaiser Permanente-Fresno Fresno

Kaiser Permanente-Modesto Modesto

Kaiser Permanente-Oakland Oakland

Kaiser Permanente-Panorama City Panorama City

Kaiser Permanente-Redwood City Redwood City

Kaiser Permanente-Riverside Riverside

Kaiser Permanente-Roseville Roseville

Kaiser Permanente-San Francisco San Francisco

Kaiser Permanente-San Jose San Jose

Kaiser Permanente-San Leandro San Leandro

Kaiser Permanente-Santa Rosa Santa Rosa

Kaiser Permanente-South Sacramento Sacramento

Kaiser Permanente-Vacaville Vacaville

Kaiser Permanente-Vallejo Vallejo

Kaiser Permanente-Walnut Creek Walnut Creek

Kaiser Permanente-West Los Angeles Los Angeles

Kaiser Permanente-Woodland Hills Woodland Hills

Kern Medical Center Bakersfield

Loma Linda University Medical Center Loma Linda

Lompoc Valley Medical Center Lompoc

Los Alamitos Medical Center Los Alamitos

Los Angeles County USC Medical Center Los Angeles

Mad River Community Hospital Arcata

Mammoth Hospital Mammoth Lakes

Marin General Hospital Greenbrae

Marshall Hospital Placerville

Mercy Hospital of Folsom Folsom

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Mercy Medical Center-Redding Redding

Mercy San Juan Medical Center Carmichael

Montclair Hospital Medical Center Montclair

Natividad Medical Center Salinas

Northern Inyo Hospital Bishop

Olive View UCLA Medical Center Sylmar

Oroville Hospital Oroville

Palo Verde Hospital Blythe

Petaluma Valley Hospital Petaluma

PIH Health Hospital-Whittier Whittier

Pioneers Memorial Healthcare District Brawley

Plumas District Hospital Quincy

Pomona Valley Hospital Medical Center Pomona

Rancho Springs Medical Center Murrieta

Redlands Community Hospital Redlands

Redwood Memorial Hospital Fortuna

Riverside University Health System-Medical Center Moreno Valley

Saddleback Memorial Medical Center Laguna Hills

Salinas Valley Memorial Healthcare System Salinas

San Gabriel Valley Medical Center San Gabriel

San Joaquin Community Hospital Bakersfield

San Joaquin General Hospital French Camp

Santa Clara Valley Medical Center San Jose

Santa Paula Hospital Santa Paula

Scripps Mercy Hospital-San Diego San Diego

Sharp Grossmont Hospital La Mesa

Sierra Nevada Memorial Hospital Grass Valley

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Source: The California Maternal Quality Care Collaborative (CMQCC) based on 2015 Patient Discharge Data from the Office of Statewide Health Planning and Development linked to Birth Certificate Data from the California Department of Public Health-Vital Records.

Sierra View Medical Center Porterville

Simi Valley Hospital Simi Valley

Sonoma Valley Hospital Sonoma

St. Bernadine Medical Center San Bernardino

St. Elizabeth Community Hospital Red Bluff

St. Helena Hospital - Clear Lake Clearlake

St. Mary Medical Center-Apple Valley Apple Valley

St. Rose Hospital Hayward

Sutter Davis Hospital Davis

Sutter Delta Medical Center Antioch

Sutter Lakeside Hospital Lakeport

Sutter Maternity & Surgery Center-Santa Cruz Santa Cruz

Sutter Medical Center Santa Rosa Santa Rosa

Sutter Medical Center-Sacramento Sacramento

Sutter Roseville Medical Center Roseville

Sutter Solano Medical Center Vallejo

Tulare District Hospital Tulare

Twin Cities Community Hospital Templeton

UC Irvine Health Orange

UC San Diego Health San Diego

UC San Francisco Medical Center San Francisco

Ukiah Valley Medical Center Ukiah

Ventura County Medical Center Ventura

Woodland Healthcare Woodland

Zuckerberg San Francisco General San Francisco

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C-section Honor Roll News Coverage

1. Some big Valley names missing from state C-section honor rollhttp://www.fresnobee.com/news/local/article110715317.htmlMost San Diego Hospitals Fail To Meet Goal For Reducing C-Sections

2. http://www.kpbs.org/news/2016/oct/26/two-san-diego-hospitals-meet-federal-goal-reducing/Dignity Health St. Bernardine Medical Center Makes Statewide Honor Roll for Reducing C-Sections

3. http://www.highlandnews.net/news/top_stories/dignity-health-st-bernardine-medical-center-makes-statewide-honor-roll/article_5f89fc9a-9c5f-11e6-9696-6bcb8361c721.html

4. Sierra View recognized for low C-section ratehttp://www.recorderonline.com/news/sierra-view-recognized-for-low-c-section-rate/article_0d49af44-9ff1-11e6-919b-2b2ea461d842.html

5. Twin Cities reports lowest C-section rate on the central coasthttp://pasoroblesdailynews.com/twin-cities-reports-lowest-c-section-rate-central-coast/63627/

6. Desert Regional Medical Center Reports One of the Lowest C-section Rates in Californiahttp://patch.com/california/palmdesert/desert-regional-medical-center-reports-one-lowest-c-section-rates-california

7. SVH honored for low C-section ratehttp://www.sonomanews.com/news/6306405-181/svh-honored-for-low-c-section

8. Twin Cities reports lowest C-section rate on the central coasthttp://templetonguide.com/twin-cities-reports-lowest-c-section-rate-central-coast/ (full story ofabove article from Paso Robles Daily News)

9. Three hospitals honored for lowering C-section rateshttp://www.sandiegouniontribune.com/news/health/sd-me-csection-hospitals-20161027-story.html

10. Bakersfield Memorial recognized for low C-section rate, resulting in one of lowest rates instatehttp://www.turnto23.com/news/local-news/bakersfield-memorial-recognized-for-reducing-c-section-rate

11. Saddleback Memorial Medical Center Recognized by State of California for Achieving Goal ofLowered Cesarean Deliverieshttp://www.prnewswire.com/news-releases/saddleback-memorial-medical-center-recognized-by-state-of-california-for-achieving-goal-of-lowered-cesarean-deliveries-300378579.html

12. The Women's Hospital at Saddleback Memorial Medical Center Celebrates 75,000th Deliverywith Birth of Twinshttps://www.yahoo.com/news/womens-hospital-saddleback-memorial-medical-center-celebrates-75-180400264.html

13. Lompoc hospital recognized by state for reduced C-section ratehttp://santamariatimes.com/lompoc-hospital-recognized-by-state-for-reduced-c-section-rate/article_fdd272a9-c752-53d9-a4ba-b16de7e63d03.html

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http://www.fresnobee.com/news/local/article110715317.htmlhttp://www.kpbs.org/news/2016/oct/26/two-san-diego-hospitals-meet-federal-goal-reducing/http://www.highlandnews.net/news/top_stories/dignity-health-st-bernardine-medical-center-makes-statewide-honor-roll/article_5f89fc9a-9c5f-11e6-9696-6bcb8361c721.htmlhttp://www.highlandnews.net/news/top_stories/dignity-health-st-bernardine-medical-center-makes-statewide-honor-roll/article_5f89fc9a-9c5f-11e6-9696-6bcb8361c721.htmlhttp://www.recorderonline.com/news/sierra-view-recognized-for-low-c-section-rate/article_0d49af44-9ff1-11e6-919b-2b2ea461d842.htmlhttp://www.recorderonline.com/news/sierra-view-recognized-for-low-c-section-rate/article_0d49af44-9ff1-11e6-919b-2b2ea461d842.htmlhttp://pasoroblesdailynews.com/twin-cities-reports-lowest-c-section-rate-central-coast/63627/http://patch.com/california/palmdesert/desert-regional-medical-center-reports-one-lowest-c-section-rates-californiahttp://patch.com/california/palmdesert/desert-regional-medical-center-reports-one-lowest-c-section-rates-californiahttp://www.sonomanews.com/news/6306405-181/svh-honored-for-low-c-sectionhttp://templetonguide.com/twin-cities-reports-lowest-c-section-rate-central-coast/http://www.sandiegouniontribune.com/news/health/sd-me-csection-hospitals-20161027-story.htmlhttp://www.sandiegouniontribune.com/news/health/sd-me-csection-hospitals-20161027-story.htmlhttp://www.turnto23.com/news/local-news/bakersfield-memorial-recognized-for-reducing-c-section-ratehttp://www.turnto23.com/news/local-news/bakersfield-memorial-recognized-for-reducing-c-section-ratehttp://www.prnewswire.com/news-releases/saddleback-memorial-medical-center-recognized-by-state-of-california-for-achieving-goal-of-lowered-cesarean-deliveries-300378579.htmlhttp://www.prnewswire.com/news-releases/saddleback-memorial-medical-center-recognized-by-state-of-california-for-achieving-goal-of-lowered-cesarean-deliveries-300378579.htmlhttps://www.yahoo.com/news/womens-hospital-saddleback-memorial-medical-center-celebrates-75-180400264.htmlhttps://www.yahoo.com/news/womens-hospital-saddleback-memorial-medical-center-celebrates-75-180400264.htmlhttp://santamariatimes.com/lompoc-hospital-recognized-by-state-for-reduced-c-section-rate/article_fdd272a9-c752-53d9-a4ba-b16de7e63d03.htmlhttp://santamariatimes.com/lompoc-hospital-recognized-by-state-for-reduced-c-section-rate/article_fdd272a9-c752-53d9-a4ba-b16de7e63d03.html

Topic 1: Low Back Pain Meeting Materials

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Relieving Spine Pain in America

Spine pain care accounts for $90 billion in direct cost annually in the US. While the vast majority of spine pain complaints are self-limited and respond to physical therapy and exercise, many patients undergo high cost testing and high risk treatments which may lead to worsened pain and disability. This results in over $90 billion in direct cost annually in the US. The Clinical Excellence Research Center (CERC) at Stanford Medicine has developed an innovative model for patients with spine pain which aims to substantially reduce costs while improving outcomes.

