DCRI faculty recently contributed to a paper advocating for a focus on pain management so that progress in combatting the U.S. opioid crisis is not lost in the midst of the COVID-19 pandemic.
A recent collaboration between DCRI Musculoskeletal faculty and faculty from the Duke-Margolis Center for Health Policy outlines the major challenges associated with establishing integrated pain management (IPM) programs.
IPM programs focus on individualized care and incorporate both pharmacological and non-pharmacological treatments, including rehabilitative approaches like chiropractic care and physical therapy, integrative health approaches such as acupuncture or yoga, and surgical management. Although evidence shows this integrated approach is the best option to help many patients manage pain, thereby helping to combat the opioid crisis, IPM programs have not been widely implemented.
A recent paper authored by DCRI and Duke faculty published in NEJM Catalyst: Innovations in Care Delivery outlined six challenges that a wide array of stakeholders must address to improve pain management and reduce opioid use and misuse. Addressing these challenges is especially crucial as health care systems increasingly shift their focus to the COVID-19 pandemic, the authors write. The paper reflects findings from a February 2020 roundtable co-hosted by the Duke-Margolis Center for Health Policy and the Duke Department of Orthopaedic Surgery, which convened more than 30 stakeholders including payers, purchasers, employers, health policy experts, pain researchers, front-line clinicians, and patient representatives to discuss key challenges associated with the development, implementation, and maintenance of IPM programs.
The primary challenges identified during the roundtable were as follows:
- Financial incentives are misaligned with comprehensive, integrated care models under Fee-for-Service (FFS) payment. The FFS model inadequately supports care coordination and individualized treatment. Major roadblocks include lack of coverage or payment restrictions on some of the methods of treatment used in an IPM program, such as acupuncture and physical therapy.
- Health care systems, payers, and purchasers need more comprehensive data to better establish the business case for sustainable programs. Additional data on the financial implications of implementing an IPM program are needed, and these data must be specific to each health care organization’s needs.
- Delivering comprehensive, integrated care is often not feasible in underserved or rural areas. There may be fewer resources to devote to an IPM program in underserved or rural communities, areas often disproportionately impacted by the opioid crisis. In the future, telehealth may provide opportunities to administer this needed care.
- There is a lack of consensus on how to measure quality and define program success. Without clear performance and quality measures, it is difficult to implement payment reforms. Patient-reported outcomes may provide insight into care quality and improvements.
- Workforce training and knowledge in appropriate pain care is inadequate. Enhanced workforce training could expand options for providing better and more comprehensive care through existing service lines.
- There is a lack of public knowledge regarding the risks and benefits of different pain treatments. Additionally, many patients are not aware of the available evidence-based, conservative options for effective pain management and may view medication or surgery as their only treatment avenues.
The paper also provides recommendations regarding how to mitigate and overcome the challenges associated with building IPM programs that provide optimal care for pain management. Although revenue uncertainties caused by COVID-19 could discourage investment in new programs at this time, the paper’s authors encourage stakeholders across the health care ecosystem to take immediate steps to address these challenges and continue forward motion in alleviating the opioid crisis.
The team behind the paper will continue work toward addressing these challenges by conducting interviews with stakeholders to gather data to help inform implementation strategies for IPM programs. The team will also be conducting case studies on existing IPM programs, making available practical guidance for health care systems that are interested in developing their own programs.
DCRI faculty members who contributed to this paper include Christine Goertz, DC, PhD, (pictured top) and Trevor Lentz, PT, PhD, MPH (pictured bottom). Contributors from the Duke-Margolis Center for Health Policy include Isha Sharma, Jonathan Gonzalez-Smith, and Robert Saunders, PhD.