Holistic Approach To Eliminating Opioids

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Each year, more than 300 patients with chronic pain take part in a three-week program at the Pain Rehabilitation Center at Mayo Clinic in Rochester, Minnesota. 

Their complaints range widely, from specific problems such as intractable lower-back pain to systemic issues such as fibromyalgia. By the time patients enroll, many have tried just about everything to get their chronic pain under control. Half are taking opioids.

In this 40-year-old program, that’s a deal breaker. Participants must agree to taper off pain medications during their time at Mayo.

More than 80 percent of the patients who enroll stay for the entire program, said Wesley Gilliam, the center’s clinical director, and many previous opioid users who finish the treatment report six months later that they have been able to stay off opioids. Just as important, he added, they have learned strategies to deal with their pain.

But such a program is not for everyone. Insurers might disagree that the intensive, interdisciplinary approach is medically necessary for some patients or simply not cover the program’s billing codes, he said. Mayo’s insurance team is sometimes an advocator on a patient’s behalf if they are a good candidate for treatment, however,  success is not assured.

Mayo’s program is not the only one to address the emotional, social and psychological aspects of pain, and other programs also focus on reducing patients’ reliance on addictive medications to manage their pain. But as our nation weathers an opioid epidemic, there are too few programs like these around the country to address the need, Gilliam says.

Gilliam, is a clinical psychologist with a specialty in behavioral pain management and talks about the program.

Q: How do pain medications work? By blunting the pain?

They blunt some of the pain. Opioids are very effective for acute problems, but they were never designed to be used chronically. They are not effective in the long term.

Opioids are central nervous system depressants. They soothe people who are in distress. Many people are not demonstrating improved functioning when they take opioids; it’s calming their nerves and it’s chemical coping.

Q: In treating pain, does it matter what may be the cause or it’s severity?

Pain is pain. The fundamental approach to self-managing it does not change based on the cause or severity of the pain. 

Q: How is someone chosen for a program such as yours?

Virtually all of our patients have tried and exhausted primary and secondary treatment options for pain.

[In] primary care, a patient has a complaint and a treatment plan is developed. It generally involves encouraging the patient to be active, to stretch, maybe the doctor initiates a non-opioid medication like a non-steroidal anti-inflammatory or an antidepressant.

If the patient continues to complain of chronic pain, the primary care provider will step up to level two and refer someone to a neurologist or maybe a pain psychologist or pain anesthesiologist.

If patients do not respond, they start to think about step three, which is a pain program like Mayo.

Q: How does the Mayo program work?

People come to us every weekday from 8 a.m. to 4 p.m. for three weeks.

We do not take a medical approach. It’s a biopsychosocial approach, [which] acknowledges not only the biological aspect of pain, but also recognizes that psychological and social variables contribute to how people experience pain.

That is not to say that pain is imagined, but rather how people experience pain is influenced by mood, anxiety and how that person’s environment responds to the person’s symptoms.

A more medical approach tends to focus on targeting and eliminating symptoms at the expense of the recognition of individual differences.

Q: What does that mean for the patient who’s in pain?

People need to accept that they have pain and focus on their quality of life. Some approaches reinforce in patients that the only way you can function is if you reduce your pain, as measured on a pain scale from zero to 10.

We focus on how to get a person back into their life by focusing on function instead of eliminating symptoms and pain. When I refer to functioning, I mean getting back into important areas of their life such as work, social activities and recreation. If a person is waiting for pain to go away, they are never going to get back into their life. When that happens, people get despondent, they get depressed.

Q: So how do you help people manage pain?

When a person is in chronic pain and it’s poorly managed, the nervous system can get out of whack. Their body behaves as if it’s under stress all the time, even when it’s not. Their muscles may be tense and their heart and breathing rates elevated, among other things.

With meditation and relaxation exercises, we are trying to teach people to learn how to relax their bodies and hopefully kick in a relaxation response.

If I have low-back pain, for example, during periods of stress, muscular tension is going to exacerbate the pain in my back. We focus on helping people to disengage from their symptoms.

By learning to relax in response to stress, muscular tension can be diminished and the experience of pain eased. This does not require a medication or a procedure, just insight and implementation of a relaxation skill.

Relaxation/meditation training is one component of a much broader treatment package. All aspects of our treatment — cognitive techniques for managing mood, anxiety and anger, physical therapy, occupational therapy — are all designed to settle the nervous system.

Q: Does insurance typically cover the program? 

Insurance companies may want to see patients complete more conservative treatment approaches before approving an interdisciplinary pain rehabilitation program like ours.