ICE Model for Spine Pain Care

The Identification, Coordination, Evaluation (ICE) model is designed to curb excessive spending by optimizing patient-treatment matching through risk stratified care pathways. The specific components of this model include the following:

Risk stratification of patients into care pathways (using a modified STartT Back tool1) Low risk patients receive physical therapy and self-management tools Higher risk patients receive coordinated care from a specialized team of providers Guideline-concordant and shared decision support tools for physicians and patients

Based on published evidence, we estimate a net savings of 25% per patient per year for a full-scale implementation of ICE. The CERC Spine Care team has several ongoing pilot collaborations with self-insured employers, health provider systems, health plans to test the program and a funded 4-year multi-site pragmatic randomized controlled trial that will begin patient enrollment in 2017. We are also collaborating with the Stanford Artificial Intelligence Lab on technology solutions to further improve and scale our model. Pilot testing will focus on feasibility testing and evaluation of predicted improvements in clinical health outcomes, patient experience, and per capita health spending.

About CERC

The Clinical Excellence Research Center (CERC) organizes research teams from multiple Stanford University-affiliated Schools to discover, design, and demonstrate nationally new methods of health care delivery that substantially reduce annual per capita health spending and population-wide disability in the near term. Design and testing is led by teams of post-doctoral research fellows and faculty from multiple Stanford Schools with initial emphasis on Engineering, Social Sciences, and Medicine. Please direct questions and inquiries about participation in pilot testing to

Eugene Hsu, MD, MBA 510.378.6000 [email protected]

1 Beneciuk JM et al. The STarT back screening tool and individual psychological measures: evaluation of prognostic capabilities for low back pain clinical outcomes in outpatient physical therapy settings. Phys Ther. 2013 Mar;93(3):321-33. doi: 10.2522/ptj.20120207. Epub 2012 Nov 2. PMID 23125279.

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Sy n t h esi s of R esear c h on Hi gh est V al ue U S Car e for Spi n e P ai n

Solution 1:Identify and Triage

Solution 3: Enhance Decision-Making for Patients

and Providers

Over 90% of spine pain patients improve spontaneously

These patients are often prescribed opioids, undergo MRI identifying common abnormalities, and are subject to extraneous procedures

The top 10% of spine pain patients are responsible for over 50% of health care costs

Patients with back pain cost nearly double their counterparts without pain

Patients with chronic pain often have concomitant undiagnosed mental health diagnoses and modifiable behavioral attributes

There is no superior therapy or provider for spine pain

The care pathway is chaotic Care provided at each point in a

network of providers is often not guideline concordant,

Patients make uninformed decisions on preference-sensitive therapies

Brief questionnaire segments population into at low- and at high-risk for chronic pain

Low-risk patients receive a course of conservative care and rapid PT

High-risk patients are referred to individualized spine programs

Spine clinician establishes care plan Back coach empowers patients to

execute care plan Medical director oversees complex

patient management

Physicians receive decision support for opioids, imaging, and referrals

Offer patient education tools Physicians and patients engage in

high-quality, value-driven, shared decision making

Challenge 1: Spine pain patients are often over-treated

Challenge 2: Patients at high risk for chronic pain do not receive needed biopsychosocial treatment

Challenge 3: Care is disorganized and does not follow guidelines

3% ne t sa v ings 15% ne t sa v ings 7% ne t sa v ings

The CERC Model can save $21 Billion (25% Total National Net Savings) in Year 3

The United States spends $86 Billion per year on spine pain care.

2016A.Milstein/StanfordUniversity

Solution 2: Coordinate Care

Clinical ExcellenceResearch Center

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Core Program ElementsBelow are best practices and evidence-based interventions that IEHP is looking to include in its TPC COE program:

1. Medical Treatment a. Fellowship trained and board certified Pain Specialist b. Interventional treatments (office based, non-surgical) c. Medication management in coordination with Pharmacy Home d. Direct access to surgical intervention e. 24/7 access coverage for urgent patient calls, Emergency Department and hospital communication 2. Functional Restoration a. Physical therapy/occupational therapy b. Physiatrist or equivalent highly desirable c. Comprehensive bundle of alternative therapy: acupuncture, chiropractic, yoga, biofeedback and other modalities as indicated d. Osteopathic manipulation treatment 3. Behavioral Health a. Capacity to treat full spectrum of Diagnostic and Statistical Manual of Mental Disorders (DSM)- 5 psychiatric disorders with licensed behavioral health professionals and Psychiatrists b. Capacity to deliver substance use counseling and medication assisted treatment on site, direct linkage with inpatient and outpatient substance use treatment programs c. Individual, family, and peer group therapy d. Trauma informed care approach to interdisciplinary treatment 4. Self-Management a. Licensed Social Worker and Vocational Counselor with capacity to provide individual case management and support to Member and family, develop Members self-management skills, and coordinate with Primary Care Physician and other care providers b. Individual and group coaching and navigation to support self management and education c. Guided mindfulness and meditation, stress reduction, life skills d. Health and nutrition education

IEHP Total Pain Care COE Program Guidelines

OverviewChronic pain affects more Americans than heart disease, diabetes, and cancer combined; with an estimated 100 million Americans suffering from chronic pain costing society over $600 billion annually.1 Inland Empire Health Plan (IEHP) is dedicated to creating a Total Pain Care (TPC) Program that includes in-network Centers of Excellence (COE) where individuals utilizing a high-level of Opioids and suffering from severe, refractory chronic pain can be referred for a comprehensive, integrative and holistic treatment program focused on promoting patient self-efficacy and functional restoration.

Updated: 1/26/1716

Program EvaluationCOE sites will be evaluated on cost, utilization, patient outcomes and program engagement.

1. Cost Analysis (IEHP responsibility) a. Total medical costs including pharmacy, facility, professional and cost of COE program b. Total number, Rx Per Member Per Month (PMPM), total cost of Opioids Rx c. Total number, Rx PMPM, total cost of Benzodiazepines Rx 2. Utilization Analysis (IEHP responsibility) a. Emergency Room, Urgent Care, and inpatient utilization b. Total utilization of interventional pain management procedures (spinal injections, etc.) c. Average Morphine Equivalent Dosage (MED)3 3. Patient Outcomes (COE responsibility) a. PROMIS Patient-Reported Outcomes Measurement Information System b. GAD-7 Generalized Anxiety Disorder c. PHQ-9 Patient Health Questionnaire d. ODQ Oswestry Disability Questionnaire e. Substance Use Assessment Tool f. Member Satisfaction Survey 4. Program Engagement (COE responsibility) a. Percent of Members that agree to referral to COE b. Percent of Members referred that show for initial visit c. Number of missed appointments by Member d. Percent of Members that complete each phase e. Number of medical visits per Member f. Number of psychotherapy visits per Member i. group or individual g. Number of physical reconditioning per Member h. Number of alternative treatment per Member

Target PopulationIEHP is still finalizing the target population criteria for COE sites, but is currently utilizing the following criteria: 1. MED > 120 mg/day 2. MED 45-119 and at least one of the following: a) Prescription of Benzodiazepines; or Opioid, Benzodiazepines, and Carisoprodol (Holy Trinity); or prescription of Anti-depressants 3. Three or more ER visits related to chronic pain 4. Two or more Hospitalizations related to chronic pain 5. Spinal interventional pain procedures (i.e., epidurals, acet injections/Medial branch blocks)

1. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. (2011, June 29). Committee on Advancing Pain Research, Care, and Education; Board on Health Sciences Policy; Institute of Medicine, 382.3. Utilization Analysis will include review of 12 months before, during, and 12 months after the program.

