Session # F3a
Friday, October 11, 2013
Changing the Way We Treat Chronic Pain:
Practical and Profitable
Evidence‐Based Methods
Daniel Bruns, PsyD FAPA
Collaborative Family Healthcare Association 15th Annual Conference
October 10-12, 2013
Broomfield, Colorado U.S.A.
Faculty Disclosure
I currently have the following relevant
financial relationship (in any amount)
during the past 12 months:
Psychological test author and consultant
Objectives
• Understand how to create a pain treatment
program that is practical and economically
viable in both
– Fee for service systems
– ACO/capitated systems
• Handouts:
www.healthpsych.com/handouts/cfha2013.zip
Daniel Bruns, PsyD
• Have been involved in developing evidencebased medical treatment guidelines
• Conducted a 15 year longitudinal study of 29
million patients regarding the cost benefits of
the biopsychosocial model
• Have run a profitable clinic for 28 years
There are a variety of economic models
in the field. Where do you fit?
• Payers
– Medicare/Medicaid
– Private pay
– Grant
• Private Payer type
– HMO
– PPO
– In/Out of network
• Billing codes
– E&M
– Psych, H&B
• Economic systems
– Fee for service
– Bundled
– Capitated
• Clinic type
– Integrated
– Co-located
– Accountable Care
Organizations
Pain Is Arguably The Most
Expensive Medical Condition
• The most common reason why patients see a
physician
– National Center For Health Statistics, 1992
• Annual cost of chronic pain in the US = $635 Billion
– Institute of Medicine, 2011
• Pain is a priority in the Affordable Care Act
– Mentioned more often than diabetes, heart disease,
substance abuse and obesity
A Comprehensive Pain Treatment
Program Begins With a Better
Understanding of Pain
Physiologically,
pain is half sensation
and half emotion
Neurologically,
pain is a complex,
multidimensional
sensory experience
Spinal Cord and
Ganglia
©2013 Daniel Bruns, PsyD
… nerve
dysfunction, and
neurotransmitters
(e.g. Substance P)
Pain also
comes from
nerve injury…
Pain Nerve
Pathways
Thermal
Heat
Acute “First Pain”
Chronic “Second Pain”
Primarily A-∂ fibers
C fibers
(sharp/localized)
(achy/diffuse)
Pressure
Cold
Chemical
Tension
Pain Sensory
Receptors
“Sleeping”
Thermal
Pressure
Chemical
Pain Center
The Pain
Sensory System
(Central sensitization: multiple
factors in the neuromatrix
sensitize you to pain)
Sensation and
Movement
Many parts of the brain are
involved when you feel pain
(self-protective
behavior)
©2013 Daniel Bruns, PsyD
Emotion
(irritability and
depression)
Thoughts and worries
about pain
Muscle Tension
& Spasms
(Will I ever get better???)
(knots in muscles)
Arousal
Sensory Regulation:
Descending Neural
Inhibition vs Windup
(I can’t sleep)
TSSP*
“A-delta” Acute Pain
Nerve Fibers
“C” Chronic Pain
Nerve Fibers
(sharp, localized pain)
(broad pattern of dull,
achy pain)
How do you create
a clinically practical
and economically viable
program to treat pain?
Fee For Service
How Safe Are Pain Medications?
American Mortality Rates For Accidental Overdose
Opioid Analgesics
Cocaine
Heroin
•
Centers for Disease Control, 2012
© 2012 by Daniel Bruns
This Plan Starts With The Physician
• Opioid-only model is not the best care
– Not very effective, increased risk
– Best is biopsychosocial model
• “We are committed to the best care for you”
– Comprehensive pain treatment
– To get opioids, you must attend the
comprehensive program
Pain Assessment
Medical Assessment
Accurate diagnosis must
precede treatment
Celsus, 35 AD
Psychological Assessment
It is more important to know
what sort of person has a disease,
than to know
what sort of disease a person has.
