Chronic Pain as a Driver of Cost in ACO Arrangements

The American Journal of Accountable Care. 2018;6(1):29-32

Much has been written about the crippling effect of America’s overreliance on opioids and the country’s ongoing chronic pain crisis.¹ Major news outlets have chronicled the tragic individual circumstances, often focusing on rural communities and overwhelmed primary care providers (PCPs). Simultaneous to this pain and opioid crisis, there has been an expansion in alternative payment models, such as accountable care organizations (ACOs), in which providers take on some degree of financial risk for the total cost of care for a population based on outcomes and quality metrics. As a result of taking on financial risk, the hope is that providers will care for patients using a more holistic approach and may be increasingly involved in treating conditions that pay poorly in a fee-for-service (FFS) environment but have a significant impact on the total cost of care (eg, behavioral health conditions).

At University of California, San Francisco (UCSF) Health, we currently participate in a number of commercial ACOs. This arrangement motivated us to understand what conditions drive the total cost of care. Chronic pain has been a hot topic, but this is the first exploration of chronic pain in the ACO context at a major academic medical center. As a result of clinical expertise on our ACO team, we asked the question: Do our patients with chronic pain have greater-than-​expected healthcare utilization? If so, can we design interventions that improve the quality of care while simultaneously decreasing costs? Anecdotally, providers felt that patients with uncontrolled pain often sought care in the emergency department (ED) and perhaps had longer lengths of stay when they were admitted to the hospital. 

To answer these questions, we analyzed both the prevalence of chronic pain in the UCSF Health ACO population and its link to utilization. Using the Tian et al algorithm,² we identified that nearly 20% of the UCSF Health commercial ACO populations had chronic pain. The rate of chronic pain at UCSF Health was nearly identical to the rate of hypertension and 3 times the rate of diabetes there. This algorithm was based on billing coding, pain scores, and prescription medications and was validated with reported sensitivity and specificity of 84.8% and 97.7%, respectively. Tian et al reported more accurate identification of patients with chronic pain using their algorithm than estimates based on pain scores or International Classification of Diseases, Ninth Revision codes alone. Given the high specificity of the Tian algorithm, the 20% chronic pain prevalence may be conservative. Epidemiologic estimates of the prevalence of chronic pain have historically varied, ranging from 2% to 45% of primary care populations.³ Most recently, an analysis of the 2012 National Health Interview Survey estimated 126.1 million American adults as reporting pain in the previous 3 months and 25.3 million adults suffering daily pain.⁴

Substantiating clinicians’ instincts, subsequent analysis of utilization patterns among UCSF Health ACO patients indicated that patients with chronic pain had 2 to 3 times the rates of ED, inpatient, urgent care, and primary care visits compared with patients without chronic pain (Table 1). Utilization was used as a proxy for cost.⁵ 

Given the finding that chronic pain was highly prevalent in our ACOs and was associated with increased overall utilization of healthcare services, we considered the current state of pain management and possibilities for improvement. We interviewed over 30 internal stakeholders and external experts, including PCPs, pain management specialists, alternative medicine providers, general and pain-specific psychiatrists, physical therapists, opioid specialists, inpatient pain nurses, and representatives from a local integrated pain treatment center. We found that pain management was divided into silos of excellence within UCSF, with limited communication or coordination of services between providers. Providers described limited integration and misaligned expectations between PCPs and specialists.

Guided by these interviews with clinicians at the front lines and based on evidence in the literature and proposals suggested by the individuals we interviewed, we identified the following opportunities for redesigning chronic pain management (specific solutions are outlined in Table 2):

Education

Physicians and other healthcare providers need education and training in pain management. Less than half of US medical schools dedicate more than 10 teaching hours to pain management, resulting in underprepared physicians.⁶ Similarly, the goals of pain education could be reframed to focus on patient communication and multimodal treatment while approaching medications as just one part of a broader plan. In addition to provider education, patients must understand the risks of pain management and be informed so they can set realistic expectations and be active participants in shared decision making. As chronic pain has not been a point of emphasis in the past, changing medical education would require both individual institution- and national-level changes in curriculum development. 

Communication and Coordination of Care

Improvement in clinical chronic pain management could involve change at 2 levels: primary care and specialty centers. Integrating pain management into primary care could take the form of embedded psychiatric and physical therapy services within primary care centers.⁷ The specialty pain center could also be integrated by offering patients with complex pain management needs joint evaluations by a pain specialist, psychiatrist, and physical therapist during longer visits.⁸ Integrating chronic pain management into primary care, following the model of behavioral health integration efforts by UCSF Health and other health systems, could yield substantial benefits, but it requires significant investments of money and time, as well as culture shifts, in order to alter provider approaches to chronic pain. 

Opioid Utilization

Opioid prescribing patterns are being increasingly scrutinized in the setting of the US opioid epidemic, and specialized pain centers have an opportunity to shape application of the newly released CDC opioid guidelines.⁹  Pain centers can lead their institutions toward adopting responsible forward-thinking opioid prescribing policies and press other departments to think critically about chronic pain management. More broadly, pain centers can serve as advocates for individuals struggling with opioid addiction and explore novel strategies to decrease opioid usage. 

