Saturday, February 24, 2018

The Business of Chronic Pain Care

Adam Perlman, MD, MPH, FACP.

Adam Perlman, MD, MPH, FACP.

In the past, non-traditional, health-promoting practices, such as acupuncture, massage, healthy lifestyle training and mind-body practices, have appeared to be at odds with the disease-management through medication and procedure focused model of medical care within our healthcare system. Non-traditional approaches to care (often referred to as integrative medicine, integrative health or integrative care) no longer need to be a source of tension to the health care industry, according to Adam Perlman, MD, MPH, Executive Director of Duke Integrative Medicine, because they benefit both the patients and the health care system:

“Here at Duke, we’re looking to pilot an in-patient symptom management program that incorporates acupuncture, massage and mind-body medicine,” said Dr. Perlman. “It really addresses the Triple Aim in that it’s not only ideally going to help the hospital with improved outcomes, it potentially is going to lower costs through earlier discharges, and through less use of expensive pain medications. And it’s also going to impact positively on patient experience, which will lead to downstream revenue through positive word of mouth, improved patient satisfaction scores and by extension increased market share. This means additional business for the hospital, as well as potential improvement in important metrics such as HCAHPS and Press Gainey—all leading to a positive impact on the bottom line.”

Making Integrative Care Sustainable and Impactful

“The need today is to begin to find models that can be readily integrated into the existing system in a way that is sustainable,” said Dr. Perlman.

Dr. Perlman is working with Samueli Institute to guide clinics to build sustainable integrative practices that make quality pain care more accessible and timely to relieve patients of their chronic pain symptoms and reduce opioid use. This effort, the Chronic Pain Breakthrough Collaborative, is leading the path to innovation in chronic pain care by teaching civilian, military and veteran health care clinics and hospital systems to build integrative practices for chronic pain management. “This breakthrough collaborative is an opportunity for healthcare systems to rapidly develop programs that they can implement and ultimately grow and that will have an almost immediate impact.”

The collaborative is currently enrolling participants for a collaborative to launch this spring.

 Using systems knowledge to reduce costs and improve profit

“Organizations that are early adopters of integrative care will have the experience, track record and refined processes, and will be in a better position to take advantage of bundled payments and other aspects of value-based care that are continuing to evolve,” said Dr. Perlman.

Integrating evidence-based non-conventional practices into traditional care is complex. Integrative care requires changes at all levels of an organization. For example, merely adding an acupuncturist to the health care team does not mean that patients will receive better care. Structures and processes must be developed that support team-based care. Communication must be strengthened among providers, with patients and their families. And all constituents—including leadership—must be educated on the evidence-base and proper use of the therapy.

Employing an appropriate health care improvement model is essential. Those who aren’t prepared for the shift to broader integration of integrative health are already behind, according to Dr. Perlman: “You’re spending money that isn’t effective, you may be losing market share, and you’re not capturing dollars that you could be capturing if you had a more comprehensive program.”

 Lower Costs; Higher Value in Chronic Pain Care

Integrative care addresses many of the common issues that make modern health care so expensive especially in chronic pain care. Almost 50 people die each day from opioid overdose caused by addiction to painkillers. National authorities and even President Obama have called for action to curb this epidemic and develop better approaches to treat pain.

“What hospitals have traditionally turned to is primarily medications and procedures. Proper use of medications and procedures are critical for effective management of patients with pain and suffering. However, they can often contribute to increased expense and have concerning potential side effects. They can lead to increased length of stay and other iatrogenic issues. These issues are contributing to an increased interest on the part of hospitals, hospital administrators and providers in finding effective non-medication ways of dealing with pain,” said Dr. Perlman.

Integrative care can improve chronic pain and related symptom management. It has the potential to positively impact the bottom line through improving patient satisfaction scores, HCAHPS, decreased length of stay and readmission rates—all tied to hospital reimbursement. More importantly, integrative care can relive suffering and is the right thing to do for our patients.

The Competitive Landscape of Health Care

Health care is a competitive industry. In a system where patients have a choice, integrative care can increase market share through quality of care and differentiation.

It’s Just Good Care

Perhaps the most important driver for integrative care is that it’s what is best for the patient. Practitioners dealing with chronic pain care know that pain is neither purely of the body nor of the mind. Pain is expressed in physical changes, but it is also processed in the brain and experienced in different ways.

“The best and most effective approach to pain management is to take a very comprehensive one—a perspective that addresses pain from a physiologic, emotional, and even a spiritual context,” said Dr. Perlman.

In addition to science-backed interventions, integrative care includes self-care practices to reduce stress, improve sleep and increase healthy decision-making. These all help to reduce chronic pain and improve chronic pain coping skills.

Integrating more integrative care into one’s approach to pain management helps to relive the suffering of our patients and by extension is good for business, noted Dr. Perlman.

Learn more about Samueli Institute’s efforts to combat chronic pain and the nation’s opioid crisis at

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About Wayne B. Jonas, MD, President and CEO of Samueli Institute