August 19, 2013—Trillium Community Health Plan, the coordinated care organization serving Oregon Health Plan patients in Lane County, is hoping to start a new, integrated approach to treating patients suffering from chronic pain by early next year.
Dr. Holly Jo Hodges, Trillium’s medical director, said various providers in Lane County had noticed over the years that patients with chronic pain were often the most difficult and expensive to treat, made frequent emergency room visits, and often only went to the doctor to have their prescription pain medication re-filled.
“The general consensus is that these [patients] can be difficult,” Hodges said. “They’re the folks who don’t show up for their appointments. And doctors don’t feel like they have the adequate training for the large doses of narcotics that are prescribed now.”
Coordinated care organizations (or CCOs) like Trillium’s were created by the Oregon Legislature in 2011 to revamp the care Oregon Health Plan patients receive by integrating physical, mental and dental healthcare. In the process, CCOs are expected to dramatically lower healthcare costs and provide more efficient and effective healthcare.
One strategy many CCOs are using to do that is targeting a specific, expensive sub-population in their patient pool. In the case of FamilyCare Health Plans, it’s pre-natal care and high-risk pregnancies; for Central Oregon’s CCO, it’s patients who visit the emergency room dozens of times each year.
Trillium Community Health Plan is looking at ways to better treat chronic pain because approximately one-third of its 22,657 adult patients, or 6,750, sought medical care related to spinal or back pain in 2012. There were 115 surgeries, and $5.8 million was spent on surgeries, prescription medication and other services. Approximately eight percent of patients were prescribed opiate medication. Overall, Trillium found, those patients are 21 percent more expensive than patients not on prescription opiates.
Since October, a large workgroup comprised of doctors, mental health and addictions treatment providers, chiropractors, acupuncturists, and physical therapists in Lane County have been meeting, and have made numerous recommendations that Trillium Community Health Plan’s community advisory board and board of directors will consider in the coming months.
A major goal is to help patients become less reliant on prescription opiates, such as OxyContin or Vicodin, which are the most common medications prescribed for chronic pain.
Such medication has become popular because it’s a quick fix for pain. Prescription opiates are released over time, and relieve pain by dulling the nervous system. They’re highly addictive, and long-term use can lead to side effects such as disruption of sleep patterns, hyperalgesia (increased sensitivity to pain), and immune system suppression.
The most important recommendation from the workgroup is improving access to “acute spinal care,” such as phsyical therapy that lasts between four and six weeks, and other treatments that prevent the pain from worsening. “There would be a very comprehensive evaluation and treatment plan…to prevent acute pain from becoming chronic,” Hodges said.
Trillium is also expected to designate a single health provider to receive referrals for complex spine care to streamline services and referrals. That provider would offer imaging services, physical therapy and surgery. A request for proposals for the position was released in early June, and the application closes August 30.
Another major recommendation is connecting patients with mental health and substance abuse treatment. “There is certainly a large proportion of folks with chronic pain who have mental health, addictions, depression, and anxiety [issues],” Hodges said.
Oftentimes, patients are self-medicating for their pain, and their conditions can go untreated because a doctor may be unable to recognize the presence of a mental health condition. Trillium is likely to adopt a standardized screening and evaluation that all patients would take, which would screen their chronic pain and mental health or substance abuse issues, Hodges said.
Another recommendation would allow patients to directly refer themselves to chiropractic care, rather than needing a referral from a primary care doctor.
Doctors will also help patients become more pro-active by teaching them how to manage their health and prevent pain, such as encouraging them to exercise, heat and ice their muscles to reduce pain, and use medication when appropriate.
If those strategies don’t work, patients will be encouraged to seek short-term physical therapy or chiropractic care rather than request prescription drugs. “That’s going to take a lot of education and work with our providers, but they’re willing,” Hodges said.