Research

More research into alternative approaches to manage and treat chronic pain and the impact of treatment on healthcare utilization is needed to guide future interventions. During the transition from FFS to ACO models, there will likely be the need to develop improved short-term FFS payment models for comprehensive pain management. No single strategy has been shown to effectively and reproducibly treat chronic pain, making ongoing research of paramount importance.

It is important to acknowledge the obstacles preventing change in chronic pain management. The proposed changes are focused at the system level, requiring changes in culture, infrastructure, and care patterns. 
As many health systems across the country take on financial risk for the total cost of care for specific populations, it may be time to take a closer look at chronic pain. With chronic pain increasingly recognized as a disease, we hope that it will be addressed with preventive measures that focus on nonmedication and noninterventional approaches to pain management, including rehabilitation, pain psychology, and several modalities of complementary and integrative medicine.

It may be the perfect time to make systematic changes to how we deliver care to patients with chronic pain. Systems that take the lead in such changes will improve care for people with chronic pain, help better control the opioid crisis, and control costs in the setting of alternative payment mechanisms. Well-designed interventions to help provide coordinated effective care for patients with chronic pain could truly improve the value of care delivered at the population level.

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Capitated Doc Is Indicted in First MA Upcoding Criminal Case in S. Fla.

Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in MA and Medicaid managed care.

In the first criminal case the U.S. Attorney’s Office in South Florida has brought on alleged fraud via up-coding of Medicare Advantage diagnoses, the feds this month obtained a grand-jury indictment against a Palm Beach County physician accused of causing at least $2.11 million in excessive MA payments. At the time, Isaac Kojo Anakwah Thompson, M.D., was a capitated member of Humana Inc.’s MA provider network, but he no longer is in the network, says the company, which is not accused of wrongdoing in the indictment and contends it has repaid money as part of cooperating with the feds on the case.

Thompson pleaded not guilty in U.S. District Court in West Palm Beach, Fla., on Feb. 18, and a trial was set for March 23.

On the same date as Thompson’s plea, Humana disclosed Feb. 18 that it “recently” has received a request for information from the U.S. Department of Justice’s Civil Division about how it oversees risk-adjustment data in MA, including such aspects as medical-record reviews, use of health assessments and fraud-detection efforts. The company said in its Form 10-K filing with the SEC that it is cooperating with that request as well.

The grand jury in Florida on Feb. 3 indicted Thompson on eight counts of health care fraud that it said occurred between about January 2006 and April 2010. He allegedly did this by reporting to Humana “false and fraudulent diagnoses of Medicare beneficiaries enrolled in a Humana Medicare Advantage plan, thereby increasing the capitated payments that Medicare made to Humana and that Humana in turn made to” two entities in which Thompson was a principal.

Diagnoses Submitted Were for Serious Illnesses

The indictment charges that the claimed diagnoses the beneficiaries involved “did not suffer from” included ankylosing spondylitis (a chronic inflammatory disease of the spine), sacroiliitis (an inflammation in joints in the pelvis), inflammatory polyarropathy (five or more inflamed, swollen, tender joints) and major depressive affective disorder. Humana, which paid Thompson’s medical center about 80% of the MA capitation pay it got for beneficiaries who picked one of two Thompson entities as their primary care provider, “reported the false and fraudulent diagnoses to Medicare,” the indictment says.

The document adds that Thompson “obtained control of the fraudulent proceeds” that Humana paid to the two entities and “diverted these monies for his personal use and benefit, as well as that of others.” The charges carry maximum penalties that include 10 years of imprisonment.

Robert Nicholson, a Fort Lauderdale, Fla., attorney representing Thompson, told MAN Feb. 19 that his firm had “just entered” this case and had been told by the court not to comment on it to the media.

Asked by MAN to elaborate on the company’s role in the Thompson situation and investigation, Humana spokesperson Tom Noland said only, “We are cooperating fully with the authorities. Dr. Thompson is no longer a participating physician with Humana and was never a Humana employee. Humana has reimbursed the government to ensure that both the 20% [portion of Thompson’s billed charges kept by the insurer] and the 80% [Thompson portion] were paid back in full, thus making the government whole.”

He declined to comment on why Humana’s systems themselves wouldn’t have detected such large amounts for unusual diagnoses being billed by one of its capitated network providers or to say how much money the company reimbursed the government.

Asked whether in DOJ’s view Humana did anything wrong in the Thompson situation, a spokesperson for the U.S. attorney’s offices in south Florida told MAN, “Since this matter is ongoing, we will decline the opportunity to comment.” She also wouldn’t discuss the Humana filing.

http://aishealth.com/archive/nman022615-05

Diagnoses from 2/3/15 indictment:

..., ::::: :::: 0 u	Date	Entity	i'.:' «"J" :1:1:::    ..., <l)   .... i:o  ..::	HICN (last 5 d igits)	Fraudulent Diagnosis
1	2/8/ 2010	IM Med ical	M H	9471A	Inflammatory polyarthropathy
2	2/ 16/ 2010	IKAT	BB	2528A	Ankylosing spondylitis
3	2/ 16/ 2010	IKAT	ECi	5014A	Ankylosing spondylitis
4	2/ 16/2010	IKAT	RH	3396A	Ankylosing spondylitis
5	2/ 16/ 2010	IKAT	cs	4705A	Ankylosing spondylitis
6	4/ 5/2010	IM Med ical	RI	5697A	Major depressive affective disorder
7	4/9/2010	IM Med ical	TV	4666M	Major depressive affective disorder