2017 Inland Empire Health Plan All Rights Reserved. ADM-17-08120

For questions or more information:

Joshua Crouch, MPHSpecial Programs Manager

(909) [email protected]

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Potential Patient Clinical and Functional Measures

Measure Description of Measure Currently in Use Notes

Stanford ICE model

Desert Clinic Pain Institute

Virginia Mason

Oswestry Disability Index ODI)1,2

Measures a patient's permanent functional disability in 10 functional areas (i.e. pain intensity, standing, sitting, etc)

X X X One of the most commonly used tools to measure disability

Keele STarT Back Tool3 9 item questionnaire predicts whether patients are at low, medium, or high risk of having of poor back pain outcomes

X X

EuroQol Group EQ-5D4

Health questionnaire provides a simple descriptive profile and a single index value for health status and is applicable to a wide range of health conditions

X

Absenteeism or Presenteeism (e.g. Days off from work due to back pain)

Assesses the extent to which workers back pain inhibited them from going to work or from doing their jobs

X

Measurement of this could include a question on how many days missed due to pain or use of a validated scale like the 6-item Stanford Presenteeism scale5

PROMIS (Patient-Reported Outcomes Measurement Information System)

Set of person-centered measures that evaluates and monitors physical, mental, and social health in adults and children

X X

GAD-7 (Generalized Anxiety Disorder)

Screening tool and severity measure for generalized anxiety disorder (GAD) X X

These measures are non-specific to back pain but can be helpful in addressing the psychosocial aspects of pain

PHQ-9 (Patient Health Questionnaire)

Multipurpose instrument for screening, diagnosing, monitoring, and measuring severity of depression

X X

Substance Use Assessment Identify patients who use substances at at-risk levels, and those already experiencing substance use-related issues

X

1 Source: Fairbank JC et al. The Oswestry low back pain disability questionnaire. Physiotherapy. 1980 Aug;66(8):271-3. 2 Other validated tools to assess disability include the Roland Morris Disability Questionnaire, the Short-Form 36 Questionnaire, or the 3 item PEG scale. 3 Source: Hill JC et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. The Lancet. 2011 Sept;378(9802):1560-1571. 4 Source: Whynes DK, McCahon RA, Ravenscroft A, Hodgkinson V, Evley R, Hardman JG. Responsiveness of the EQ-5D Health-Related Quality-of-Life Instrument in Assessing Low Back Pain. Value Health. 2013 Jan;16(1):12432. 5 Source: Koopman C et al. Stanford Presenteeism Scale: Health status and employee productivity. J Occup Environ Med. 2002 Jan;44(1):1420.

18

Potential Health System/Health Plan Level Measures

Measures Description of Measure Example of Use Notes

Patie

nt U

tiliz

atio

n

Use of Imaging for LBP

% adults 18-50 years of age with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI or CT scan) within 28 days of the diagnosis

CA OPA Testing for Back Pain, IHA VBP4P, NCQA

HEDIS

ER and Urgent Care utilization

Emergency Room and Urgent Care utilization of the Members

Inland Empire Health Plan (IEHP)

Utilization of complimentary care and alternative therapies

Percent of patients who use complimentary care (such as physical medicine, massage, acupuncture, chiropractic care modalities, PENS/TENS)

Oregon Health Care Quality Corporation Report March 2013

This data might be underreported since acupuncture and massage are

self-pay. Preventing unnecessary surgery

Percent of patients diagnosed with low back pain who receive surgery within 6 weeks of diagnosis

WA State Health Alliance

Opioid Use

Percent of patients diagnosed with acute lowback pain with a new or existing narcoticsprescription

Use Smart Care CA opioid metrics

Oregon Health Care Quality Corporation Report March 2013, Inland Empire Health

Plan

Acce

ss

Increased Access to Physical Therapy (PT) Time between request for PT and first PT visit

Virginia Mason, Stanford ICE model

There is no standard definition of early access to PT. Virginia Mason and Stanford ICE model have same

day access to PT.

Cost

Total cost of Opioids Rx Total annual cost of opioid prescriptions IEHP

Total Cost of Care Total medical costs of the members IEHP

Population Level Measures

Measures Description of Measure Example of Use Notes Spine Surgery Rates Laminectomy and Spinal Fusion Rates

per 100,000 state or county at-risk population (Observed and age-sex adjusted rate)

OSHPD Inpatient Quality Indicators (IQIs)

There is no benchmark for spine surgery rates so difficult to tell what is overuse vs appropriate use.

19

http://reportcard.opa.ca.gov/rc2017/hmomeasurenotopic.aspx?Category=HMOHEDIS&Topic=TestingForCauseOfBackPain&Measure=TestingForCauseOfBackPainhttp://reportcard.opa.ca.gov/rc2017/hmomeasurenotopic.aspx?Category=HMOHEDIS&Topic=TestingForCauseOfBackPain&Measure=TestingForCauseOfBackPainhttp://www.iha.org/sites/default/files/resources/my_2017_measure_set.pdfhttp://q-corp.org/sites/qcorp/files/LBP-Baseline-Utilization-Report-2013_0.pdfhttp://q-corp.org/sites/qcorp/files/LBP-Baseline-Utilization-Report-2013_0.pdfhttp://q-corp.org/sites/qcorp/files/LBP-Baseline-Utilization-Report-2013_0.pdfhttp://wahealthalliance.org/wp-content/uploads/2013/12/LowBackPainCITReportFINAL_Jan_07.pdfhttp://wahealthalliance.org/wp-content/uploads/2013/12/LowBackPainCITReportFINAL_Jan_07.pdfhttp://q-corp.org/sites/qcorp/files/LBP-Baseline-Utilization-Report-2013_0.pdfhttp://q-corp.org/sites/qcorp/files/LBP-Baseline-Utilization-Report-2013_0.pdfhttp://q-corp.org/sites/qcorp/files/LBP-Baseline-Utilization-Report-2013_0.pdfhttps://www.oshpd.ca.gov/HID/Products/PatDischargeData/AHRQ/iqi_overview.htmlhttps://www.oshpd.ca.gov/HID/Products/PatDischargeData/AHRQ/iqi_overview.html

# Category Title Organization Organization TypeTarget

AudienceType of Material Brief Description Date

Citations Provided URL

1 Patient Support Low Back Pain Fact SheetNIH (National Institute

of Neurological Disorders and Stroke)

federal govt patients, patient advocates

online fact sheet (32 pgs, very

comprehensive)

Describes the causes of lower back pain and how it may be diagnosed. Also lists a variety of treatments, surgical options, and prevention methods.

11/5/2015 No

http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm

2 Patient Support Back Pain National Library of Medicine federal govtpatients, patient

advocates

Descriptions plus links to

additional info

Comprehensive guide on what back pain is and what causes it. Includes links for health assessment tools, video tutorials, print handouts, and resources for patients.

10/5/2016 No

https://medlineplus.gov/backpain.html

3 Patient Support Low back pain - acute MedlinePlus federal govt patients, patient advocates online fact sheet

Guides patients on how to identify lower back pain and what appropriate measures they can take to mitigate the pain and improve their condition. Also lists situations in which patients may need to seek medical attention.

10/5/2016 Yes

https://medlineplus.gov/ency/article/007425.htm

4 Patient Support Treatment Options for Low Back PainAmerican Academy of Orthopedic Surgeons

professional society

patients, patient advocates online video

Provides information about the range of treatment options for low back pain, including medications, physical therapy, and surgery.

May 2012 No

http://orthoinfo.aaos.org/topic.cfm?topic=AV0002

5 Fact Sheet What is Back Pain? Fast Facts

NIH (National Institute of Arthritis and

Musculoskeletal and Skin Diseases)

federal govt patients, patient advocates online fact sheet

Describes causes, diagnosis, treatments, and research efforts for back pain. August 2016 No

https://www.niams.nih.gov/health_info/back_pain/back_pain_ff.pdf

6 Patient Support knowyourback.org North American Spine Society (NASS)professional

society PatientsDescriptions plus links to

additional info

Contains multiple links to topics such as back pain prevention, information on spinal conditions, and treatments for spine pain.

unknown no

http://knowyourback.org/Pages/Default.aspx

7 Fact Sheet 9 For Spine 9 "Back-to-Basics" Tips North American Spine

Society (NASS)professional

society

patients, plans, payers,

providersFact sheet

Contains 9 simple tips from spine experts on how to keep your back healthy.

