Bio-psychosocial Model

Dr. Letz is among occupational medicine and pain management experts who support the application of a bio-psychosocial treatment model in at-risk cases and as an alternative to the use of interventions such as narcotic pain medications, injections, and back surgery. Clinicians who spoke at the conference say a growing body of evidence suggests workers’ compensation patients who are identified early as “high risk” for chronic pain and disability, and who receive targeted medical and behavioral interventions as a result, are more likely to recover function than those who do not.

Multi-disciplinary pain management programs based on the bio-psychosocial model involve collaboration among medical and behavioral health professionals. The treatment team includes physicians, physical and occupational therapists, vocational experts, and psychologists. The goal is to reduce treatment costs, maximize function, and improve the quality of life for patients.

According to Steven Feinberg, M.D., a Palo Alto, CA-based physical medicine and rehabilitation and pain medicine specialist, the bio-psychosocial treatment model typically includes the following components:

assessment of an individual’s physical, functional, and psychosocial status;
directed conditioning and exercise;
cognitive behavioral therapy;
patient and family education and counseling;
functional goal setting; and
ongoing assessment of participation, compliance, and progress.

Ideally, “functional restoration means the patient takes personal responsibility for his or her own physical and emotional well-being post illness or injury,” said Dr. Feinberg, who reports his patients are often de-motivated, on high doses of narcotic pain medications and feeling discouraged about their quality of life when they first present at his practice. He finds it is not unusual for these types of patients to have medication costs ranging from $5,000 to $20,000 a month.

“My response to the skeptical patient is that while there are no guarantees, the functional restoration approach has improved quality of life for many people with chronic pain, and with commitment, there is an excellent chance of success,” said Dr. Feinberg, whose topic at the conference was Recognition of Delayed Recovery and Cost-effective Early Intervention Treating with a Functional Restoration Approach.

In some cases, limited or adjunctive use of pain medications may be recommended to support maximum functional improvement and minimize relapse, he added.

“The majority of people I see do okay with lower doses, and they do even better when they go off them entirely,” Dr. Feinberg said. “At the end of a functional restoration program, on average we see an 83 percent or greater reduction in opioid and benzodiazepine mediation costs and usage.”

A purely biomedical approach may result in unrealistic expectations on the part of the physician and the patient, he said. A bio-psychosocial approach allows practitioners to look at the whole person – their pathophysiology, psychological state, childhood and life experiences, cultural background and belief system, relationships at work and home, and how they view disability and health care, in general.

“It’s so important to get a sense of what these people are made of,” said Dr. Feinberg. “I am trying to figure out why they are in my office. It is my job to understand their beliefs about cause, meaning, impact, expectation, perceptions, and goals.”

Following the Money

Despite their apparent efficacy, bio-psychosocial treatment teams are not widely available in the U.S. Instead, the vast majority of workers’ compensation claimants with musculoskeletal disorders and pain-related complaints tend to shuttle from one provider to the next in search of relief. Observers attribute this to a number of factors including the payment system, lack of stakeholder education, and misplaced incentives.

“The entire system is based on people not getting better,” said Doug Benner, M.D., occupational health coordinator and medical director of employee health and medical provider networks, at Kaiser Permanente Medical Care Program, Northern California. “The average carrier just passes the expenses along.” He spoke at the conference on Applying Evidence-Based Care and Measuring Their Outcomes.

On the provider side, incentives are misaligned. “Physicians are encouraged to do things to and for people rather than talk to them,” Dr. Feinberg said. “Until we change that, we are going to continue to have problems.”

Dr. Letz believes education needs to occur at the payer level before the paradigm can shift.

“We need to start out by making it very clear to the people who are paying to look at the percentage of claims and percentage of costs,” said Dr. Letz, whose topic was A Collaborative Approach to the Prevention of Medically Unnecessary Disability. “Regardless of the jurisdiction, the findings are consistent: Partial disability represents more than 80 percent of costs, and most of the high-cost claims we see today are people who come in with a backache or sore shoulder that is not severe from a medical point of view.”

Insurers tend to view multi-disciplinary care as expensive care and are not well-educated about the potential for a positive associated outcome, according to Jeffrey Livovich, M.D., medical director of the medical policy organization at Aetna, who spoke at the conference on Chronic Pain Treatment from an Insurer’s Point of View. “It is really not in their vocabulary,” he said.

Using the team approach, the average treatment cost is about $30,000 per case, Dr. Livovich said, and “that amount is in fact low” compared to the cost of various interventions introduced over an extended period of time without achieving marked functional improvement.

He said the insurer’s job is to control costs while simultaneously encouraging the use of evidence-based care. “We want to provide education and promote health and wellness. Insurers are much more interested in the well-being of patients than you would imagine,” Dr. Livovich said.

At Aetna, clinicians decide what will be covered based on the evidence – or lack thereof. This includes policies related to surgical interventions, acupuncture, electric stimulation, and injections. Clinical claims review is primarily based on ICD-9 and CPT codes and reimbursement is largely automated, he said.

Because of the challenges associated with establishing charges for multi-disciplinary care in current payment systems, Dr. Livovich advises occupational medicine providers to first identify all their costs and then attempt to negotiate a case rate with insurers.

“Start with contract negotiators in your region: ‘This is the program we would like to provide, these are our credentials, and these are our outcomes.’ Then work out what you will get paid for it,” he suggested.

