While social distancing has made it difficult to provide routine care – much less implement integrated care – the pandemic has pushed the medical industry to think creatively about healthcare delivery – and this may be an unforeseen benefit, as argued by pain researchers in a recent commentary.
“The major thing the pandemic has caused is a lack of access or reduced access to some of the services that people with pain would commonly seek out,” said Trevor Lentz, PhD, MHA, assistant professor in orthopedic surgery at Duke University and lead author of a paper published in NEJM on the need for integrative pain management.
With limited doctor visits and fewer interventions, such as injections or in-person physical therapy, “This could result in an impact on the function, pain intensity, and quality of life of patients with pain,” Dr. Lentz added. And the industry knows all too well that poorly managed pain can lead patients down the wrong path.
On the other hand, the COVID cloud may have a silver lining. “It’s kind of a double-edged sword,” said Dr. Lentz. “Over the last couple of months, there have been leaps and bounds in improvements in the ways that healthcare can be delivered virtually. It may otherwise have taken years and years to develop virtual platforms for delivering physical therapy or chiropractic care or even psychological care. Those things have now been fast-tracked on virtual platforms.”
Still, if this type of progress is to be truly effective, and perhaps more importantly – if it is to last beyond the crisis – key challenges must be met. Dr. Lentz and coauthors outlined six specific obstacles that healthcare organizations, payers, policymakers, and providers need to overcome in order to operationalize integrated pain management programs and to ensure continued progress in combating the opioid crisis.
1) Payment models must be aligned with integrated care models. Fee-for-service “poorly supports care coordination and conversations with patients about their goals and needs,” the authors wrote. In addition, many complementary and integrative therapies, such as yoga and acupuncture, are not widely reimbursed by payers.
2) HCPs need more data to use in making the business case for the sustainability of integrative pain management programs, including statistics on wait times and usage rates.
3) Access barriers must be overcome. The areas hardest hit by the opioid epidemic are rural and underserved communities. These communities are also the ones where access to integrative pain management is limited or lacking altogether. (Editor's Note: There are many state reports on how opioid-related overdoses are rising in parallel with COVID cases.)
4) There must be a consensus on how to measure the quality of pain management, including integrative care programs. Dr. Lentz, et al, pointed to patient-reported outcomes as a key measure for capturing function and quality of life.
5) The healthcare workforce needs to be trained in pain management best practices. “Enhancing workforce training in pain management also provides novel options for delivering more comprehensive pain care through existing service lines,” the authors wrote.
6) The public also needs to be educated about the potential risks and benefits of different treatments for pain.
An ideal integrative pain management program would, according to Dr. Lentz and team, adhere to a few basic principles:
Lentz and team cited the US Department of Veteran’s Affairs (VA) Whole Health System as an example of a successful integrative pain management model. “The Whole Health Model wasn’t specifically designed for pain management,” noted Dr. Lentz, “though pain management is certainly one of the conditions it’s particularly helpful for. What it does is put the person and what’s important to the person at the center of healthcare. It blends the line between health are that’s delivered in a more traditional setting, like a hospital, and opportunities to improve health through more community-based services.”
For example, he shared that the VA uses health coaching and group interventions, works on nutrition and psychological distress, and provides opportunities to not only address the psychological and social and behavioral needs of patients.
Meeting these challenges and creating a truly workable integrative pain management model is no small task. Dr. Lentz points out that the VA has a lot of resources that other healthcare systems do not. But it is, he says, “a nice model for what potentially could be done.”
The SARS-Cov-2 pandemic certainly makes regular pain management and opioid therapy monitoring more challenging. In the end, however, it may provide the push US healthcare needs to make progress.
“My gut is that we’ll probably start to see models where healthcare systems or payers are starting to give opportunities to deliver some care virtually, say for instance follow-up care but also have some requirements for in-person care as well,” said Dr. Lentz.
“Hopefully what will happen is we’ll start to get some of the cost and utilization data back from this natural experiment and see that [alternative care delivery] will not only reduce costs but increase patient satisfaction because of the flexibility.”
While some of the authors’ recommendations may seem out of reach or even unfamiliar to practitioners, Dr. Lentz highlighted that “non-pharmacological management and complementary and integrative health approaches are guideline concordant, they are effective, and they are cost effective.” He explained the methods and changes recommended in this paper are meant to offer more resources to providers.
“Physicians often struggle with how to effectively manage pain, and so providing options for non-pharmacological, non-surgical approaches, is just another tool in their toolbox to try to help these patients.”