The Right Stuff for Acute & Chronic Pain Syndromes

The Team Approach to Pain Management and Treatment Enables Pain Sufferers to Resume Work and Reduces Their Use of Healthcare Services

 By

Dr. Peter G. Furno

Pain Management Specialists of Indianapolis

Indianapolis, Indiana

You would think that a treatment method that returns about two-thirds of people with acute and chronic pain to their work, lowers their subsequent healthcare bills and is cheaper than the common traditional alternative would be embraced by providers, health plans and employers?  Hardly!  Multidisciplinary treatment centers, which accomplish these goals, are usually the last to see the patient, instead of the first.  As a result, they are often faced with the results of misdiagnosis, and inappropriately managed pain syndromes.  Usually these patients have endured years of suffering, failed surgery and are out of work – in many cases they are on disability compensation.1

Delays in access to skilled caregivers can and does prove costly.  Just as an example, most cases of back pain that are acute resolve in a few weeks to a few months, but patients whose low back pain is allowed to persist for more than 8 weeks are at a high risk of developing a chronic condition.2,3  People with chronic spine pain face a poor prognosis and account for the majority of the healthcare and social costs attributed to low back pain in general.3,4

Employers, thus, have much to gain from knowing what constitutes proper therapy and how to identify the best treatment centers.

Evaluating Pain

The highly subjective nature of pain creates a diagnostic challenge for primary care physicians, who generally are not well trained to diagnose and treat pain, and more specifically, spine injuries.  Primary care physicians may even question whether patients with no detectable abnormality are malingering or emotionally unstable.  Health plans and employers may make similar assessments, leaving the patient despondent, untreated, hurting and angry.  Many patients complain that the primary delay in their treatment is that no one takes them seriously because they look well. 

Even providers who accept that their patient’s pain is real, often may not know how to appropriately manage it.  Many physicians and insurers are unfamiliar with good quality multi-specialty treatment programs and their benefits and the result may be the referral of the patient-but unfortunately for inappropriate care. 

Next Stop, Surgery

Many people, in suffering pain, see a surgeon at some point.  About 1-2% of adult Americans are estimated to have undergone back surgery.5  Paradoxically, Health plans generally pay for surgery, notwithstanding the risk, unfavorable outcomes and the fact that many operations appear to be unnecessary.  The failure rate for low back surgery approaches 40%.  Persistent pain often results in repeat-surgery which increases overall costs and the risk of total disability. 5  The Worker’s Compensation Board, Ontario, Canada, estimated that after a second back operation, 20% worsen and 60% stay the same, 20% improve, but no one is cured.

It is imperative that Physicians or healthcare plans wishing to refer for non-surgical treatment must do so in a timely fashion and, more importantly, to medical teams well versed in these conditions, if they want to circumvent disastrous outcomes. 

The Case for Multi-Specialty Treatment Centers 

A growing body of scientific evidence indicates that multidisciplinary treatment centers (MTCs) are very successful in returning the injured employee to work with significantly improved function and lowered pain levels.  Almost 70% of MTC-treated patients returned to work, compared with 24-44% of those managed with conventional medical care or physical therapy.5    MTCs were about twice as likely to return injured employees to work or to show an improvement in activity levels as those who refuse treatment, who are wait-listed or are treated with traditional medical care or physical therapy.6 

Only about 50% of surgically treated back pain patients return to work after operation.  MTCs also reduce patients’ use of healthcare resources – a significant issue because diagnosis and appropriate treatment is much more effective at resolving an injury quickly before costs start escalating.  Patients with unresolved pain often see many providers in search of relief. In one study, patients treated at an MTC under HMO auspices made 36% fewer visits to the treatment center in the first year after treatment.  Studies following patients for 1-2 years post treatment consistently found that back patients cared for at MTCs used fewer healthcare services than do patients managed wit conventional therapy. 

Taken together, about 17% of MTC treated patients required surgery or were hospitalized within 1-2 years, compared to 47% of persons treated only with conventional therapy.  The results are all the more impressive when one considers that MTCs are often the patient’s last resort.  Most having become chronic through inappropriate medical care, with more than half having failed surgery.  Only a third are working, and about half have lapsed into significant depression.1,5 

MTCs – Too Expensive? 