For the bio-psychosocial model to gain recognition and members of the provider community to be appropriately reimbursed for their expertise, Dr. Livovich believes providers need to give insurers:

More detailed information about the value of a multi-disciplinary approach.
A description of at-risk patient characteristics.
Outcome data related to return to work, increased function and other meaningful measures.
Instructions on how to find and access multi-disciplinary teams with good track records.
Insights on parameters for accreditation and credentialing of provider teams.

Red Flags

Most experienced occupational medicine physicians say they can instinctively spot a patient who is at risk for chronic pain and disability and recommend an appropriate course of action. However, that is not always the case. For example, a workers’ compensation claimant with a back complaint may have already seen one or more less-attuned providers before arriving at the occupational medicine clinic, eliminating the chance for early intervention, or they may not appear at first to fit the “typical” at-risk profile.

Because of the potential for confounding variables in any given case, Kaiser Permanente’s occupational health team has developed a coordinated approach to assessing patients with musculoskeletal complaints.

“We do an intake questionnaire using various methodologies by the second, and no later than the third, visit,” Dr. Benner said.

In addition to a questionnaire, the risk assessment includes consultation with the primary treating provider, other medical team members such as physical and occupational therapists, and the assigned claims examiner.

“Any one of the team members can classify someone as high, moderate, or low risk,” Dr. Benner said.

A simple functional improvement assessment is conducted on each return visit using CareConnections Outcomes System, a Therapeutic Associates product formerly known as TAOS, which allows clinicians and health plans to measure the impact of therapy services. According to the company, the system facilitates benchmarking of functional improvement, perceived pain and improvement, and return to work. (1)

In addition, in a collaborative effort to identify at-risk individuals, Safeway, Inc., a major grocery store operator headquartered in Northern California, and Kaiser on the Job have introduced the use of a modified version of the StartT Back Musculoskeletal Screening Tool. (2) Developed at Keele University in Great Britain, the tool is a brief validated questionnaire designed to screen primary care patients with low back pain for prognostic indicators that are relevant to initial decision-making.

Keele University reports the instrument is used by clinicians to systematically identify patients as low, medium (physician indicators), or high risk (physical and psychosocial indicators) for persistent symptoms. The tool features nine statements to which patients answer “agree” or “disagree.” For example: “My back pain has spread down my leg(s) sometime in the last two weeks,” and “Worrying thoughts have been going through my mind a lot of the time.”

The Kaiser version of the assessment tool features two additional questions related to job satisfaction and the patient’s perception of their supervisor’s concern about their condition. Research shows that the way an employer – particularly an immediate supervisor – responds to an injured worker plays a significant role in return to work and delayed recovery. (3)

So far, the results, though not scientifically validated by a control group, are positive from Safeway’s perspective: Of 66 at-risk employees with low back pain who were followed between 2006 and 2010, all of them returned to work; only two had surgery and none of the cases became litigious.

Best Practices

William Zachry, vice president of risk management at Safeway, explained the impetus behind the at-risk screening program during a presentation on Best Practices with the Functional Restoration Project. While the company’s injury incidence rate was decreasing, he was concerned about the increasing level of severity among injuries that were occurring.

“Our medical director said he knew in the tum-tum by the second visit when he had a problem child,” he said. “Things were not happening. Recovery was not taking shape as you might expect.”

Acting on the belief that such patients have “poor coping skills,” Safeway sought to develop a more consistent approach to identifying at-risk employees and an associated protocol for physical and psychosocial interventions for those with “red flags,” including specialized training for medical examiners and store managers.

Mr. Zachry is so pleased with the results to date that he has tried to spread the gospel to other major employers and insurers. While he reports that corresponding changes in practice outside of his immediate locus of control seem to be occurring at glacial speed, he has not given up trying.

Meanwhile, plans are in the works to implement musculoskeletal screening and treatment protocols in other states and regions where Safeway has stores. Mr. Zachry said the company will pay an upfront flat fee to medical providers who agree to use the questionnaire and corresponding follow-up protocols with those who are identified as at-risk.

He also offered these lessons from Safeway’s experience to date:

Do not limit risk assessment to back complaints. Take into account “the sisterhood of the traveling body parts.” In other words, pain in patients with poor coping skills may manifest itself in other parts of the body without a medical explanation.
Keep claims examiners engaged. Examiners are inclined to ignore early signs that a case will require both medical and behavioral health interventions because of cost and complexity issues.
Medical professionals, not insurance professionals, should make all medical decisions. At Safeway, a medical professional following evidence-based guidelines reviews recommendations on every doctor’s report and approves/disapproves them within eight hours of receipt. This approach dramatically improves return-to-work rates.
Take early steps to avert litigious situations and legal escalation of disability claims by keeping lines of communication open among all parties.
Retirement-related claims are another piece of the puzzle. A patient within a few years of retirement may have good coping skills but see disability as an early way out.
Obesity has been shown to increase claims costs and length of disability. Consider directing patients with elevated body mass indices to nutrition and weight-loss resources.

A fraud commission in California found in 20 percent of workers’ compensation cases that the treatment rendered was fee for service, never authorized by a third party, nor was it evidence-based.

“I believe that early identification of individuals with poor coping skills is the way of the future in workers’ compensation because that is what drives the problems,” Mr. Zachry said.

“We are talking about people’s lives. We miss the point when we make it all about the money. It is extraordinarily important to take care of these people and get them back to work. It is the right thing to do.”

References

www.careconnections.com/outcomes/index.aspx.
Employee perspectives on the role of supervisors to prevent workplace disability after injuries; W Shaw, et al., Liberty Mutual; Journal of Occupational Rehabilitation, Vol. 13(3):129-142, 2003. This study found “there is no substitute for the involvement of immediate supervisors in the return-to-work planning process.”