Redefining diagnosis can help treat chronic pain
Avoid unproven, often ineffective treatment
By Arthur Runyon-Hass, MD, PhD
Diplomate, American Board of Anesthesiology
Medical Director of Pathway Healthcare
A consulting and medical management company
Brentwood, TN
The treatment of workers with chronic pain has become big business. In spite of the emergence of dedicated pain treatment centers within only the past 15 years, there has been a dramatic economic and demographic growth in this discipline. A worker with chronic pain can now choose from more than 3,000 different clinics, facilities, or individual practitioners in the pain industry.
Despite the increased attention to chronic pain, the biggest challenge for the occupational health professional may be getting the worker to the treatment. Too often, payers, employers, and patients give up before they get as far as a pain treatment center.
The expansion of the pain treatment discipline was due in large part to the explosion of disability claims in the previous decade. The rate of increase in U.S. disability claims during one five-year period (1977-1981), for example, was 14 times the rate of population growth.1 Many of these patients already had undergone restorative procedures but still were unable to return to work, despite any evidence of ongoing anatomic limitations.
What were the workers’ residual diagnoses? Chronic pain. Therefore, a sophisticated system of pain treatment, often coupled with rehabilitation services is often the last chance to restore a growing population of disabled workers to productivity.
Cost also has increased along with the number of chronic pain patients. The remarkable increase in the number of patients with chronic pain was followed closely by additional subspecialty-trained physicians and newer technologies developed to care for these patients.
The most predictable results of growth in this field was an almost exponential increase in the overall cost of treating the population of clients with chronic pain.
Unfortunately, the employer, the payer, and even the patient have become increasingly wary of the phrase "there is one more thing we can try." Wisely, payers and workers’ compensation case managers have begun defiantly asking "Why?" when additional charges are suggested. Simply saying, "I’m the doctor and I think it will help" isn’t enough any more.
Pain treatment is appropriate for many
Unfortunately, some payers have gone too far in their efforts to contain costs. They simply deny any form of chronic pain treatment. They cite the lack of outcome studies by their financially successful and frequently adversarial disability doctors as an indication that there are far too many treatments being provided. Right premise wrong conclusion!
Chronic pain treatment is appropriate for many disabled workers. It simply needs to be managed and closely monitored in the context of patient needs and growing fiscal constraints. In this column, you will read how pain management can employ a multidisciplinary approach to patient care incorporating varied techniques from neurosurgery, orthopedics, psychiatry, anesthesiology, and physical therapy to develop and implement care.
Most importantly, a method in which care can be provided in a compassionate and cooperative manner between these practitioners and managed care will be included. (For more on the steps in critical pathway development, see related story, p. 18.)
Understanding the interrelationship of various pathway components will then illustrate just how the following four main players will benefit:
• the worker;
• the clinician;
• the case manager;
• the payer.
We began by developing treatment pathways for our clinicians. We found that while they were knowledgeable of diagnostic and therapeutic techniques, clinicians needed a road map to see how the treatment of these complicated patients fits into the real world.
Pathways take cost and medical approach
Later, when our practice-based case manager moved into a position as a payer-based case manager, she was able to make a rather interesting observation: Our treatment pathways, if properly implemented, provide the opportunity to monitor and track patient outcomes from both a medical and a cost basis.
When she shared our approach with other case managers, they too were interested in how well we could predict, track, and monitor the treatment for such a complicated group of patients.
Clinicians have been impressed with how well patients accept the treatment pathway system. Workers suffering with chronic pain often feel a great loss of control. Given the opportunity to visualize their treatment goals and monitor their progress, they develop a sense of ownership in their treatment. When even slight improvement occurs, we often see a profound increase in motivation and energy level.
But the most concrete benefits go to the payers and the employers. They can accurately predict cost and time course of treatments, particularly if they refer to a limited number of providers. The progress of both patients and providers can be monitored in real time. As a result, there is a built-in mechanism for tracking patient compliance with the suggested treatments. We believe a pathway-based approach will significantly decrease costs for all concerned.
Reference
1. Frymoyer JW, Cats-Baril W. Predictors of low back disability. Clinical Orthopedics 1987; 221:89-98. t
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