Agenda Item 9, Attachment 1 Page 1 of 31

Statewide Collaboration through Smart Care California: Low Back Pain

Kathy Donneson Chief, Health Plan Administration Division

Dr. Richard Sun Preventive Medicine and Public Health Physician

Benefit Programs Policy and Planning

March 14, 2017

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• Background

• Introducing Dr. Tobias Moeller-Bertram

• Lower Back Pain Findings

• Next Steps

Agenda

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Background

Low back pain is the single leading cause of disability worldwide

Global Burden of Disease 2010

Spine pain care accounts for $90 billion in direct cost annually in the US

Stanford Clinical Excellence Research Center

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Background | Low Back Pain (LBP)

Common and costly for CalPERS

$106.6 million in 2015

Smart Care California Prevent progression of acute LBP to chronic pain and disability

Introducing Dr. Tobias Moeller-Bertram

Dr. Toby Medical Director Desert Clinic Pain Institute

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CHRONIC LOW BACK PAIN: A Whole Patient Problem….

Requiring A Whole Patient Solution....

Tobias Moeller-Bertram, MD, PhD, MAS Desert Clinic Pain Institute

March 14, 2017

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PERCEPTION Agenda Item 9, Attachment 1 Page 7 of 31

PAIN

"Part III: Pain Terms, A Current List with Definitions and Notes on Usage" (pp 209-214) Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy, edited by H. Merskey and N. Bogduk, IASP Press, Seattle, ©1994.

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

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CHRONIC VS RECOVERED BRAIN CIRCUITS

Visit 1 Visit 2 Visit 3 Visit 4

Apkarian 2013 data (Hashmi JA et al., "Shape shifting pain...")

Chronic

Recovered

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BEST TREATMENT MODEL? Agenda Item 9, Attachment 1 Page 10 of 31

Historically, management of patients’ pain was addressed by individual health care providers, usually a physician. However, the presence of pain affects all aspects of an individual’s functioning. As a consequence, an interdisciplinary approach that incorporates the knowledge and skills of a number of health care providers is essential for successful treatment and patient management.

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Interdisciplinary care involves the execution of the treatment plan concurrently. That is, disciplines involved in care will be engaged in parallel and in collaboration and not sequentially whenever possible.

The availability of interdisciplinary care is not solely the responsibility of team members, all stakeholder (institutions, people with pain, referring clinicians, and payers) need to support, encourage, and demand a comprehensive approach to pain management as it is in all of their best interests.

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• Although there are perceptions that opioid therapy for chronic pain is less expensive than more time intensive non-pharmacologic management approaches, many pain treatments are associated with lower mean and median annual costs compared with opioid therapy.

• Multimodal therapies and multidisciplinary bio-psycho-social rehabilitation-combining approaches (e.g., psychological therapies with exercise) can reduce long-term pain and disability compared with usual care and compared with physical treatments (e.g., exercise) alone.

http://www.cdc.gov/media/dpk/2016/dpk-opioid-prescription-guidelines.html

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MEDICAL DEPARTMENT Doctors, Physician Assistants, Nurse Practitioners, Interventional Pain Specialists

ALTERNATIVE CARE DEPARTMENT

Naturopathic Doctors, Acupuncturists, Chinese Medicine, Dietitians

FRAMEWORK FOR TREATMENT SERVICES

PHYSICAL RECONDITIONING DEPARTMENT

Chiropractors, Physical Therapists, Fitness Instructors, Yoga & Tai Chi Masters, Massage Therapists

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FRAMEWORK FOR TREATMENT PHASES (1 YEAR)

• Phase 1 = “Rescue” • Phase 2 = “Restore” • Phase 3 = “Re-entry” Phase

2

Phase 3

Phase 1

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1. Diagnosis Based Approach: Low Back Pain: Treatment A Headache: Treatment B Arthritis: Treatment C

2. Mechanism Based Approach: Neuropathic Pain: Treatment A Nociceptive Pain: Treatment B Mixed Pain: Treatment C

3. Patient Based Approach: Emotional Suffering from Pain: Treatment A Physical Suffering from Pain: Treatment B Mixed Suffering from Pain: Treatment C

