What do we pay for and why

Chronic Knee Pain: Internet-Delivered Exercise and Pain-Coping Skills Work Well for Patients, But Will Payers Cover It?

By M2|2017-10-09T01:54:34+00:00April 27th, 2017|Chronic pain, Evidence-Based Medicine, Reimbursement, Uncategorized, What do we pay for and why|

Chronic Knee Pain: Internet-Delivered Exercise and Pain-Coping Skills Work Well for Patients, But Will Payers Cover It?

Knee pain has increased in the past 20 years, and researchers have connected this increase to aging and obesity. Perhaps more importantly, the increasing prevalence of knee pain has led to a surge in knee replacements. This highlights the growing need for effective, accessible treatments to manage chronic knee pain on a population level. In light of this need, researchers at the University of Melbourne conducted a study of Internet-delivered exercise and pain-coping skills training.

The study, published in the Annals of Internal Medicine, found that for people with chronic knee pain, Internet-delivered, physiotherapist-prescribed exercise and pain-coping skills training (PCST) provide “clinically meaningful improvements in pain and function that are sustained for at least 6 months.”

The Internet-delivered interventions included seven videoconferencing (Skype) sessions with a physiotherapist for home exercise, a PCST program and educational materials, delivered over a period of three months.

At three months, the intervention group reported “significantly more improvement in pain” compared to the control group, Kim Bennell, Centre for Health, Exercise, and Sports Medicine, University of Melbourne, at al., say.

The intervention group also showed improved physical function versus the control group and improvements were sustained at nine months.

The intervention group also reported high levels of satisfaction, and had high rates of completion; 78% accessed the educational materials, with an average of 6.3 of seven Skype physiotherapy sessions completed, and an average of 6.4 of the eight pain management modules completed.

This study sheds light on an important challenge for the U.S. health care system; chronic knee pain, is “associated with significant disability and decreased quality of life,” as noted in an accompanying editorial by Lisa Mandl, Hospital for Special Surgery/Weill Cornell Medicine.

“With the aging of the U.S. population, the medical community has braced itself for a tsunami of elderly patients with chronic knee pain – a reasonable response to the projection that almost half of U.S. adults will develop osteoarthritis in at least one knee by age 85 years,” she says. In addition, 50% of people with symptomatic knee osteoarthritis are younger than 65.

“These patients will need effective pain therapy for decades,” Mandl says. “Because osteoarthritis currently has no cure, these demographic characteristics guarantee that a large and diverse cohort of patients will be seeking treatment for chronic knee pain well into the foreseeable future. Therefore, there is a clear and pressing need to identify effective, inexpensive, and low-risk strategies to improve pain and decrease disability in these patients.

The results are also interesting given that “existing therapies have many drawbacks,” as noted in this article on the study. For example, current treatments have adverse effects or may be “cost prohibitive,” and “non-pharmacological therapies, such as physiotherapist-directed exercise and pain-coping training, may be difficult to access, especially for those in rural areas.”

“These results are encouraging and show that ‘telemedicine’ is clearly ready for prime time,” the study authors say. “An Internet-based intervention circumvents multiple issues related to access to care, making this an inexpensive and easily scalable option for people living in remote areas or any location with an inadequate supply of health care providers.”

This study is an excellent example of evidence-based medicine; the Internet-delivered intervention is a low-risk approach that is clearly preferable to knee surgery, and one that improves access for patients, particularly those in rural areas. However, the key questions are: Will U.S. insurers pay for it? And will physicians be willing to perform this service?

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Coverage Drives Treatment: The Case of Pain

By M2|2017-10-09T01:59:34+00:00March 31st, 2017|Uncategorized, What do we pay for and why|

Coverage Drives Treatment: The Case of Pain

Last week Congress decided not to move forward with repealing and replacing the Affordable Care Act with the American Health Care Act of 2017. This doesn’t mean health reform is over in the U.S., though.

Patient access to care and the costs of that care are still hot topics in Washington, D.C. and statehouses across the country. As we move forward in reform, I would propose a close look at the opioid epidemic and ways we can push for payers to cover treatment that is patient-centered and evidence-based. Seems straightforward, but it isn’t.

A USA Today op-ed from last fall had a subtitle on the opioid epidemic that said it all: “There are other ways to manage chronic pain, but insurance companies won’t pay for them.”