2012 nohttp://knowyourback.org/Documents/9back_to_basics_tips.pdf

8 Patient Support 9 for Spine, All tips North American Spine Society (NASS)professional

societypatients, patient

advocates VideoVideo containing all "9 for Spine" tips for a healthy back. July 23, 2014

http://youtu.be/Ef42Oa77Dk0

9 Patient Support Four common mistakes in back pain treatment: Why Consumer Reports nonprofitpatients, patient

advocates Online article Describes four common mistakes in treating back pain and what patients can August 2014 no

http://www.consumerreports.org/cro/2014/08/four-common-mistakes-in-treating-back-pain/index.htm

10 Fact Sheet

Imaging tests for lower-back pain

You probably don't need an X-ray, CT scan, or MRI

Consumer Reports nonprofit patients, patient advocates Fact sheet

Discusses the risks and harms of imaging tests for low back pain, when imaging is appropriate, and advice on how to treat low back pain.

2016 no

http://consumerhealthchoices.org/wp-content/uploads/2012/06/ChooseWiselyBackPainAAFP-ER.pdf

11 Fact Sheet 5 Ways to Be Smart About Back Pain Consumer Reports nonprofitpatients, patient

advocates Poster5 questions to ask about low back pain

2016 nohttp://consumerhealthchoices.org/wp-content/uploads/2016/04/ChoosingWiselyBackPainPoster-ER.pdf

12 Fact Sheet

Does Your Lower Back Hurt? You Probably Don't

Need an MRI, X-ray, or CT Scan

Consumer Reports nonprofit patients, patient advocates Rack card

5 things to do to help your LBP and avoid imaging tests 2016 no

http://consumerhealthchoices.org/wp-content/uploads/2016/01/ChoosingWiselyBackPainCard-ER.pdf

13 Fact SheetTreating lower-back pain: How much bed rest is too

much?Consumer Reports nonprofit patients, patient advocates Fact sheet

Describes the risks of staying in bed with LBP and offers treatment / prevention solutions

2014 nohttp://consumerhealthchoices.org/wp-content/uploads/2014/09/ChoosingWiselyBackPainBedRestNASS-ER.pdf

Sample Low Back Pain Resources

Patients, Families, and Caregivers20

http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htmhttp://www.ninds.nih.gov/disorders/backpain/detail_backpain.htmhttps://medlineplus.gov/backpain.htmlhttps://medlineplus.gov/ency/article/007425.htmhttp://orthoinfo.aaos.org/topic.cfm?topic=AV0002https://www.niams.nih.gov/health_info/back_pain/back_pain_ff.pdfhttps://www.niams.nih.gov/health_info/back_pain/back_pain_ff.pdfhttp://www.moveforwardpt.com/PatientResources/VideoLibrary/detail/back-low-pain-tipshttp://www.niams.nih.gov/health_info/back_pain/http://www.niams.nih.gov/health_info/back_pain/http://youtu.be/Ef42Oa77Dk0http://www.consumerreports.org/cro/2014/08/four-common-mistakes-in-treating-back-pain/index.htmhttp://www.consumerreports.org/cro/2014/08/four-common-mistakes-in-treating-back-pain/index.htmhttp://consumerhealthchoices.org/wp-content/uploads/2012/06/ChooseWiselyBackPainAAFP-ER.pdfhttp://consumerhealthchoices.org/wp-content/uploads/2012/06/ChooseWiselyBackPainAAFP-ER.pdfhttp://consumerhealthchoices.org/wp-content/uploads/2012/06/ChooseWiselyBackPainAAFP-ER.pdfhttp://consumerhealthchoices.org/wp-content/uploads/2016/04/ChoosingWiselyBackPainPoster-ER.pdfhttp://consumerhealthchoices.org/wp-content/uploads/2016/04/ChoosingWiselyBackPainPoster-ER.pdfhttp://consumerhealthchoices.org/wp-content/uploads/2016/04/ChoosingWiselyBackPainPoster-ER.pdfhttp://consumerhealthchoices.org/wp-content/uploads/2016/01/ChoosingWiselyBackPainCard-ER.pdfhttp://consumerhealthchoices.org/wp-content/uploads/2016/01/ChoosingWiselyBackPainCard-ER.pdfhttp://consumerhealthchoices.org/wp-content/uploads/2016/01/ChoosingWiselyBackPainCard-ER.pdfhttp://consumerhealthchoices.org/wp-content/uploads/2014/09/ChoosingWiselyBackPainBedRestNASS-ER.pdfhttp://consumerhealthchoices.org/wp-content/uploads/2014/09/ChoosingWiselyBackPainBedRestNASS-ER.pdfhttp://consumerhealthchoices.org/wp-content/uploads/2014/09/ChoosingWiselyBackPainBedRestNASS-ER.pdf


AudienceType of Material Brief Description Date

Citations Provided URL

1 Clinical pathways and guidelinesLow back pain (early management):

overview

National Institute for Health and Care

Excellence

Government agency Clinicians

Clinical guidelines

Pathway on the early treatment and management of persistent or recurrent low back pain, defined as non-specific low back pain that has lasted for more than 6 weeks, but less than 12 months.

unknown yes

https://pathways.nice.org.uk/pathways/low-back-pain-early-management

2 Education and Training Tools The Bree Collaborative Spine and Low Back Pain Report and Recommendations Bree Collaborative NonprofitHospitals and care facilities Report

Workgroup recommendations to prevent the transition of acute lower back pain to chronic pain and improve surgical outcomes for patients with lower chronic back pain.

March 2013 yes

http://www.breecollaborative.org/topic-areas/spine/

3 Education and Training Tools Examination of Low Back Pain Technique Medscape For profit Clinicians Video tutorial

How to evaluate patients with lower back pain, ranging from initial evaluation based on patient descriptions, muscle and motion tests, and checking for joint and neurological dysfunction.

April 2016 no

http://emedicine.medscape.com/article/2092651-technique#showall

4 Clinical pathways and guidelines

Low Back Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the

Orthopaedic Section of the American Physical Therapy Association

Orthopaedic Section of the American

Physical Therapy Association

(published by Journal of Orthopaedic & Sports Physical

Therapy)

Professional Society Clinicians Journal Article

Evidence-based recommendations for treating back pain from diagnosis to examination to intervention.

2012 yes

http://www.jospt.org/doi/pdf/10.2519/jospt.2012.42.4.A1

5 Clinical decision support Oswestry Low Back Pain Disability QuestionnaireAmerican Academy of Orthopedic Surgeons

Professional Society Clinicians

Sample questionnaire

Questionnaire to help clinicians evaluate the extent to which back pain has affected the patient's daily life. 1980 yes

http://www.aaos.org/uploadedFiles/PreProduction/Quality/Measures/Oswestry%20Low%20Back%20Pain%20Score%20-%20Orthopaedic%20Scores.pdf

6 Clinical decision support Roland Morris Disability Questionnaire (RMDQ)

National Primary Care Research and

Development Centre

Government agency

Sample questionnaire

Self-administered questionnaire designed to assess physical functions likely to be affected by low back pain.

2005 yeshttp://www.rmdq.org/

7 Education and Training Tools Move Forward Radio-Treating Back Pain: Avoiding Unnecessary Treatment

American Physical Therapy Association

(APTA)

Professional Society

Clinicians, patients Podcast

Podcast on avoiding unnecessary treatment for low back pain. September 2013 no

http://www.blogtalkradio.com/moveforwardpt/2013/09/19/treating-back-pain-avoiding-unnecessary-treatment

8 Education and Training Tools Low Back Pain History of Present Illness (HPI) Form

University of Washington Dept of

Family MedicineUniversity Clinicians Assessment Tool

Form to assess and document low back pain physical exam findings. unknown no

https://depts.washington.edu/fammed/files/Primary_Care_Sports_Medicine_Fellowship/Low%20Back%20Exam.pdf

9 Clinical pathways and guidelinesHealth Care Guideline: Adult Acute and

Subacute Low Back Pain

Institute for Clinical Systems Improvement

(ICSI)Nonprofit Clinicians Clinical guidelines

Clinical guideline for treatment of acute and subacute back pain containing treatment algorithms, table of recommendations, support for quality improvement, and supporting evidence (92 pages).

November 2012 yes

https://www.icsi.org/_asset/bjvqrj/LBP.pdf


Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the

American College of Physicians and the American Pain Society

American College of Physicians and the

American Pain Society (published by

Annals of Internal Medicine)


Clinical guidelines

Evidence-based diagnosis and treatment guidelines for low back pain featuring seven recommendations and summary tables with level of evidence and grades for noninvasive interventions in patients with acute and chronic low back pain.

