Four Ways to Advance Accountable Chronic Pain Care

Published by Health Affairs on December 10, 2024

Dec 10, 2024

Hello to all of my Chronic Pain Chats readers! Sharing this more wonky piece I had published today by Health Affairs, a leading U.S. policy publication. The punchline for the less policy-wonk reader is this: If we want pain care to change, the systems and policies driving care have to change. THE END. Happy reading!

The Center for Medicare and Medicaid Innovation (the Innovation Center) and Centers for Medicare and Medicaid Services (CMS) leaders have recently outlined their next steps to advance accountable care in Medicare, and it is important to consider how chronic pain should be addressed within these models. Fifty million people in the United States live in chronic pain; ongoing pain is more widespread than cancer, heart disease, diabetes, or stroke. Among Medicare beneficiaries, more than 16 million live with chronic pain, costing Medicare at least an estimated $65 billion annually. The future of accountable care in Medicare must include tailored strategies to address persistent pain, given that it is the leading cause of long-term disability and a major cost driver.

The goal of accountable care models is to center the care relationship among patients and all of their providers. For those living in chronic pain, the care relationship can be complex often relying on the support of specialists and should include mental health supports. The biopsychosocial model of care for chronic pain is the gold standard, but providers generally fall short in delivering such care. This model emphasizes that chronic pain is always complex and involves not only one’s physical being but also mental health and environment. This is why those in chronic pain are five times more likely to experience anxiety and depression, and those with lower socioeconomic status are also at higher risk of chronic pain. Despite this proven model, a siloed pain care system with misaligned incentives is largely to blame for those in pain receiving inadequate and inappropriate medications and surgical interventions. Given the significance of care relationships in accountable care, it is an ideal space for addressing complex needs and integrating care for those with chronic pain.

The Innovation Center and CMS can provide a roadmap to address these issues, leveraging four key actions to advance accountable chronic pain care:

Evaluate Chronic Pain Patient Use And Costs In ACOs

As a major driver of emergency department (ED) visits, understanding the experiences of patients living in chronic pain in accountable care organizations (ACOs) is critical to addressing high costs and improving quality. While there has been little analysis, a study of University of California, San Francisco’s commercial ACO arrangements found that nearly 20 percent of ACO participants had chronic pain, three times the rate of diabetes in that patient population. These patients had utilization rates that were two to three times that of patients without chronic pain including inpatient, urgent care, and ED visits. To fully rein in Medicare costs through an ACO approach, analysis of approaches to chronic pain within the model must be evaluated.

Require ACOs To Implement A Biopsychosocial Approach For Chronic Pain

While emphasis on a strong primary care foundation is important, most people experiencing chronic pain are referred to specialists for surgeries and other interventions that are often ineffective. Multifaceted approaches to chronic pain care that include behavioral health services must be prioritized in these models to reduce unnecessary ED use and reduce costs. For example, the Mayo Clinic’s Comprehensive Pain Rehabilitation Program that provides a three-week intensive program involving both physical reconditioning and group cognitive-behavioral therapy has been shown to improve self-reported pain scores and reduced pain interference. Testing strategies that engage pain specialists in targeted primary care value-based payment approaches is also needed, with a particular focus on the biopsychosocial approach to chronic pain care.

Assess The Impact Of New Chronic Pain Management Codes

Primary care visits are often driven by pain. CMS acknowledged the importance of chronic pain management by expanding its Healthcare Common Procedure Coding System codes in 2022 to include G3002 and G3003 for chronic pain management services. These codes require that a provider maintain a person-centered care plan and provide comprehensive pain management care and coordination. No research has been conducted yet to evaluate how providers are using these codes and what outcomes have occurred as a result. CMS should analyze the impact of G3002 and G3003, which can inform further development of chronic pain-centered approaches in ACO and advanced primary care models.

Expand Chronic Pain Bundled Payment Models

Accountable care pain management must include a menu of services within a biopsychosocial model. The state of Vermont is leveraging the success of a Blue Cross Blue Shield of Vermont chronic pain bundled payment initiative within its Medicaid program. In partnership with the University of Vermont Health Network’s Comprehensive Pain Program, Vermont state Medicaid has piloted a 16-week outpatient chronic pain program reimbursed through a bundle. CMS should consider expanding opportunities to test bundled payments for chronic pain and explore how such an approach can be incorporated into ACO and advanced primary care models.

The future of accountable care in Medicare looks promising but cannot fully achieve its goals without laser focus on the needs of those in chronic pain that will only grow as the population ages. These four targeted actions can be a step in the right direction.