One perception multidisciplinary treatment centers continues to fight is a reputation for being expensive.  In fact, effective treatment at an MTC compares most favorably in comparison to that of surgery.  The cost of surgical treatment for back pain has been conservatively estimated at $40K - $50K.  In 1995, the price of outpatient treatment at an MTC averaged between $2K - $8K, dependent on severity of case. 

Study Results 

Study results strongly suggest that MTC treatment is both clinically effective and cost effective; yet, insurers often will not cover these programs.  Although health plan administrators pay lip service to controlling costs, in reality, this does not appear to be the case.  Insurers will think nothing of paying up to $30K for a third laminectomy, for example, but will balk at paying $8K for an intensive outpatient functional restoration program already shown to be far more effective and cost-efficient than surgery. 

There is a substantial amount of clinical data favoring multidisciplinary pain management over surgery, but, incomprehensibly, insurers continue to demand still more studies before they will consider covering it. 

Ensuring Access to Quality Care 

Employers can take several steps to ensure that their employees and dependents suffering with acute or chronic pain have access to the best options for treatment: 

●      Determine the type and extent of coverage for pain conditions

●    Ask for evidence that injured employees are referred to specialists in a timely manner.

●    Seek  out credentialed  specialists in pain medicine and accredited multi-speciality treatment centers.  Insist that the medical facility is a State approved C.O.R.F. (Certified Outpatient Rehabilitation Facility).

●    Medical Treatment Centers should provide clear cut patient entry criteria and be able to tell you  what type of patient is likely to benefit.

●    They should offer a variety of treatment options, including medication, physical therapy, occupational therapy, manipulation therapy, psychotherapy, biofeedback, nerve blocks and epidural steroid injection.  Few patients need all of these interventions, but flexibility is a key factor in the multi-disciplinary approach.  The treatment center should provide a detailed therapeutic plan with specific goals after an initial patient evaluation.  Treatment goals generally center on work, resuming home responsibilities, restoring the ability to engage in recreational activities, and using healthcare and medications appropriately.  Maximizing function expeditiously is the end goal. 

Multi-Disciplinary Team Medicine is Effective 

Multidisciplinary treatment centers base their approach on two fundamental assumptions about pain:  First, that it is a complex phenomenon involving physical, psychosocial and behavioral factors; and second, that pain problems are best evaluated and treated by a team of healthcare specialists from various disciplines.  The staff of an MTC typically includes physicians (Occupational Medicine, Neurology, Anesthesiology), psychologists, nurses, physical therapists, podiatrists, occupational therapists, and in a growing number of instances manipulation therapists (chiropractic physicians), and acupuncturists. 

Past research on spine an musculoskeletal ailments has show that MTC’s effectively reduce pain, drug use, and utilization of healthcare facilities as well as improve activity levels, return to work time-lines and closure of disability claims.  Studies comparing the outcomes of MTC treated patients versus conventional treatments suggest clear clinical and cost benefits of this approach. 

On average, patients treated for low back pain with conventional methods were three times more likely to require additional surgery or hospitalization than MTC treated patients.  Previous studies have shown that treatment with MTC reduces the number of additional surgeries needed by about 31% and lowers medical costs by 58%. 

It is clear that earlier referral would most likely reduce the human and financial burden of pain. 

The Spine Rehabilitation and Ambulatory Surgery Center 

The Spine Rehabilitation and Ambulatory Surgery Center is a State accredited Certified Outpatient Rehabilitation Center (CORF), one of only eight such entities in Indiana.  It is a vertically integrated, single site, medical treatment facility focused on the spine injured, musculoskeletally compromised patient, suffering both acute and chronic pain syndromes.  The facility incorporated occupational/preventative medicine, primary care, interventional pain medicine, acupuncture, chiropractic therapeutics, therapeutic  massage therapy, physical therapy, neurology, podiatry, clinical psychology, and nutritional counseling. 

The center was conceptualized as a direct antagonist to the traditional medical “merry-go-round” of horizontal integration (the initial delay of appropriate treatment and the then seemingly perpetual inter-referral of patients between specialty physicians practicing in multiple site locations), to that of vertical integration whereby timely, effective, cost efficient, integrated and focused team medicine is offered by appropriate specialty providers, in a single site center of excellence. 

Pgf/1/2000

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