October 2007 yes

http://annals.org/aim/article/736814/diagnosis-treatment-low-back-pain-joint-clinical-practice-guideline-from

12 Education and Training ToolsEffective treatments for back pain: Kieran O'Sullivans practical tips within a guiding

framework. Part 1.BMJ talk medicine Nonprofit clinicians podcast

The 1st in a series of podcasts with Dr Kieran O'Sullivan, a physical therapist and researcher, that discusses effective treatments for back pain. 2015 no

https://soundcloud.com/bmjpodcasts/effective-treatments-for-back-pain-kieran-osullivans-practical-tips-within-a-guiding-framework?in=bmjpodcasts/sets/bjsm-1#t=0:00

11 Education and Training ToolsDr Kieran O'Sullivan on managing back pain: 7 habits of highly effective clinicians. Part 2,

2016BMJ talk medicine Nonprofit Clinicians podcast

The 2nd in a series of podcasts with Dr Kieran O'Sullivan discussing highly effective clinician practices for managing back pain. 2016 no

https://soundcloud.com/bmjpodcasts/dr-kieran-osullivan-on-managing-back-pain-7-habits-of-highly-effective-clinicians-part-2-2016


Providers 21

https://pathways.nice.org.uk/pathways/low-back-pain-early-managementhttps://pathways.nice.org.uk/pathways/low-back-pain-early-managementhttp://www.breecollaborative.org/topic-areas/spine/http://www.breecollaborative.org/topic-areas/spine/http://emedicine.medscape.com/article/2092651-technique#showallhttp://emedicine.medscape.com/article/2092651-technique#showallhttp://www.jospt.org/doi/pdf/10.2519/jospt.2012.42.4.A1http://www.jospt.org/doi/pdf/10.2519/jospt.2012.42.4.A1http://www.aaos.org/uploadedFiles/PreProduction/Quality/Measures/Oswestry%20Low%20Back%20Pain%20Score%20-%20Orthopaedic%20Scores.pdfhttp://www.aaos.org/uploadedFiles/PreProduction/Quality/Measures/Oswestry%20Low%20Back%20Pain%20Score%20-%20Orthopaedic%20Scores.pdfhttp://www.aaos.org/uploadedFiles/PreProduction/Quality/Measures/Oswestry%20Low%20Back%20Pain%20Score%20-%20Orthopaedic%20Scores.pdfhttp://www.aaos.org/uploadedFiles/PreProduction/Quality/Measures/Oswestry%20Low%20Back%20Pain%20Score%20-%20Orthopaedic%20Scores.pdfhttp://www.blogtalkradio.com/moveforwardpt/2013/09/19/treating-back-pain-avoiding-unnecessary-treatmenthttp://www.blogtalkradio.com/moveforwardpt/2013/09/19/treating-back-pain-avoiding-unnecessary-treatmenthttp://www.blogtalkradio.com/moveforwardpt/2013/09/19/treating-back-pain-avoiding-unnecessary-treatmenthttp://www.blogtalkradio.com/moveforwardpt/2013/09/19/treating-back-pain-avoiding-unnecessary-treatmenthttps://depts.washington.edu/fammed/files/Primary_Care_Sports_Medicine_Fellowship/Low%20Back%20Exam.pdfhttps://depts.washington.edu/fammed/files/Primary_Care_Sports_Medicine_Fellowship/Low%20Back%20Exam.pdfhttps://depts.washington.edu/fammed/files/Primary_Care_Sports_Medicine_Fellowship/Low%20Back%20Exam.pdfhttps://www.icsi.org/_asset/bjvqrj/LBP.pdfhttps://www.icsi.org/_asset/bjvqrj/LBP.pdfhttp://annals.org/aim/article/736814/diagnosis-treatment-low-back-pain-joint-clinical-practice-guideline-fromhttp://annals.org/aim/article/736814/diagnosis-treatment-low-back-pain-joint-clinical-practice-guideline-fromhttp://annals.org/aim/article/736814/diagnosis-treatment-low-back-pain-joint-clinical-practice-guideline-fromhttps://soundcloud.com/bmjpodcasts/effective-treatments-for-back-pain-kieran-osullivans-practical-tips-within-a-guiding-framework?in=bmjpodcasts/sets/bjsm-1#t=0:00https://soundcloud.com/bmjpodcasts/effective-treatments-for-back-pain-kieran-osullivans-practical-tips-within-a-guiding-framework?in=bmjpodcasts/sets/bjsm-1#t=0:00https://soundcloud.com/bmjpodcasts/effective-treatments-for-back-pain-kieran-osullivans-practical-tips-within-a-guiding-framework?in=bmjpodcasts/sets/bjsm-1#t=0:00https://soundcloud.com/bmjpodcasts/effective-treatments-for-back-pain-kieran-osullivans-practical-tips-within-a-guiding-framework?in=bmjpodcasts/sets/bjsm-1#t=0:00https://soundcloud.com/bmjpodcasts/effective-treatments-for-back-pain-kieran-osullivans-practical-tips-within-a-guiding-framework?in=bmjpodcasts/sets/bjsm-1#t=0:00https://soundcloud.com/bmjpodcasts/effective-treatments-for-back-pain-kieran-osullivans-practical-tips-within-a-guiding-framework?in=bmjpodcasts/sets/bjsm-1#t=0:00https://soundcloud.com/bmjpodcasts/dr-kieran-osullivan-on-managing-back-pain-7-habits-of-highly-effective-clinicians-part-2-2016https://soundcloud.com/bmjpodcasts/dr-kieran-osullivan-on-managing-back-pain-7-habits-of-highly-effective-clinicians-part-2-2016https://soundcloud.com/bmjpodcasts/dr-kieran-osullivan-on-managing-back-pain-7-habits-of-highly-effective-clinicians-part-2-2016https://soundcloud.com/bmjpodcasts/dr-kieran-osullivan-on-managing-back-pain-7-habits-of-highly-effective-clinicians-part-2-2016

13 Clinical decision support The Keele STarT Back Screening Tool Keele University University clinicians Questionnaire

9 item questionnaire that aids clinical decision making by stratifying patients with low back pain into low, medium, and high risk of persistent disabling back pain.

2011 yes

https://www.keele.ac.uk/media/keeleuniversity/group/startback/Keele_STarT_Back9_item-7.pdf

14 CME An Integrative Approach to Chronic Low Back Pain Medscape For profit clinicians Online course

Reviews the evidence on the safety and efficacy of complementary and integrative health approaches for treating chronic low back pain. 3/2/2016 unknown

http://www.medscape.org/viewarticle/857372

15 CME ACP Practice Assessment Tool: Low Back PainAmerican College of

Physicians Nonprofit clinicians Online course

Free quality improvement tool to assist clinicians in identifying, targeting, and implementing high value care in the treatment of patients with low back pain. This course qualifies for Practice Improvement CMEs.

unknown unknown

https://www.acponline.org/practice-resources/quality-improvement/practice-assessment/low-back-pain

16 CME Chronic Pain Management American Academy of Family Physicians Nonprofit clinicians Online course

Peer-reviewed information on the classification systems for chronic pain and appropriate evaluation. Reviews options for treating pain including behavioral therapies, interventional techniques, and pharmacologic options.

May 2015 unknown

http://www.aafp.org/cme/subscriptions/fp-essentials/editions/432-ed.html

17 Research and Evidence

Physical Therapy or Advanced Imaging as First Management Strategy Following a New Consultation for Low Back Pain in Primary Care: Associations with Future Health Care

Utilization and Charges

Health Services Research Journal clinicians article

Findings show low-back-pain patients who received advanced imaging as a first management strategy following a new primary care consultation was associated with higher health care utilization and charges compared to patients who received physical therapy as first line treatment.

3/16/2015 yes

https://www.ncbi.nlm.nih.gov/pubmed/25772625

18 Research and EvidenceOpioids Compared With Placebo or Other Treatments for Chronic Low Back Pain: An

Update of the Cochrane ReviewSpine Journal clinicians article

An updated Cochrane review of randomized control trials comparing opioid treatment to placebo and other treatments for the management of chronic low back pain.

4/1/2014 yes



Effect of Stratified Care for Low Back Pain in Family Practice (IMPaCT Back): A

Prospective Population-Based Sequential Comparison

Annals of Family Medicine Journal clinicians article

Results from a prospective, quality improvement study showed stratified care for patients with low back pain implemented in family practice leads to significant improvements in patient disability outcomes and a halving in time off work, without increasing health care costs.

March/April 2014 yes

http://www.annfammed.org/content/12/2/102.full

20 Research and EvidenceEarly Physical Therapy vs Usual Care in

Patients With Recent-Onset Low Back Pain: A Randomized Clinical Trial

JAMA Journal Clinicians article

Results from a randomized clinical trial evaluating whether physical therapy within 72 hours was more effective than usual care (no additional intervention beyond education) for low back pain. The study found early physical therapy resulted in statistically significant improvement in disability, but the improvement was modest compared to usual care across the study population, though subgroups may benefit more from early PT.

