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Changing the Way We Treat Chronic Pain: Practical and Profitable Evidence‐Based Methods Daniel Bruns, PsyD FAPA Collaborative Family Healthcare Association.

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Presentation on theme: "Changing the Way We Treat Chronic Pain: Practical and Profitable Evidence‐Based Methods Daniel Bruns, PsyD FAPA Collaborative Family Healthcare Association."— Presentation transcript:

1 Changing the Way We Treat Chronic Pain: Practical and Profitable Evidence‐Based Methods Daniel Bruns, PsyD FAPA Collaborative Family Healthcare Association 15 th Annual Conference October 10-12, 2013 Broomfield, Colorado U.S.A. Session # F3a Friday, October 11, 2013

2 Faculty Disclosure I currently have the following relevant financial relationship (in any amount) during the past 12 months: Psychological test author and consultant

3 Objectives Understand how to create a pain treatment program that is practical and economically viable in both – Fee for service systems – ACO/capitated systems Handouts:

4 Daniel Bruns, PsyD Have been involved in developing evidence- based medical treatment guidelines Conducted a 15 year longitudinal study of 29 million patients regarding the cost benefits of the biopsychosocial model Have run a profitable clinic for 28 years

5 There are a variety of economic models in the field. Where do you fit? Payers – Medicare/Medicaid – Private pay – Grant Private Payer type – HMO – PPO – In/Out of network Billing codes – E&M – Psych, H&B Economic systems – Fee for service – Bundled – Capitated Clinic type – Integrated – Co-located – Accountable Care Organizations

6 Pain Is Arguably The Most Expensive Medical Condition The most common reason why patients see a physician – National Center For Health Statistics, 1992 Annual cost of chronic pain in the US = $635 Billion – Institute of Medicine, 2011 Pain is a priority in the Affordable Care Act – Mentioned more often than diabetes, heart disease, substance abuse and obesity

7 A Comprehensive Pain Treatment Program Begins With a Better Understanding of Pain Physiologically, pain is half sensation and half emotion

8 Pain also comes from nerve injury… Neurologically, pain is a complex, multidimensional sensory experience Spinal Cord and Ganglia Acute “First Pain” Primarily A-∂ fibers (sharp/localized) Thermal HeatCold PressureChemicalTension“Sleeping” Chronic “Second Pain” C fibers (achy/diffuse) ThermalPressureChemical … nerve dysfunction, and neurotransmitters (e.g. Substance P) ©2013 Daniel Bruns, PsyD Pain Sensory Receptors Pain Nerve Pathways

9 Sensory Regulation: Descending Neural Inhibition vs Windup Emotion (irritability and depression) Sensation and Movement (self-protective behavior) Arousal (I can’t sleep) Pain Center (Central sensitization: multiple factors in the neuromatrix sensitize you to pain) Thoughts and worries about pain (Will I ever get better???) Muscle Tension & Spasms (knots in muscles) “A-delta” Acute Pain Nerve Fibers (sharp, localized pain) “C” Chronic Pain Nerve Fibers (broad pattern of dull, achy pain) Many parts of the brain are involved when you feel pain The Pain Sensory System Many parts of the brain are involved when you feel pain ©2013 Daniel Bruns, PsyD TSSP*

10 How do you create a clinically practical and economically viable program to treat pain?

11 Fee For Service

12 How Safe Are Pain Medications? American Mortality Rates For Accidental Overdose Centers for Disease Control, 2012 Opioid Analgesics Cocaine Heroin © 2012 by Daniel Bruns

13 This Plan Starts With The Physician Opioid-only model is not the best care – Not very effective, increased risk – Best is biopsychosocial model “We are committed to the best care for you” – Comprehensive pain treatment – To get opioids, you must attend the comprehensive program

14 Pain Assessment

15 Medical Assessment Accurate diagnosis must precede treatment Celsus, 35 AD

16 Psychological Assessment It is more important to know what sort of person has a disease, than to know what sort of disease a person has. Hippocrates, 400 BC