In the summer of 2016 the U.S. Surgeon General sent a letter to physicians in the U.S. basically saying they haven’t been properly trained to manage pain and they could do better to manage patients with pain than just handing over a prescription for an opioid. Dr. Vivek Murthy was more eloquent, writing, “We often struggle to balance reducing our patients’ pain with increasing their risk of opioid addiction. But, as clinicians, we have the unique power to help end this epidemic.”

Prescriptions for painkillers vary dramatically by state, further supporting the argument that prescribers may not be following a standard of care for treating pain.

Source: CDC, Policy Impact: Prescription Painkiller Overdoses

It is true that clinicians are uniquely situated to address responsible opioid use and pain management, but that will be difficult to do without support from health insurers. Dr. Robert Bonakdar, the author of the USA Today piece and the Director of Pain Management at the Scripps Center for Integrative Medicine, and immediate past president of the Academy of Integrative Pain Management, succinctly explained the entire U.S. health care system’s approach to pain management:

… many well-established non-pharmacologic treatments like biofeedback and cognitive behavioral therapy (CBT), endorsed [by Murthy], are routinely denied by insurance companies. As an ironic example of the campaign’s shortcomings, on the same day I received the surgeon general’s letter, I received one of the standard insurance denial letters for the biofeedback I had requested for a patient’s headache.

Government agencies and other advisory organizations are coming together to acknowledge that addressing pain is not as simple as writing a script – which is clearly what the system pays for right now.

The National Pain Strategy reminds health care providers and policymakers (and anyone else who will read its 72 pages) that, “Chronic pain is a biopsychosocial condition that often requires integrated, multimodal, and interdisciplinary treatment, all components of which should be evidence-based.”

The Principles of Chronic Pain Treatment prompt health care providers who are treating patients with pain to “use nonopioid therapies to the extent possible,” but also to “identify and address co-existing mental health conditions (e.g., depression, anxiety, PTSD)” in patients in order to best define their treatment needs.

The health care system needs to move in the direction of covering what works. Like other examples we have covered in the Pondering Policy blog, opioids are no exception to the rule.

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Lung Cancer Screening: Who Gets To Decide?

By M2|2017-10-09T02:02:29+00:00March 10th, 2017|Evidence-Based Medicine, Uncategorized, What do we pay for and why|

Lung Cancer Screening: Who Gets To Decide?

While the U.S. Preventive Services Task Force (USPSTF) has issued recommendations on annual screening for lung cancer using low-dose computed tomography (CT), and Medicare uses similar criteria for determining coverage of lung cancer screening, a recent article in the Journal of the American Medical Association (Katki, et al.) offers a new enhanced risk-based model for determining who should undergo this type of screening.

Katki, et al., used data from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, the National Cancer Institute’s National Lung Screening Trial, and the 1997-2001 National Health Interview Survey to develop and validate statistical models to estimate lung cancer incidence and death.

In an accompanying editorial, Michael Gould, MD, MS, Kaiser Permanente Southern California, Department of Research and Evaluation, says the findings are “provocative and support the notion that an enhanced risk-based approach to screening is potentially more effective and more efficient than performing a risk assessment based only on age and smoking history.” (There are about nine million adults in the U.S. who meet USPSTF criteria for lung cancer screening.)

However, while this new lung cancer death model constitutes an “important contribution” to the discussion of who should be screened and when, the “overwhelming majority of patients who undergo low-dose CT screening will not benefit, even using enhanced risk assessment,” Gould says. The enhanced risk-based screening “was projected to only marginally increase the number of lung cancer deaths averted from estimates of approximately 5 per 1,000 screened” to “approximately 6 per 1,000.”

In addition, the limitations of the risk-based model include the fact that the authors “did not consider the increased risk of procedure-related complications or reduced operability that would accompany screening when performed in a population at higher risk,” he says. “For lung cancer screening to be effective, patients need to be fit enough for surgery.” And while less invasive treatments exist, they “have not yet been shown effective in the context of lung cancer screening,” Gould notes. “Thus, a valid counterargument is that the net benefit of screening is highly uncertain in populations (even high-risk populations)” that differ from those that informed the risk-based model.