There are patients whose policies do not cover our billing codes. If we deem a patient as a good candidate, we will write letters saying they should be accepted.

There are a very select few who have paid out-of-pocket for our program. This is a significant minority, however. The program can cost up to $40,000 for someone with other complicated medical problems in addition to chronic pain.

There are studies that show these programs do save money over the long term in health care costs and reduced health care utilization.

If we are going to manage this chronic pain problem, we have to look at it for what it is: multifaceted. You cannot just treat the symptom, you have to treat the whole person.

Mayo’s Case for Medicare Telemedicine Reimbursement

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Dr. Daniel Brown - Mayo

The Mayo Clinic in Rochester says electronic intensive care unit services could pack a bigger punch if lawmakers would bolster Medicare reimbursement. Nurses stand in front of monitors in a small eICU room at the clinic reading vital signs and occasionally calling up video images of patients lying in beds.

All of the 40-some patients cycling across the screens are in intensive care in the Mayo Clinic Health System. But none of them are actually at Mayo.

The clinic’s electronic intensive care unit, known as eICU, is one of the frontiers of telemedicine. Backed by Dr. Daniel Brown, (pictured) Mayo’s chief of critical care, and nurse managers Sarah Bell, Jennifer Meindel and Chad Ditlevson direct the care of very vulnerable patients from afar.

They zoom in remote video cameras to get detailed focus on individuals. They watch blood pressure numbers and respiration. They talk to patients. If they need to insert a breathing tube or reinflate a collapsed lung, they contact doctors and nurses at the hospitals where the patients are located and tell them what to do. They also listen to feedback on how patients are progressing.

But even as they deliver intensive care in hospitals that could not otherwise provide it, government and private health insurance companies are not reimbursing them.

“Medicare pays me if I’m at the bedside,” Brown explained. “They will not pay for telemedicine.”

So Mayo absorbs the cost of providing the service to seven hospitals that are part of the Mayo Clinic Health System.

Mayo’s Medicare reimbursement issue is representative of a national dilemma. Health care payment policies often lag cost-saving advances in technology by many years.

“Medicare reimbursement for telehealth is kind of stuck in the 1990s,” said Randy Schubring, Mayo’s public policy manager.

Telehealth is another name for telemedicine, but whichever term you choose, Medicare’s stance is critical because the government program that offers health insurance to Americans over 65 sets the trend for the private insurance market. Although a few private insurers such as Minnetonka-based UnitedHealthcare have stepped up telemedicine coverage, most of the private sector will follow Medicare’s lead.

That’s why the lack of deadlines in “21st-century cures” legislation winding its way slowly through Congress has become a disappointment to institutions like Mayo. Its leaders believe they have demonstrated the effectiveness of telemedicine.

To others the jury is still out.

Telemedicine for certain services is “equivalent to face-to-face treatment,” said University of Minnesota Prof. Stuart Speedie, director of the Great Plains Telehealth Resource and Assistance Center. “There are still questions about whether telemedicine leads to cost savings.”

New legislation that orders the Centers for Medicare and Medicaid Services to draw up plans to pay Medicare benefits for telemedicine is open-ended. The telemedicine language in a House bill directs Medicare regulators to come up with a list of telemedicine services that will be covered by Medicare a year after the bill’s approval.

The House has not voted on that bill and the Senate is not expected to take up 21st-century cures legislation until later this year. It is hard to say how much longer old reimbursement rules will apply. It could be years.

Mayo will remain a financial powerhouse without extended Medicare coverage of telemedicine. In 2014, the clinic posted income from operations of $834.3 million, up 36 percent from 2013.

But to Mayo and other health care innovators across the country, telemedicine will play an increasingly major role in the future of effective and affordable health care. They think federal policies which recognize that fact make more sense than forcing care providers to overcome licensing restrictions as well as payment restrictions as they remotely treat ICU patients, remotely diagnose strokes, remotely direct the delivery of babies and remotely monitor patients in real time in their homes.

Twenty-seven states, including Minnesota, have passed individual laws requiring insurance coverage of telehealth services. But those laws cannot compel Medicare to change its telemedicine reimbursement policies, Speedie said.

As a result, hospitals outside the Mayo health system pay a subscription fee for Mayo’s telestroke diagnosis, while the clinic picks up the tab for those within its health system.

Mayo began paying for the eICU in August 2013. The service now extends to 95 beds in seven Mayo Clinic Health System hospitals in Minnesota, Wisconsin and Georgia. It will soon grow to 101 beds at eight facilities when a hospital in Red Wing, Minn., comes aboard.

