By Ty Thomas, MD
In recent years, the Centers for Medicare & Medicaid Services (CMS) has been promoting value-based care (VBC) initiatives in an effort to improve the American healthcare system, and last year, CMS added pain management to the value-based care umbrella.
Value based care is a shift from a volume-based mindset to a value-based mindset. VBC aims to improve patient outcomes, enhance care quality, and reduce healthcare costs. We typically think of chronic disease conditions like diabetes, heart disease, COPD/asthma, obesity, kidney disease, mental health disorders, arthritis and cancer when we think of value-based programs because these are prevalent, have a large impact on quality of life, and have high costs. It makes sense then that CMS would try to tackle chronic pain from a value-based care position.
Chronic pain affects approximately 52 million Americans with a new case incidence rate of 52.4 per 1,000 persons per year. In comparison, diabetes incidence is 7.1, depression is 15.9, and heart failure is 10. Chronic pain patients utilize healthcare often, and can cost the system upwards of $20,000 per year more than a non-chronic pain patient.
With this in mind, VBC for chronic pain makes sense and I agree with the approach. However, VBC models’ successes are anything but clear and there have been many failures. Likewise, the successes have been modest when it comes to cost savings and patient outcomes. The implementation of these programs have been complicated and labor intensive, often costing more to implement and manage than the value returned. For most primary care doctors, VBC has been a mandatory add-on required to meet quality reporting scores in order to optimize reimbursement, and not as a valuable tool to actively manage patients.
I think VBC models have been underwhelming because the programs are add-ons to doctors current existing daily patient loads. So doctors have been tasked to get annual wellness exams (AWE) on all their patients so these patients can be better risk stratified, but the tools to manage the risks are still not incorporated into a cohesive usable tool. For example, to maintain preferred status with payers, the AWE is pushed which is used by payers to maximize insurance premium revenue. However, the identification of multiple comorbidities does nothing in terms of outcomes if those risks are not actively managed by the patient and the doctor on an ongoing basis, which is a tall ask when the doctor’s workload has been added to and not augmented to accomplish this goal.
VBC has mostly been implemented via remote patient monitoring and chronic disease management programs. This has led to alert fatigue and non-meaningful management. That requires more from the doctor who is already overloaded. This is where AI can help.
To make VBC work, we have to automate as much possible. And automating patient monitoring with built-in interventions using software and AI can be done. At my practice, we had to develop it to make it work for chronic pain management.
For us, chronic pain management is the disease management program. We spend time making the correct diagnosis, and if it’s a chronic pain syndrome like arthritis associated degenerative spinal pain (chronic low back pain), we know it’s a management goal and not a cure goal. We set up an individualized multimodal treatment program for the patient and we monitor our results closely, often daily. In this program, our patients journal in their pain diary. We track their pain scores and progress with a treatment plan involving medication, diet, exercise, meditation or other coping skills. It’s one thing to state these things in an office visit and hand out a summary to the patient, expecting them to implement this plan. In reality, patients need more guidance and support.
Many treatment programs fail because the patient didn’t understand the program, can’t afford it, or doesn’t have time. Most of the failures are due to patient noncompliance. They didn’t get their prescription filled, they haven’t been able to schedule PT due to work or child care, they just aren’t ready for a drastic diet plan change. All of these require a level of communication often not achieved in todays’ doctor office visit.
Having the program outlined with benchmarks and to-do’s, we can have the patient use our application to execute their plan. We communicate with the patient daily about how they are doing, program to-dos for the day like moving or exercise (even walk them through the specific movements), when to take medications, log any side effects like constipation, unsteadiness, and even guide them through meditation and self-coping skills. If the pain flare is bad, they have access to get in right away for a block or medication change before a trip to the ER or Urgent Care.
We tried to find this in a platform, but it didn’t exist in a way we thought it needs to be. So we developed our own. Our platform automates our multimodal plan. We know where the pitfalls are for our patients. We know what causes them to utilize other medical resources. We can build our individualized programs to intervene before our patients need to escalate care. Our platform communicates daily with our patients via personalized, individualized preprogrammed bots with defined engagement parameters, nurse monitors, and technology to read vitals, micro-expressions, and other behavior and mental health data. The result is a toolset that can be used to accomplish value-based care objectives. However, there still has to be a doctor ready to make a timely, meaningful intervention in order for that value to be realized.
I truly believe this is the future model of all medical care. It makes sense to convert our way of providing care based on actual value, something that has been missing from medicine since fee schedules took over, and started paying all doctors the same, regardless of outcome. This will replace most in-office medicine.
Ty Thomas, MD is the co-founder of Alabama Pain Physicians.