Agenda Item 9, Statewide Collaboration through Smart Care ... · PDF fileStatewide...
Transcript of Agenda Item 9, Statewide Collaboration through Smart Care ... · PDF fileStatewide...
Agenda Item 9, Attachment 1 Page 1 of 31
Statewide Collaboration through Smart Care California: Low Back Pain
Kathy Donneson Chief, Health Plan Administration Division
Dr. Richard Sun Preventive Medicine and Public Health Physician
Benefit Programs Policy and Planning
March 14, 2017
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• Background
• Introducing Dr. Tobias Moeller-Bertram
• Lower Back Pain Findings
• Next Steps
Agenda
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Background
Low back pain is the single leading cause of disability worldwide
Global Burden of Disease 2010
Spine pain care accounts for $90 billion in direct cost annually in the US
Stanford Clinical Excellence Research Center
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Background | Low Back Pain (LBP)
Common and costly for CalPERS
$106.6 million in 2015
Smart Care California Prevent progression of acute LBP to chronic pain and disability
Introducing Dr. Tobias Moeller-Bertram
Dr. Toby Medical Director Desert Clinic Pain Institute
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CHRONIC LOW BACK PAIN: A Whole Patient Problem….
Requiring A Whole Patient Solution....
Tobias Moeller-Bertram, MD, PhD, MAS Desert Clinic Pain Institute
March 14, 2017
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PERCEPTION Agenda Item 9, Attachment 1 Page 7 of 31
PAIN
"Part III: Pain Terms, A Current List with Definitions and Notes on Usage" (pp 209-214) Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy, edited by H. Merskey and N. Bogduk, IASP Press, Seattle, ©1994.
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage
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CHRONIC VS RECOVERED BRAIN CIRCUITS
Visit 1 Visit 2 Visit 3 Visit 4
Apkarian 2013 data (Hashmi JA et al., "Shape shifting pain...")
Chronic
Recovered
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BEST TREATMENT MODEL? Agenda Item 9, Attachment 1 Page 10 of 31
Historically, management of patients’ pain was addressed by individual health care providers, usually a physician. However, the presence of pain affects all aspects of an individual’s functioning. As a consequence, an interdisciplinary approach that incorporates the knowledge and skills of a number of health care providers is essential for successful treatment and patient management.
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Interdisciplinary care involves the execution of the treatment plan concurrently. That is, disciplines involved in care will be engaged in parallel and in collaboration and not sequentially whenever possible.
The availability of interdisciplinary care is not solely the responsibility of team members, all stakeholder (institutions, people with pain, referring clinicians, and payers) need to support, encourage, and demand a comprehensive approach to pain management as it is in all of their best interests.
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• Although there are perceptions that opioid therapy for chronic pain is less expensive than more time intensive non-pharmacologic management approaches, many pain treatments are associated with lower mean and median annual costs compared with opioid therapy.
• Multimodal therapies and multidisciplinary bio-psycho-social rehabilitation-combining approaches (e.g., psychological therapies with exercise) can reduce long-term pain and disability compared with usual care and compared with physical treatments (e.g., exercise) alone.