From a care delivery perspective, the scope of eICU services around the country and the world is limited only by the existence of reliable, secure information technology networks, Brown said. Health care facilities in the Middle East have approached Mayo about extending the service there.

But as a practical matter, eICU’s broader application lives and dies at the will of Medicare and U.S. health insurers who follow its lead.

“It takes a longer vision than what some people in the health care community have,” Brown said. “It’s kind of shortsighted what’s happening now.”

Connected care:

Medicare currently reimburses only for a limited number of telehealth services and then only when patients receiving it live in an officially defined “Health Professional Shortage Area” or a county outside of a Metropolitan Statistical Area. The treatment also has to take place in a medical facility. Medicare will not pay if it takes place in a patient’s home.

“Limited reimbursement continues to be a major barrier to the expansion of telehealth,” the Robert J. Waters Center for Telehealth & e-Health Law reported in 2011. “This barrier may preclude timely, quality, appropriate care for patients throughout the nation.”

Mayo and institutions around the country claim that Medicare policies stymie their efforts to provide what they call “connected care.” This includes using technology to extend care to patients in ways that keep them healthy, but reduce expensive trips to the doctor or the hospital.

This isn’t just for people living in some rural outpost,” said Mayo connected care director Dr. Steve Ommen, who testified on the issue to the Senate Special Committee on Aging in the fall of 2014.

Connected care extends beyond eICUs or “telestroke diagnosis” to such things as sharing electronic medical records, video consultations between doctors at different facilities and the use of more wearable devices by patients. It embraces a broad concept of prevention “so patients don’t just come in when the wheels fall off,” Ommen explained.

Medicare may require congressional empowerment to wrap its arms around the broad concept of telemedicine, he added, because regulators write rules, not laws.

House leaders have not done that, according to the American Telemedicine Association, an industry trade group. In May, the association’s CEO, Jonathan Linkous, predicted that the current House proposal to study which telemedicine services should receive Medicare coverage could “delay any action for years.”

Getting doctors licensed to practice telemedicine in several states is another sticking point. The Department of Veterans Affairs has national licensing for physicians, but telemedicine practitioners don’t have that option.

What people like Linkous and Ommen say they want is a nod to the future instead of the past.

Said Ommen: “To those of us involved in telemedicine, it is inevitable that we will practice this way.”

‘Carrying on as usual’

When she ran into complications delivering babies as a midwife in rural Scotland decades ago, Jessie Todd dialed a telephone number for an ambulance crew known as “the flying squad.” She finds the notion of Mayo directing deliveries from iPad images projected over the Internet “fantastic.”

Todd, 80, offers her observation as she walks around her Rochester home. She wears a monitor that records her health information and ships it to a company that immediately passes any suspicious readings on to Mayo for near-instant analysis by technicians sitting in a room full of computer monitors. The technicians measure what’s happening to Todd against a protocol that tells them whether to refer the situation up a medical chain of command that can lead to immediate intervention when necessary.

Todd welcomes the technology. She has not gotten a bill or a notice of insurance coverage yet, so she doesn’t know what her share of the costs will be. Meanwhile, she hopes the data collected at her home will allow doctors to figure out why she’s had a series of ministrokes.

Whether or not it does, the monitor has left her “quite confident that this is taking care of any problems that erupt.”

I’ve been carrying on as usual,” she said. “I have two children and five grandchildren. I just had all of them over for dinner and had no problems.”

This is what Dr. Peter Brady, a British-trained cardiologist who directs Mayo’s Electrocardiographic, Heart Rhythm and Physiological Monitoring Laboratory, has in mind.

At first, he focused his efforts in getting electrocardiograms read quickly for inpatients at Mayo.

“We have a turnaround time of less than 20 minutes,” he said. “We have saved lives with that.”

Now, technicians remotely track a number of other signs of physical health among the hospital’s patients. But they are also extending that analysis beyond the institution’s physical space to places like Todd’s house.

The greatest challenge is not gathering information, Brady said. It is figuring out how to manage it.

“When I speak to physicians about home monitoring, they roll their eyes. We need to organize the avalanche of data that is available in a way they can use it.”

As she looks at a graph of a remote patient’s current heart activity, monitoring lab manager Revelee Kaplan talks about a small device that can be implanted under the skin that continually transmits heart rhythms information for three years.

Nearby, Brady considers this and other advances in remote information gathering and care delivery that he thinks can save lives while letting the health care system save money. Then, he thinks about the way those services are being paid for.

“The technology,” he concludes, “is way ahead of anything in terms of reimbursement.”