Other limitations include the social dimensions; for example, given that the risk-based approach “preferentially includes more African-Americans and more individuals with lower educational attainment, compared with screening using the USPSTF criteria,” implementation of enhanced risk-based screening will “require more intensive outreach to communities that have experienced limited access to screening programs,” he says.

Looking more broadly and summarizing the current state of lung cancer screening, he notes there are now “multiple statistical models of lung cancer risk—which ones are most accurate? How does risk evolve dynamically over time?”

At issue is the fundamental question of who gets to decide about lung cancer screening.

This question will be answered differently, depending on whether we examine it from a policy perspective or from an individual patient care perspective. While policymakers are likely to focus on the trade-off in costs – in both dollars and lives – between screening efficiency and avoided deaths, “in clinical practice, the decision to screen is very personal and should be individualized for each patient,” says Gould.

One idea is to let the patient decide whether to undergo testing. Gould recommends offering lung cancer screening to high risk patients who don’t meet the USPSTF or Medicare criteria and letting the patient choose whether to be tested. However, what Gould looks past is the cost to the patient when such a choice is made. Policymakers make recommendations on what insurers should pay for, and cancer screening is a great example. There is a reason for the screening recommendations to have a cut-off value – and that reason is cost.

Letting the patient decide, also means, letting the patient pay. A more nuanced view would be to pay for lung cancer screening in some instances, but not in others. If lung cancer screening to high-risk patients is cost-effective, shouldn’t insurers cover this intervention?

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Cardiac Rehab Programs: Yet Another Evidence-Based Intervention That Isn’t Paid For

By M2|2017-10-09T02:07:38+00:00November 7th, 2016|Evidence-Based Medicine, Social Determinants of Health, Uncategorized, What do we pay for and why|

Cardiac Rehab Programs: Yet Another Evidence-Based Intervention That Isn’t Paid For

Evidence shows cardiac rehabilitation programs –which teach patients who have had a cardiac event about exercise, diet and prescription drugs – substantially cut the risk of dying from another cardiac problem; they also improve quality of life and lower costs. But as Kaiser Health News notes, fewer than one-third of patients whose conditions qualify for cardiac rehab actually participate.

One of the main reasons for the low participation rate is cost; patients must generally pay a co-pay to participate in such programs – about $20 per session for regular Medicare beneficiaries, and anywhere from zero to over $60 per session for Medicare Advantage enrollees and those who are privately insured.

Aside from cost, other barriers include distance/travel time to the facility, lack of referrals at the time of hospital discharge, and capacity of existing cardiac rehab programs. This is particularly troubling because in spite of the increased likelihood of death within five years of a first heart attack, certain populations are less likely to be referred for cardiac rehabilitation, including women, minority populations and patients of lower education levels of socioeconomic status.

[Note to readers: I am a bit obsessed about the evidence for cardiac rehab, as well as the social determinants of health that prevent it from being routinely recommended and included it as Case 17 in the textbook I co-edited, Essential Case Studies in Public Health: Putting Public Health into Practice, published by Jones and Bartlett.]

What do we pay for, and why?
In considering innovation and value, there are frequently situations in which patients are receiving a health care service that runs counter to recommendations based on the latest evidence- clearly a waste, but politically difficult to stop, especially if it runs counter to patient or provider preferences. However, this is an example of where the evidence clearly supports reimbursing for the intervention, but the service is underutilized considering its value to the patient and the system.

As noted, this low participation rate in cardiac rehab is due in part to patients’ reactions to time requirements, but can also be blamed on health insurer cost-sharing requirements that discourage use of a valuable intervention. To be clear, studies show 25% reduction in all-cause mortality rates and 31% reduction in hospital readmissions, translating into millions in annual savings.

Medicare is inching forward with its Cardiac Rehabilitation (CR) Incentive Payment Model which pays hospitals incentive payments based on total cardiac rehabilitation use for patients in their care after a heart attack or bypass surgery. Hospitals can receive $25 per cardiac rehabilitation service for the first 11 services they provide and the payment increases to $175 per service after those first 11 services.

If the evidence shows significant reductions in adverse events and cost of care for those who participate, is it time for payers to reflect that increased value in lower co-pays? And perhaps more importantly, is it time for payers to require providers to recommend cardiac rehab for everyone who could benefit, regardless of their gender, race or income?

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