http://www.cdc.gov/media/dpk/2016/dpk-opioid-prescription-guidelines.html
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MEDICAL DEPARTMENT Doctors, Physician Assistants, Nurse Practitioners, Interventional Pain Specialists
ALTERNATIVE CARE DEPARTMENT
Naturopathic Doctors, Acupuncturists, Chinese Medicine, Dietitians
FRAMEWORK FOR TREATMENT SERVICES
PHYSICAL RECONDITIONING DEPARTMENT
Chiropractors, Physical Therapists, Fitness Instructors, Yoga & Tai Chi Masters, Massage Therapists
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FRAMEWORK FOR TREATMENT PHASES (1 YEAR)
• Phase 1 = “Rescue” • Phase 2 = “Restore” • Phase 3 = “Re-entry” Phase
2
Phase 3
Phase 1
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1. Diagnosis Based Approach: Low Back Pain: Treatment A Headache: Treatment B Arthritis: Treatment C
2. Mechanism Based Approach: Neuropathic Pain: Treatment A Nociceptive Pain: Treatment B Mixed Pain: Treatment C
3. Patient Based Approach: Emotional Suffering from Pain: Treatment A Physical Suffering from Pain: Treatment B Mixed Suffering from Pain: Treatment C
FRAMEWORK FOR TREATMENT PHILOSOPHY
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FRAMEWORK FOR TREATMENT LOGISTICS Agenda Item 9, Attachment 1
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• Patients with LBP Diagnosis – 656 of 734 (89.4% of total Pts in COE)
• Patients with five+ Pain Diagnoses
– 395 of 656 (60.2% of LBP Pts)
• Patients with at least one additional Behavioral Diagnosis – 357 of 656 (54.5% of LBP Pts)
BASELINE COHORT CHARACTERISTICS Agenda Item 9, Attachment 1
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CLINICAL OUTCOMES – PHYSICAL Numeric Pain Rating Scale
Oswestry Low Back Pain Disability Questionnaire
* “Pain average,” “interference with Enjoyment of life,” and “interference with General activity”
Pain Intensity and Interference Scale*
Pain Disability Index
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Pain Catastrophizing Scale
Generalized Anxiety Disorder-7 Questionnaire
Patient Health Questionnaire-9
Patient’s Global Impression of Change
CLINICAL OUTCOMES – EMOTIONAL Agenda Item 9, Attachment 1
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Drug Abuse Screening Test-10 Alcohol Use Disorders Identification Test
CLINICAL OUTCOMES – SUBSTANCE USE Agenda Item 9, Attachment 1
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COST TRENDS OF COHORT
• Out of the 79 patients on both Adjusted Clinical Group (ACG) reports given by IEHP:
– 43 patients (54%) had a decrease in the Probability of High Total Cost.
– 34 patients (44%) had an increase in the Probability of High Total Cost.
– 2 patients (2%) remained the same.
Probability of High Total Cost
Increased
44%
Unchanged
2%
Decreased
54%
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$36,817
$19,671
$0
$10,000
$20,000
$30,000
$40,000
Pre-intervention Post-intervention
Total Cost of Care• 65 Total Members • Total Cost of Care = All claims (Rx and
Medical)
• Pre-intervention = 12 months before intervention
• Post-intervention = 6 months after intervention
• Intervention = Member engagement with COE
COST ANALYSIS Agenda Item 9, Attachment 1
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Vision: Ensure that members utilizing a high-level of opioids and suffering from severe, refractory chronic pain will receive a comprehensive, integrative and holistic treatment program focused on promoting patient self-efficacy, functional restoration, and wellbeing.
Goal: Develop a network of Pain COEs building on Desert
Clinic Pain Institute Model
IEHP'S APPROACH TO SCALING PAIN COES: TOTAL PAIN CARE (TPC) PROGRAM
COE = Center of Excellence IEHP = Inland Empire Health Plan
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25
Desert Clinic Pain Institute
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COE sites will be evaluated on cost, utilization, patient outcomes and program engagement:
1. Cost Analysis/Return on Investment (ROI)
Total medical costs including pharmacy, facility, professional and cost of COE program
2. Utilization Analysis
Emergency room, inpatient interventional utilization pain procedures and morphine equivalent dosage (MED)
3. Patient Outcomes
Pain level, disability, depression, anxiety, patient satisfaction
4. Program Engagement
Member Engagement rate and retention rate
PROGRAM EVALUATION Agenda Item 9, Attachment 1
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➤ Engagement before and during treatment is key
➤ Implementation of transitional support program after completion is needed for successful outcomes
➤ Longitudinal coordination of care between all treating providers and entities is essential
➤ Non-clinical (and clinical) support staff needs to have training to attend to these complex members
➤ Linkage to and coordination with carve out services and community services is essential
LESSONS LEARNED Agenda Item 9, Attachment 1
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Thank You
Dr. Tobias Moeller-Bertram Medical Director
Item 8b, Attachment 1, Slide 30 Page 1 of 11
Next Steps
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Next Steps
Identify nationally defined measures
Conduct additional data analytics
Identify variations in cost and use
Business Planning Initiative