Interdisciplinary pain management and prevention offer positive results
"It's a paradigm shift," said Michael Coupland of Florida-based Integrated Medical Case Solutions. "I've really been finding that you've got to engage the injured worker, our treating psychologist, treating physician, payer and the brokers, underwriters, employers, the lawyers, and everybody."
Coupland is the developer of a pain management system, Control Over Pain's Effect, and chapter author of the American Medical Association Guidelines companion text, Guides to the Evaluation of Functional Ability. The approach to treat injured workers involves the biopsychosocial model with a strong reliance on evidence-based medicine. "It shows predictive factors for chronic pain," he said. "That's why the message has to just keep getting out that this is evidence-based medicine."
The approach specifically targets injured workers who have an increased risk of becoming permanently disabled. The typical patient is one who has been in the system for a while, although Coupland says it can also work for injured workers at the beginning of a claim.
The biopsychosocial model recognizes that certain people are more prone to suffer from chronic pain, he said.
"Unless you intervene, their physiology will change, and they will go into the chronic pain cycle," Coupland said. "Those people will get more surgery and more opioids."
Interdisciplinary teams. "Chronic pain requires disease management rather than symptom management used to treat acute pain," according to a recent white paper from Corvel Corporation. "Disease management considers multiple therapy options, including medication, to afford the patient a chance at a better life through medical interventions, psychological support, and different treatment and functional modalities."
Corvel is one of the companies Coupland is working in a team approach. As the paper explains, the interdisciplinary outpatient program requires a team of specialists that collaborate and focus on the total patient rather than just on the pain.
"By following the simple steps of assessment, treatment, communication, education, and follow up, it is actually possible to increase level of functioning, improve quality of life and ultimately enable return to work," according to the paper. "By integrating state-of-the-art analytics, standards of care and peer-to-peer medication review, Corvel creates a complete view of the patient and treatment plan to optimize return to work outcomes."
The process begins with a behavior assessment of the injured worker. The program only works if the patient buys in to it.
"We can identify very quickly if a person is going to engage after three sessions with the psychologist," Coupland said. "We are saying to the payer, 'we are not going to spin our wheels. If they are not going to engage, we won't keep them in the program.'"
At each phase, the team decides whether to continue or discharge the injured worker from the program. "After that [initial assessment], I think we've got about 75-80 percent of meeting our goal," Coupland said. "It's a triage approach because we want to have good outcomes. ... So it comes by careful selection and working with the team to find their motivators."
Getting buy in from all the parties to a claim can be a daunting task. However, employers are not usually a concern.
"They are quite engaging because the old cases with Medicare set-asides have huge drug spends into the future," Coupland said. "The prevention model is harder to sell than when they are bleeding money on the table."
Also actively involved are brokers. "While we can say the brokerage community has solutions, carriers, TPAs, employers, one of the biggest challenges still is getting the medical community to buy in," said Pamela F. Ferrandino, casualty practice leader of Willis North America. "Some of it is basic blocking and tackling by geography."
As Ferrandino explained, teams with concentrations in certain industries will set up networks of physicians who have the best outcomes. "They physically go out and meet with the physicians in terms of setting up a network," she said. "Depending on what area it is, for some clients we may have that engagement."
Coupland says for some physicians it's an educational process. For others, peer review works best.
"There is the bit of the dot com [approach] for the surgeons," Coupland said. "They need to know that not everybody is going to be a good surgical candidate. That's not something necessarily to educate them, but use the peer-review approach to say 'no, we are not approving it because in this case there are so many yellow flags and lack of pathology that this is not a good candidate for surgery.' It's a case-by-case basis."
By Nancy Grover
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April 18, 2013
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