FRAMEWORK FOR TREATMENT PHILOSOPHY

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FRAMEWORK FOR TREATMENT LOGISTICS Agenda Item 9, Attachment 1

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• Patients with LBP Diagnosis – 656 of 734 (89.4% of total Pts in COE)

• Patients with five+ Pain Diagnoses

– 395 of 656 (60.2% of LBP Pts)

• Patients with at least one additional Behavioral Diagnosis – 357 of 656 (54.5% of LBP Pts)

BASELINE COHORT CHARACTERISTICS Agenda Item 9, Attachment 1

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CLINICAL OUTCOMES – PHYSICAL Numeric Pain Rating Scale

Oswestry Low Back Pain Disability Questionnaire

* “Pain average,” “interference with Enjoyment of life,” and “interference with General activity”

Pain Intensity and Interference Scale*

Pain Disability Index

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Pain Catastrophizing Scale

Generalized Anxiety Disorder-7 Questionnaire

Patient Health Questionnaire-9

Patient’s Global Impression of Change

CLINICAL OUTCOMES – EMOTIONAL Agenda Item 9, Attachment 1

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Drug Abuse Screening Test-10 Alcohol Use Disorders Identification Test

CLINICAL OUTCOMES – SUBSTANCE USE Agenda Item 9, Attachment 1

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COST TRENDS OF COHORT

• Out of the 79 patients on both Adjusted Clinical Group (ACG) reports given by IEHP:

– 43 patients (54%) had a decrease in the Probability of High Total Cost.

– 34 patients (44%) had an increase in the Probability of High Total Cost.

– 2 patients (2%) remained the same.

Probability of High Total Cost

Increased

44%

Unchanged

2%

Decreased

54%

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$36,817

$19,671

$0

$10,000

$20,000

$30,000

$40,000

Pre-intervention Post-intervention

Total Cost of Care• 65 Total Members • Total Cost of Care = All claims (Rx and

Medical)

• Pre-intervention = 12 months before intervention

• Post-intervention = 6 months after intervention

• Intervention = Member engagement with COE

COST ANALYSIS Agenda Item 9, Attachment 1

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Vision: Ensure that members utilizing a high-level of opioids and suffering from severe, refractory chronic pain will receive a comprehensive, integrative and holistic treatment program focused on promoting patient self-efficacy, functional restoration, and wellbeing.

Goal: Develop a network of Pain COEs building on Desert

Clinic Pain Institute Model

IEHP'S APPROACH TO SCALING PAIN COES: TOTAL PAIN CARE (TPC) PROGRAM

COE = Center of Excellence IEHP = Inland Empire Health Plan

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25

Desert Clinic Pain Institute

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COE sites will be evaluated on cost, utilization, patient outcomes and program engagement:

1. Cost Analysis/Return on Investment (ROI)

Total medical costs including pharmacy, facility, professional and cost of COE program

2. Utilization Analysis

Emergency room, inpatient interventional utilization pain procedures and morphine equivalent dosage (MED)

3. Patient Outcomes

Pain level, disability, depression, anxiety, patient satisfaction

4. Program Engagement

Member Engagement rate and retention rate

PROGRAM EVALUATION Agenda Item 9, Attachment 1

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➤ Engagement before and during treatment is key

➤ Implementation of transitional support program after completion is needed for successful outcomes

➤ Longitudinal coordination of care between all treating providers and entities is essential

➤ Non-clinical (and clinical) support staff needs to have training to attend to these complex members

➤ Linkage to and coordination with carve out services and community services is essential

LESSONS LEARNED Agenda Item 9, Attachment 1

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Thank You

Dr. Tobias Moeller-Bertram Medical Director

Item 8b, Attachment 1, Slide 30 Page 1 of 11

Next Steps

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Next Steps

Identify nationally defined measures

Conduct additional data analytics

Identify variations in cost and use

Business Planning Initiative