October 2015 yes

http://jamanetwork.com/journals/jama/fullarticle/2456165


Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back

Pain A Randomized Clinical Trial

JAMA Journal Clinicians article

Results from a RCT showing that among adults with chronic low back pain, treatment with mindfulness-based stress reduction (MBSR) or cognitive behavioral therapy (CBT), compared with usual care, resulted in greater improvement in back pain and functional limitations at 26 weeks, with no significant differences in outcomes between MBSR and CBT.

March 2016 yes



Providers 22

https://www.keele.ac.uk/media/keeleuniversity/group/startback/Keele_STarT_Back9_item-7.pdfhttps://www.keele.ac.uk/media/keeleuniversity/group/startback/Keele_STarT_Back9_item-7.pdfhttps://www.keele.ac.uk/media/keeleuniversity/group/startback/Keele_STarT_Back9_item-7.pdfhttp://www.medscape.org/viewarticle/857372http://www.medscape.org/viewarticle/857372https://www.acponline.org/practice-resources/quality-improvement/practice-assessment/low-back-painhttps://www.acponline.org/practice-resources/quality-improvement/practice-assessment/low-back-painhttps://www.acponline.org/practice-resources/quality-improvement/practice-assessment/low-back-painhttp://www.aafp.org/cme/subscriptions/fp-essentials/editions/432-ed.htmlhttp://www.aafp.org/cme/subscriptions/fp-essentials/editions/432-ed.htmlhttps://www.ncbi.nlm.nih.gov/pubmed/25772625https://www.ncbi.nlm.nih.gov/pubmed/25772625https://www.ncbi.nlm.nih.gov/pubmed/24480962https://www.ncbi.nlm.nih.gov/pubmed/24480962http://www.annfammed.org/content/12/2/102.fullhttp://www.annfammed.org/content/12/2/102.fullhttp://jamanetwork.com/journals/jama/fullarticle/2456165http://jamanetwork.com/journals/jama/fullarticle/2456165http://jamanetwork.com/journals/jama/fullarticle/2504811http://jamanetwork.com/journals/jama/fullarticle/2504811

22 Education and Training Tools NPP Evaluation Case Study: The Spine Center at Dartmouth-Hitchcock

National Priorities Partnership and National Quality

Forum

Nonprofitclinicians,

payers, policy makers

Case study

Case study on Dartmouth-Hitchcock Medical Center (DHMC) Spine Center, a multidisciplinary model for patient-centered, comprehensive, coordinated, and cost-effective care for patients with complex spine problems.

July 2011 no

https://www.qualityforum.org/Setting_Priorities/The_Spince_Center_at_Dartmouth_-_Hitchcock.aspx


Choosing Wisely Recommendation Analysis: Prioritizing Opportunities for Reducing

Inappropriate Care

Institute for Clinical and Economic Review Nonprofit

clinicians, payers, policy

makersEvidence review

Summary, analysis, and justification of specialty society recommendations against the use of imaging for nonspecific low back pain. November 2014 yes

http://icer-review.org/wp-content/uploads/2016/01/FINAL-Imaging-for-Low-Back-Pain-final-analysis-November-28.pdf


Providers23

https://www.qualityforum.org/Setting_Priorities/The_Spince_Center_at_Dartmouth_-_Hitchcock.aspxhttps://www.qualityforum.org/Setting_Priorities/The_Spince_Center_at_Dartmouth_-_Hitchcock.aspxhttps://www.qualityforum.org/Setting_Priorities/The_Spince_Center_at_Dartmouth_-_Hitchcock.aspxhttp://icer-review.org/wp-content/uploads/2016/01/FINAL-Imaging-for-Low-Back-Pain-final-analysis-November-28.pdfhttp://icer-review.org/wp-content/uploads/2016/01/FINAL-Imaging-for-Low-Back-Pain-final-analysis-November-28.pdfhttp://icer-review.org/wp-content/uploads/2016/01/FINAL-Imaging-for-Low-Back-Pain-final-analysis-November-28.pdfhttp://icer-review.org/wp-content/uploads/2016/01/FINAL-Imaging-for-Low-Back-Pain-final-analysis-November-28.pdf


AudienceType of Material Brief Description

Date Citations Provided URL


Physical Therapy or Advanced Imaging as First Management Strategy Following a New Consultation for Low Back Pain in Primary Care: Associations with Future

Health Care Utilization and Charges

Health Services Research Journal

Payers, Providers,

PolicymakersJournal Article

Findings show low-back-pain patients who received advanced imaging as a first management strategy following a new primary care consultation was associated with higher health care utilization and charges compared to patients who received physical therapy as first line treatment.

3/16/2015 yes


2 Tools for Providers Low Back Pain Interventions Table Anthem for profitClinicians,

plans table

Summary of recommended 1st and 2nd line therapies for acute and subacute back pain based on 2007 joint clinical practice guides from the American College of Physicians and the American Pain Society.

unknown yes

https://www11.anthem.com/provider/noapplication/f1/s0/t0/pw_b156429.pdf?refer=provider

3 Tools for ProvidersLow Back Pain Diagnostic Work-Up

Checklist Anthem for profitClinicians,

plans checklist

Diagnostic workup checklist based on 2007 joint clinical practice guides from the American College of Physicians and the American Pain Society for diagnosis and treatment of low back pain

unknown no

https://www11.anthem.com/provider/noapplication/f1/s0/t0/pw_b156428.pdf?refer=ahpprovider&state=me

4 Education The Bree Collaborative Spine and Low Back Pain Report and Recommendations Bree Collaborative NonprofitHospitals and care facilities Report

Workgroup recommendations to prevent the transition of acute lower back pain to chronic pain, including recommendations for health plans on incentive structures to encourage provider adoption of evidence-based low back pain practices.

March 2013 yes

http://www.breecollaborative.org/topic-areas/spine/

5 Benefit Design

Oregon Health Authority Health Evidence Review Commission (HERC) Coverage

Guidance: Lower Back Pain: Non-Pharmacological/Non-Invasive

Oregon Health Authority (OHA)

Government Agency

Payers, Policy Makers Guidance

Guidance from OHA HERC on expanding coverage for low back pain treatments to include alternative treatments such as acupuncture, cognitive-behavioral therapy, massage therapy, yoga, and more. November 2014 no

http://www.oregon.gov/oha/herc/CoverageGuidances/Low-Back-Pain-Non-Pharmacologic-Non-Invasive-Interventions-11-13-14.pdf


Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral

Therapy or Usual Care on Back Pain and Functional Limitations in Adults With

Chronic Low Back Pain: A Randomized Clinical Trial

JAMA JournalPayers,

Providers, Policymakers

Article

Results from a RCT showing that among adults with chronic low back pain, treatment with mindfulness-based stress reduction (MBSR) or cognitive behavioral therapy (CBT), compared with usual care, resulted in greater improvement in back pain and functional limitations at 26 weeks, with no significant differences in outcomes between MBSR and CBT.

March 2016 yes



Comparison of stratified primary care management for low back pain with

current best practice (STarT Back): a randomized controlled trial

Lancet Journal Clinicians, Payers

A RCT comparing the clinical effectiveness and cost-effectiveness of stratified primary care with non-stratified current best practice for the treatment of low back pain. Oct 29, 2011 yes

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3208163/


Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians

and the American Pain Society

American College of Physicians and the

American Pain Society (published

by Annals of Internal Medicine)


Clinical guidelines

Evidence-based diagnosis and treatment guidelines for low back pain featuring 7 recommendations and summary tables with level of evidence and grades for noninvasive interventions for acute and chronic low back pain. October 2, 2007 yes

http://annals.org/aim/article/736814/diagnosis-treatment-low-back-pain-joint-clinical-practice-guideline-from

9 Education

Impact of a Value-Based Insurance Design for Back Pain on Health Plan

Member Satisfaction and its Implications for Patient Outcomes

Population Health Management Journal

Payers, Providers,

PolicymakersArticle

An evaluation of Geisinger Health Plan's Value Based Insurance Design for back pain-related physical therapy (PT) showed bundling five PT treatments for a one-time copayment can potentially improve health plan members' care experiences and their overall satisfaction.

June 3, 2015 yes

http://online.liebertpub.com/doi/full/10.1089/pop.2014.0054

10 Case Study NPP Evaluation Case Study: The Spine Center at Dartmouth-Hitchcock

National Priorities Partnership and National Quality

Forum

Nonprofitclinicians,

payers, policy makers

Case study

Case study on Dartmouth-Hitchcock Medical Center (DHMC) Spine Center, a multidisciplinary model for patient-centered, comprehensive, coordinated, and cost-effective care for patients with complex spine problems.

July 2011 no

https://www.qualityforum.org/Setting_Priorities/The_Spince_Center_at_Dartmouth_-_Hitchcock.aspx


Health care utilization and costs associated with adherence to clinical practice guidelines for early magnetic

resonance imaging among workers with acute occupational low back pain.

