Collaborating with Insurers
At the 2018 American Academy of Pain Medicine Annual Meeting, a panel discussed how payers and providers can better collaborate to provide treatment that is both cost-effective and evidence based. The panel included:
- Kimberly George – Sedgwick (moderator)
- Steven Stanos, DO – Swedish Health System (moderator)
- Teresa Bartlett, MD – Sedgwick
- Geralyn Datz, PhD – Southern Behavioral Medicine Associates
- Jeffrey Livovich, MD – Aetna Insurance
- James Moore, PhD – Rehabilitation Institute of Washington
Comments from the panel included the following:
- Unfortunately, getting approval for patients to treat in these programs is very challenging. They are not seeing the patients soon enough and when a referral is finally made often there is a battle with the payer over coverage. Half the pain management programs in Washington have failed financially because the reimbursement models did not make them viable.
- Studies show that if you intervene with functional restoration earlier the claim process the benefit received in terms of patient outcomes and cost saving is much greater than if the referral for such programs is made later during the treatment.
- The therapies being discussed today are not new and they have been proven effective for years. It is important for payers to collaborate to make these programs viable as they can provide an effective and safe alternative to opioid medications for pain control.
- Insurers/employers are afraid of the costs of these programs as often times they are expensive. However, if you consider the costs of the program relative to the long-term exposures of continued use of opioid medications they will produce cost savings. Providers should consider offering a ten-day trial program to see if the patient is willing to fully participate and it is effective. Payers may be more willing to consider a shorter and less expensive trial program rather than committing to a thirty day program that may not be effective.
- Another challenge from a payer perspective is that all providers are not motivated by what is best for the patient. There are some out there that put profits ahead of patients and have very poor outcomes and these programs have given a bad name to the pain management industry. We have to overcome the skepticism payers have because of these bad experiences.
- From the workers’ compensation perspective, it is important to include the claims adjuster and/or nurse case manager as part of the “team” as they will have insights into the patient and their history that would be helpful for the clinical team to know and understand.
- As a medical provider, you need to understand you are selling a product that most payers have very little knowledge. In fact, most treating physicians also have very little knowledge of these programs. Education is important. You have to be able to show what it does, how it works, and what the results will be.
- The Oregon project is paying on a per-diem basis. This is a better payment model because all the providers in the interdisciplinary model are sufficiently compensated. When payers unbundle the program into individual components the reimbursements end up being insufficient.
- With the move away from opioids, the timing is right for these programs. There is more need now than ever before. But providers need to do a better job with “marketing” their programs as solutions.
- Telemedicine can play a role in patient follow-up and assist with patient monitoring and compliance.
- The workers’ compensation laws in some states are very challenging when it comes to the coverage of the mental aspect of injuries and claims. The use of an interdisciplinary program puts that mental treatment under the umbrella of the program and does not create a mental health diagnosis on the claim which is often resisted by payers.
- Many primary care physicians do not have the training or infrastructure for dealing with chronic pain claims. Some healthcare systems are looking to address this and increase the focus on behavioral health.