Providers Need to Do More to Educate Insurers

Insurers are unlikely to reimburse providers for taking a multi-disciplinary approach to the treatment and management of chronic pain because they don’t understand it, Jeffrey Livovich, M.D., medical director of the medical policy unit at Aetna said today at a Musculoskeletal Disorders and Chronic Pain conference in Los Angeles.

“It is really not in their vocabulary,” he told providers in the audience.

For example, multi-disciplinary care for chronic low back pain in workers' compensation cases is not widely available in the U.S., although a growing body of evidence suggests such an approach is effective. In the majority of cases, treatment remains fragmented and patients tend to shuttle from one provider to the next in search of solutions.

Multi- and inter-disciplinary pain management programs involve collaboration among medical and behavioral health professionals using a bio-psychosocial treatment model. The goal is return to function and maximum medical improvement. Studies show a team approach that involves physicians, physical and occupational therapists, vocational experts and psychologists helps reduce treatment costs while improving quality of life for patients.  

However, insurers perceive multi-disciplinary care as expensive care. While the average cost is about $30,000 per case when using that approach, Dr. Livovich said “that amount is in fact low" compared to the cost of interventions introduced over an extended period of time without achieving marked functional improvement.

The insurer’s job is to control costs: “Somebody has got to do it,” he said. But insurers also want to encourage 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, clinical experts 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  suggests providers first identify 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, these are our outcomes.’ Then work out what you will get paid for it.”     

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

• More detailed information about the efficiency and value of a multi-disciplinary approach.

• To understand characteristics of patients most likely to benefit from this approach.

• To see outcomes related to return to work, increased function and other meaningful measures.

• To identify where and in what settings this type of care is available.

• Agree on parameters for accreditation and credentialing of provider teams.

The conference, “Musculoskeletal Disorders and Chronic Pain: Evidence-based approaches for clinical care, disability prevention and claims management,” sponsored by the Canadian Institute for the Relief of Pain and Disability and the American College of Occupational and Environmental Medicine, concludes Saturday. A key focus of the conference is the identification of high-quality research evidence that, if implemented into policy and practice, would improve clinical outcomes and prevent disability for adults with musculoskeletal disorders and chronic pain, according to the sponsors.