Health Services Research Journal


makersArticle

Study showing that workers receiving care non adherent to guidelines for early MRI was associated with increased likelihood of lumbosacral injections or surgery and higher costs for outpatient, inpatient, and nonmedical services, and disability compensation.

April 2014 yes


12 Benefit Design

Oregon Health Authority Health Evidence Review Commission (HERC) Coverage

Guidance: Low Back Pain- Corticosteroid Injections

Oregon Health Authority

Government Agency Health Plans Guidance

Draft guidance against the use of corticosteroid injections for the treatment of low back pain. November 2016 no

https://www.oregon.gov/oha/herc/DraftCoverageGuidances/Low%20back%20pain-Corticosteroid%20Injections%2011-8-2016.pdf

13 Benefit DesignDoes Unrestricted Direct Access to

Physical Therapy Reduce Utilization and Health Spending?

Health Care Cost Institute Nonprofit


makersIssue Brief

Utilization and health spending patterns of patients with low back pain who had varying levels of direct access to physical therapy services. Feb 25, 2016 yes

http://www.healthcostinstitute.org/files/HCCI-Issue-Brief-Unrestricted-Access-to-Physical-Therapy.pdf


The Cascade of Medical Services and Associated Longitudinal Costs Due to Non

Adherent Magnetic Resonance Imaging Spine Journal


makersArticle

Discordance with MRI ordering guidelines leads to expensive and unnecessary services that occur relatively soon post-MRI. Aug 2014 yes


15 Benefit Design Management Options for Patients with Low Back Disorders ICER NonprofitPayers,

purchasers, policymakers

ReportEvaluates comparative clinical effectiveness and comparative value of multiple management options for patients with 4 distinct types of low back pain: Lumbar Spinal Stenosis, Lumbar Disc Herniation,

June 24, 2011 yeshttps://icer-review.org/wp-content/uploads/2016/02/LBP-Final-Appraisal-6-24-11.pdf


Payers/Purchasers

24

https://www.ncbi.nlm.nih.gov/pubmed/25772625https://www11.anthem.com/provider/noapplication/f1/s0/t0/pw_b156429.pdf?refer=providerhttps://www11.anthem.com/provider/noapplication/f1/s0/t0/pw_b156429.pdf?refer=providerhttps://www11.anthem.com/provider/noapplication/f1/s0/t0/pw_b156428.pdf?refer=ahpprovider&state=mehttps://www11.anthem.com/provider/noapplication/f1/s0/t0/pw_b156428.pdf?refer=ahpprovider&state=mehttp://www.breecollaborative.org/topic-areas/spine/http://www.oregon.gov/oha/herc/CoverageGuidances/Low-Back-Pain-Non-Pharmacologic-Non-Invasive-Interventions-11-13-14.pdfhttp://www.oregon.gov/oha/herc/CoverageGuidances/Low-Back-Pain-Non-Pharmacologic-Non-Invasive-Interventions-11-13-14.pdfhttp://www.oregon.gov/oha/herc/CoverageGuidances/Low-Back-Pain-Non-Pharmacologic-Non-Invasive-Interventions-11-13-14.pdfhttp://jamanetwork.com/journals/jama/fullarticle/2504811https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3208163/http://annals.org/aim/article/736814/diagnosis-treatment-low-back-pain-joint-clinical-practice-guideline-fromhttp://annals.org/aim/article/736814/diagnosis-treatment-low-back-pain-joint-clinical-practice-guideline-fromhttp://online.liebertpub.com/doi/full/10.1089/pop.2014.0054http://online.liebertpub.com/doi/full/10.1089/pop.2014.0054https://www.qualityforum.org/Setting_Priorities/The_Spince_Center_at_Dartmouth_-_Hitchcock.aspxhttps://www.qualityforum.org/Setting_Priorities/The_Spince_Center_at_Dartmouth_-_Hitchcock.aspxhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3864604/https://www.oregon.gov/oha/herc/DraftCoverageGuidances/Low%20back%20pain-Corticosteroid%20Injections%2011-8-2016.pdfhttps://www.oregon.gov/oha/herc/DraftCoverageGuidances/Low%20back%20pain-Corticosteroid%20Injections%2011-8-2016.pdfhttps://www.oregon.gov/oha/herc/DraftCoverageGuidances/Low%20back%20pain-Corticosteroid%20Injections%2011-8-2016.pdfhttp://www.healthcostinstitute.org/files/HCCI-Issue-Brief-Unrestricted-Access-to-Physical-Therapy.pdfhttp://www.healthcostinstitute.org/files/HCCI-Issue-Brief-Unrestricted-Access-to-Physical-Therapy.pdfhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4105318/https://icer-review.org/wp-content/uploads/2016/02/LBP-Final-Appraisal-6-24-11.pdfhttps://icer-review.org/wp-content/uploads/2016/02/LBP-Final-Appraisal-6-24-11.pdf

Topic 2: Opioid Overuse Meeting Materials

25

Curbing the Opioid Epidemic: Checklist for Health PlansSmart Care California is a public-private partnership working to promote safe, affordable care in California, including a focus

on opioid-related morbidity and mortality. This checklist of health plan approaches is based on the most up-to-date evidence

available emerging from literature review, case studies, interviews, and surveys of California health plans. See the California

Health Care Foundations publication Changing Course: The Role of Health Plans in Curbing the Opioid Epidemic for details

and references.

Smart Care California is focused on four priority areas with the strongest evidence for impact:

Goal EXAMPLES OF DATA SUPPORTING GOAL

Decrease the number of new starts. Large health plan study showed 67% of members taking opioids for 90 days continued regular use two years later.1

Opioid prescriptions fell 20% when Blue Cross Blue Shield of Massachusetts required authorization for more than a 30-day supply.2

Identify patients on risky regimens (high dose, or opioids and sedatives) and work with them to taper to safer doses.

Doses >100 morphine milligram equivalents (MME) a day increase the death rate almost nine-fold3 compared to 1 to 20 mg daily.

30% of opioid overdose deaths include concurrent benzodiazepine use.4

High-dose opioid use fell 70% through Partnership HealthPlans multipronged initiative (treatment guidelines, formulary controls, prescriber education, and detailing).5

Streamline access to buprenorphine and methadone to treat opioid addiction.

Buprenorphine and methadone decrease rates of death, HIV, and hepatitis rates and increase retention in treatment compared to social model treatments.6

62% of physicians whose patients have insurance coverage find it difficult to access medication-assisted treatment.7

Streamline access to naloxone for overdose reversal.

Co-prescribing of naloxone with chronic opioid prescriptions lowered ED visits by 47%.8

Communities with increased naloxone availability have lower death rates.9

1. Bradley C. Martin et al., Long-Term Chronic Opioid Therapy Discontinuation Rates from the TROUP Study, Journal of General Internal Medicine 26, no. 12(December2011): 1450-57, doi:10.1007/s11606-011-1771-0.

2. Brian MacQuarrie, Blue Cross Cuts Back on Painkiller Prescriptions: An 18-Month Effort Targets Opiate Abuse, Boston Globe, April 8, 2014,www.bostonglobe.com.

3. K. M. Dunn et al., Opioid Prescriptions for Chronic Pain and Overdose: A Cohort Study, Annals of Internal Medicine 152, no. 2 (January 19, 2010): 85-92,doi:10.7326/0003-4819-152-2-201001190-00006.

4. Leonard J. Paulozzi, Karin A. Mack, and Christopher M. Jones, Vital Signs: Risk for Overdose from Methadone Used for Pain Relief United States, 1999-2010,Morbidity and Mortality Weekly Report 61, no. 26 (July 6, 2012): 493-97, www.cdc.gov.

5. Managing Pain Safely: Multiple Interventions to Dramatically Reduce Opioid Overuse, Partnership HealthPlan of California, www.partnershiphp.org (PDF).

6. A Guideline for the Clinical Management of Opioid Addiction, Providence Health Care and Vancouver Coastal Health, 2015, www.vch.ca (PDF).

7. David Kan, Insurance Barriers to Accessing Treatment of Opioid Use Disorders Identified by California Physicians, California Society of Addiction Medicine,November 2016, www.csam-asam.org (PDF).

8. Naloxone Decreases the Use of Emergency Room in Patients Taking Opioids for Pain [press release], San Francisco Dept. of Public Health, June 28, 2016,www.sfdph.org (PDF).

9. Alexander Y. Walley et al., Opioid Overdose Rates and Implementation of Overdose Education and Nasal Naloxone Distribution in Massachusetts: InterruptedTime Series Analysis, BMJ 346 (January 31, 2013), doi:10.1136/bmj.f174.