17 Biopsychosocial Assessment Medical – Exam, tests and imaging Psychological – A review of 125 meta-analyses concluded psychometric tests are the scientific equals of medical tests in their ability to diagnose and predict outcome (Meyer, et al, 2001) – Psychological tests better than MRI at predicting lumbar surgical outcome, (Carragee, et al, 2005; 2004)

18 Psych Diagnoses for Chronic Pain Psychological diagnosis may include: – DSM IV/ICD-9-CM /ICD-10: Pain disorder – DSM 5: Somatic Symptom Disorder With Predominant Pain – Plus depression, anxiety, personality disorder, opioid dependence, etc…

19 Billing For Psych Assessment: Caveats Billing criteria varies – Over time – Over areas of the country – Among payers – For each payer, among policies – You cannot rely on this presentation for definitive information on your circumstances You must know the current policies of your payers Always do the right thing

20 Billing for Psych Assessment CPT Code (Old code)Description Reimbursement (private payer) 90791 (90801)Diagnostic Interview (Not time based) $151 (83) 96101 Psychological Testing by Psychologist, Physician or Other 83 (69) 96102Psychological Testing by technician 86 (69) 96103Psychological Testing by Computer 70 (69) 96150Heath & Behavior Assessment 20 (29) 96151Heath & Behavior Reassessment 19 (29)

21 Billing CPT 96101 Psych Testing For traditional standardized tests! 96101 – 31 to 90 minutes 1 unit 31 to 90 minutes paid at $83 – Hourly rate drops from $161/hr at 31 minutes, to $55/hr at 90 minutes 96101-52 – Reduced time 96101 – 30 minutes or less pays about $42 – 20 min = $126/hr

22 What Does 96101 Include? Psych Testing 96101 – Face-to-face time administering tests – Non face-to-face time Interpreting test results Integrating other clinical data, including previously completed and reported technician– and computer– administered tests Preparing the report You can design services that fit into a 20 minute or 40 minute time frame © 2005 by Bruns and Disorbio

23 Psych Testing Codes Do Not Apply to All Assessments Mini Mental Status is specifically excluded – by implication, also probably PHQ-9, SF-12 Short psych tests that I know of with established track record of reimbursement – BBHI 2 – P3

24 Billing 96103 Computerized Assessment – For standardized computerized tests – Not for a PHQ-9 running on an Excel spreadsheet – No time listed ~ $70 for whatever time it takes – You should administer and interpret test results in context of other clinical findings

25 Evidence-Based, Interdisciplinary Treatment Guidelines for Pain Recommend Psych Assessments They Are Also Reimbursable Under Fee For Service

26 Treatments for Pain

27 The Spectrum of Treatments What is the plan? Operative procedures Medications Exercise/physical therapies Behavioral treatments © 2013 by Bruns and Disorbio

28 Behavioral Treatments One purpose of psych eval – – Group vs Individual? – Use groups when possible Some patients are not good candidates for groups though – Personality disorder – PTSD – Suicidal/Severe depression

29 Group Topics Pain Education – Chronic pain as a sensory disorder – The pain sensory system – “First pain” vs “second pain” – Pain and cognition, affect, memory, sensation – Rx for pain – Role of exercise Pain Treatment – DBT CBT Mindfulness Stress mgt, etc – Sleep hygiene – Voc rehab – Pain workbook – Support group for ongoing issues

30 Group Treatment Appropriate patients first attend pain education group with revolving agenda Later attend pain support group More complex patients may have a greater need of individual care

31 Group Treatment Psychologist/LCSW/LPC CPT 96153 –Private payers may pay more –90853: Pain disorder/somatic symptom disorder 10 members, 60-90 minutes = $245/hr Medicare 10 members, 60-90 minutes = $390/hr Pvt Payer –If you screen out the difficult patients, larger groups are possible

32 Billing for Treatment CPT Code (Old code) Description Reimbursement (private payer) 90832 (90804) Psychotherapy, 30 minutes (16 to 37 minutes) with patient and/or family member (@ 16 min= $235/hr) $62.60 (39) 90834 (90806) Psychotherapy, 45 minutes (38 to 52 minutes) with patient and/or (occasionally a) family member $80.63 (69) 90837 (90808) Psychotherapy, 60 minutes (53 minutes or longer) with patient and/or family member $118 (83) 90853Group psychotherapy$25 (39) The psychotherapy codes should not be billed for any sessions lasting less than 16 minutes.