January 2017

26

http://www.chcf.org/publications/2016/06/changing-health-plans-opioidhttps://www.bostonglobe.com/metro/2014/04/07/state-largest-health-insurer-cuts-painkiller-prescriptions/UAgtbqJL0XPrsNASuJ27sJ/story.htmlhttps://www.cdc.gov/mmwr/preview/mmwrhtml/mm6126a5.htmhttp://www.partnershiphp.org/Providers/HealthServices/Documents/Managing%20Pain%20Safely/MPS_MultipleInterventionstoDramaticallyReduceOpioidOveruse.pdf#search=managing%20pain%20safely%20white%20paperhttp://www.vch.ca/media/Opioid-Addiction-Guideline.pdfhttp://www.csam-asam.org/sites/default/files/pdf/misc/insurance_barriers_mat_2016_final.pdfhttps://www.sfdph.org/dph/files/newsMediadocs/2016PR/DPH-ReleaseNaloxoneStudy-06222016.pdfhttp://www.iha.org/our-work/insights/smart-care-california

Curbing the Opioid Epidemic: Health Plan Checklist IN

PLA

CE

IN P

LAN

NIN

GN

OT

A P

RIO

RIT

Y

Provider Network

Offer or support provider education on pain management based on CDC prescribing guidelines.

Offer or support provider education on buprenorphine prescribing (e.g., waiver training).

Offer or support provider education on co-prescribing naloxone for patients on daily opioids.

Offer or support specific programs that help providers develop taper plans for patients on high opioid doses or combinations (opioids and benzos).

Offer financial incentives or alternative payment models to encourage primary care providers to treat addiction with buprenorphine.

Analyze data to identify outlier prescribers for education, coaching, and/or fraud investigation.

Evaluate network adequacy for opioid addiction treatment with buprenorphine and develop action plan to meet demand.

Evaluate network adequacy for opioid addiction treatment with methadone and develop action plan to meet demand.

Identify members losing prescribers (e.g., due to retirement or loss of license) and coordinate referrals to pain management or addiction treatment where needed.

Ensure access to in-network pain specialists aligned with CDC guidelines for peer consultation or secondary case review.

Participate in local opioid safety coalitions.

Medical Benefit

Notify outpatient prescriber(s) about hospital admission for near-fatal overdose events.

Remove prior authorization requirement for first course of physical therapy for back pain.

Add chiropractic services as a benefit.

Add acupuncture services as a benefit.

Add health education or mindfulness resources as a benefit.

Train case managers on addiction treatment and referral options.

Train case managers on common issues in chronic pain.

Increase access to behavioral health services for patients with chronic pain.

IN P

LAC

EIN

PLA

NN

ING

NO

T A

PR

IOR

ITY

Pharmacy Benefit (all interventions should have an exception for palliative care)

Implement formulary dose limits (total morphine milligram equivalents (MME), with prompt authorization review to manage exceptions).

Implement formulary controls to limit new starts (e.g., authorization requirements for ongoing treatment after first fill).

Implement quantity limits for new starts.

Remove high-dose formulations from formulary (e.g., 80 mg OxyContin, 100 mcg fentanyl).

Remove methadone from formulary for pain treatment.

Remove Soma (carisoprodol) from formulary.

Limit concurrent prescriptions for opioids and benzodiazepines.

Implement pharmacy lock program for patients using multiple prescribers.

Implement prescriber lock program for patients using multiple prescribers.

Ensure co-prescribing of naloxone for members at risk of opioid overdose (e.g., daily opioid use).

Remove prior authorization requirements for common nonopioid pain medications (e.g., antidepressants, neuroleptics with indications for pain).

Remove authorization requirements for initiating and maintaining buprenorphine for addiction (including eliminating requirements for detox in lieu of maintenance).

Remove authorization requirements for initiating and maintaining buprenorphine for pain.

Remove authorization requirements from addiction treatment providers who have demonstrated compliance with standards.

Remove authorization requirement for naloxone.

Work with pharmacy network to support stocking and furnishing naloxone.

Member Services

Provide member education on opioid risks.

Provide member education on naloxone.

Members at high risk of addiction or opioid overuse receive outreach from peer, recovery support, or case manager.

27

Resources to Enable Action on Opioid Overuse, August 2016

A key activity for the Statewide Workgroup on Reducing Overuse is identification of actionable

information from the vast body of work that has been done around each topic area, and to organize

selected resources online in a way that is easy to navigate and access. Focusing first on opioids, a

preliminary set of resources have been compiled for each target audience, with examples; selection

criteria are provided below. Following feedback, the categories will be revised and additional resources

compiled and made available online; a spread plan will then be developed to facilitate broad

engagement.

Table 1: Provider Resources on Opioids Categories and Examples

Clinical Pathways and

Guidelines

CDC Guidelines on Opioids (JAMA, March 2016)

CDPH guide for provides with patients using opioids

Education and Training

Tools

Clinician action guide (ICER)

Commonly used opioids (NIDA)

Considerations for prescribing opioids (NIDA)

Support for Patient

Conversations

Patient Interview Simulation (NIDA)

Scripting for patient conversations about opioid prescribing

Patient agreement (contract)

Choosing Wisely

Recommendations

SWGRO October meeting materials compiled relevant CW recommendations ( p.8)

Example: dont prescribe opiates in acute disabling low back pain before

evaluation and a trial of other alternatives is considered from Amer Acad Physical

Med and Rehab

Research and Evidence ICER study on managing patients with opioid dependence

Guidance on

comparative

performance feedback

(not opioid-specific)

AHRQ -- Confidential Physician Feedback Reports: Designing for Optimal Impact on

Performance.

CHCF Working in Concert: A How-To Guide to Reducing Unwarranted Variations

in Care.

Clinical Decision Support CURES patient alerts for prescribers and pharmacists

Any specific modules or tools in EMRs?

Measures and

Benchmarks

Extensive list of indicators available, including deaths, prescriptions, and number of

people on high doses; CDPH leading dashboard effort. Various performance measures

also available, including recently-released CMS core measure for Medicaid: use of

opioids from multiple providers at high dosage in persons without cancer. See related

discussion document and matrix on measures.

28

https://www.osma.org/Documents/Resources/Smart-Rx/Smart-Rx-Patient-Education.pdfhttp://www.iha.org/sites/default/files/resources/swg-october-meeting-materials.pdfhttp://www.ahrq.gov/professionals/clinicians-providers/resources/confidreportguide/index.htmlhttp://www.ahrq.gov/professionals/clinicians-providers/resources/confidreportguide/index.htmlhttp://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20W/PDF%20WorkingInConcertReducingVariations.pdfhttp://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20W/PDF%20WorkingInConcertReducingVariations.pdf

Table 2: Purchaser/Plan Resources on Opioids Categories and Examples

Contract language re

reimbursement

requirements, quality

None identified yet

Utilization management,

e.g. prior authorization

CHCF Issue Brief Changing Course: The Role of Health Plans in Curbing the Opioid

Epidemic and summary infographic Health Plan Rx

CHCF case studies: Case Studies: Three California Health Plans Take Action

Against Opioid Overdose

Benefit design, including

formulary for Rx

Minimum Insurance Benefits for Patients with Opioid Use Disorder, CA Society of

Addiction Medicine

CHCF Issue Brief: Changing Course: The Role of Health Plans in Curbing the Opioid

Epidemic

CHCF case studies: Case Studies: Three California Health Plans Take Action

Against Opioid Overdose

Table 3: Consumer/Patient Resources on Opioids Categories and Examples

Fact Sheet Consumer Reports -Prescription Painkillers: 5 Surprising Facts

Pregnancy and opioid pain medications

Patient Guidelines CDC Guideline Information for Patients

Patient Agreement Sample patient agreement for opioid usage

Patient Support Video Best Advice for People Taking Opioid Medication available at Physicians

for Responsible Opioid Prescribing

Patient Action Guide (ICER)

Criteria for Selection of Resources

Reputable source with credibility/involvement in this space e.g., government,

nonprofit/research/think tank, university, professional societies, consumer advocacy

organizations

2014 or later

References research or other sources of content

Type of material included: website with additional resources, fact sheet, infographic, policy

brief, journal article, video vs. excluded: anecdotes/materials developed by individuals

Publicly available for free

Relevant to target audience

29

http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20C/PDF%20ChangingHealthPlansOpioid.pdfhttp://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20C/PDF%20ChangingHealthPlansOpioid.pdfhttp://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20H/PDF%20HealthPlansOpioidInfographic.pdfhttp://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20C/PDF%20CaseStudiesHealthPlansOpioid.pdfhttp://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20C/PDF%20CaseStudiesHealthPlansOpioid.pdfhttp://www.csam-asam.org/sites/default/files/pdf/misc/csam-insurance_benefits_opioids-2016-approved.pdfhttp://www.chcf.org/~/media/MEDIA%20LIBRARY%20Fil