33 Capitated Systems and Accountable Care Organizations

34 ACO/ Capitated Systems You have $X dollars to spend on your population – Under ACA, pain is one of the highest priority conditions Will adding psych services for pain – Increase costs? – Or reduce costs? ✔

35 What is the evidence that adding psych services provides better care at less cost?

36 Colorado Biopsychosocial Law Study Legislative Natural Experiment Legislative act creates treatment and control groups

37 1992: Colorado Biopsychosocial Law 1.Law mandated use of evidence-based biopsychosocial guidelines for work-related illness or injury 2.MDs must be trained in the guidelines 3.Mandated psych assessment 1.For all with delayed recovery or chronic pain 2.Prior to numerous surgeries and procedures 4.Mandated psych treatment 5.Insurers had to pay for listed treatments 6.Regulatory and judicial oversight

38 2011 We obtained 15 years of cost data on every injured worker under every payor in 45 states

39 What Happens When you Mandate The Biopsychosocial Model? 15 years of cost data Colorado N = 520,314 Rest of USA N ≈ 28.6 million –Bruns, Mueller and Warren, 2012

40 Hypotheses Colorado’s biopsychosocial approach will contain inflation in medical costs Colorado’s biopsychosocial approach will contain inflation in disability costs Provide better care

41 Medical Inflation Nation202% Colo 68%

42 Disability Cost Inflation Nation109% Colo 28%

43 Estimated Cost Savings of Colorado’s Biopsychosocial Model in 2007 alone: $859,000,000 Bruns, Mueller and Warren, 2012

44 Colorado Study Conclusion At a population level, this produces better care at reduced cost

45 Psych Assessment And Cost Offset Helpful in IPC – Who is good candidate for group treatment? – Predicting patients at risk for nonadherence, etc More helpful in ACOs – Cost of IPC + hospital + specialty + more on same spreadsheet – 1 surgery can blow the budget Patient selection can help to control specialty costs, reduce hospital re-admits

46 Psych Assessment Cost Offset Some medical treatments are extremely expensive – Some surgeries can cost > $100K – Many payers require presurgical psych evals Surgeons wouldn’t do surgery without an MRI – But psych assessments are more predictive of outcome than MRI for many pain procedures – Very high return on investment of clinical time

47 Brief Standardized Psych Evals The only published method of pain assessment with a 10 minute assessment method that is – Standardized – Evidence of validity and reliability – No gender or race bias – Identifies factors associated with poor response to surgical and nonsurgical (TBI, PT) treatments – Bruns, D., & Disorbio, J. M. (2009)

48 Psych Treatment Cost Offset For many patients behavioral treatments are much better choices than surgical ones – For some conditions behavioral treatment outcome = that of surgery – Surgery is 156X more expensive – Surgery has serious risks 3/1000 chance of death – Bruns et al, 2012

49 For ACOs to meet their financial targets They will have to find a better means of selecting patients for high-cost, high risk procedures for painful conditions. Since pain is the most expensive condition, and it is a biopsychosocial disorder, that means more psych assessment and treatment

50 References Bruns, D., & Disorbio, J. M. (2009). Assessment of biopsychosocial risk factors for medical treatment: a collaborative approach. J Clin Psychol Med Settings, 16(2), 127-147. Bruns, D., & Disorbio, J. M. (2013). The Psychological Assessment of Patients with Chronic Pain. In T. R. Deer (Ed.), Comprehensive Treatment of Chronic Pain: Medical, Interventional, and Behavioral Approaches (pp. 805-826). New York: Springer Colorado Division of Workers' Compensation. (2012). Rule 17, Exhibit 9: Chronic Pain Disorder Medical Treatment Guidelines. Colorado Department of Labor and Employment: Division of Worker Compensation

51 Questions Additional Information:

52 Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!

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