Hippocrates, 400 BC
Biopsychosocial Assessment
• Medical
– Exam, tests and imaging
• Psychological
– A review of 125 meta-analyses concluded psychometric
tests are the scientific equals of medical tests in their
ability to diagnose and predict outcome (Meyer, et al,
2001)
– Psychological tests better than MRI at predicting lumbar
surgical outcome, (Carragee, et al, 2005; 2004)
Psych Diagnoses for Chronic Pain
• Psychological diagnosis may include:
– DSM IV/ICD-9-CM /ICD-10:
• Pain disorder
– DSM 5:
• Somatic Symptom Disorder With Predominant Pain
– Plus depression, anxiety, personality
disorder, opioid dependence, etc…
Billing For Psych Assessment: Caveats
• Billing criteria varies
– Over time
– Over areas of the country
– Among payers
– For each payer, among policies
– You cannot rely on this presentation for definitive
information on your circumstances
• You must know the current policies of your
payers
• Always do the right thing
Billing for Psych Assessment
CPT Code (Old code)
Description
Reimbursement
(private payer)
90791 (90801)
Diagnostic Interview (Not time based)
$151
(83)
96101
Psychological Testing by Psychologist,
Physician or Other
83
(69)
96102
Psychological Testing by technician
86
(69)
96103
Psychological Testing by Computer
70
(69)
96150
Heath & Behavior Assessment
20
(29)
96151
Heath & Behavior Reassessment
19
(29)
Billing CPT 96101 Psych Testing
• For traditional standardized tests!
• 96101
– 31 to 90 minutes 1 unit
• 31 to 90 minutes paid at $83
– Hourly rate drops from $161/hr at 31 minutes, to
$55/hr at 90 minutes
• 96101-52
– Reduced time 96101
– 30 minutes or less pays about $42
– 20 min = $126/hr
What Does 96101 Include?
• Psych Testing 96101
– Face-to-face time administering tests
– Non face-to-face time
• Interpreting test results
• Integrating other clinical data, including previously
completed and reported technician– and computer–
administered tests
• Preparing the report
• You can design services that fit into a 20
minute or 40 minute time frame
© 2005 by Bruns and Disorbio
Psych Testing Codes Do Not
Apply to All Assessments
• Mini Mental Status is specifically excluded
– by implication, also probably PHQ-9, SF-12
• Short psych tests that I know of with
established track record of reimbursement
– BBHI 2
– P3
Billing 96103
• Computerized Assessment
– For standardized computerized tests
– Not for a PHQ-9 running on an Excel spreadsheet
– No time listed
• ~ $70 for whatever time it takes
– You should administer and interpret test results in
context of other clinical findings
Evidence-Based, Interdisciplinary
Treatment Guidelines for Pain
Recommend Psych Assessments
They Are Also Reimbursable
Under Fee For Service
Treatments for Pain
The Spectrum of Treatments
What is the plan?
Operative procedures
Medications
Exercise/physical therapies
Behavioral treatments
© 2013 by Bruns and Disorbio
Behavioral Treatments
• One purpose of psych eval –
– Group vs Individual?
– Use groups when possible
• Some patients are not good candidates for
groups though
– Personality disorder
– PTSD
– Suicidal/Severe depression
Group Topics
• Pain Education
– Chronic pain as a sensory
disorder
– The pain sensory system
– “First pain” vs “second pain”
– Pain and cognition, affect,
memory, sensation
– Rx for pain
– Role of exercise
• Pain Treatment
– DBT
• CBT
• Mindfulness
• Stress mgt, etc
–
–
–
–
Sleep hygiene
Voc rehab
Pain workbook
Support group for
ongoing issues
Group Treatment
• Appropriate patients first attend pain
education group with revolving agenda
• Later attend pain support group
• More complex patients may have a greater
need of individual care
Group Treatment
• Psychologist/LCSW/LPC
• CPT 96153
– Private payers may pay more
– 90853: Pain disorder/somatic symptom
disorder
• 10 members, 60-90 minutes = $245/hr Medicare
• 10 members, 60-90 minutes = $390/hr Pvt Payer
– If you screen out the difficult patients, larger
groups are possible
Billing for Treatment
CPT Code
(Old code)
Description
Reimbursement
(private payer)
90832
(90804)
Psychotherapy, 30 minutes
(16 to 37 minutes) with patient and/or
family member (@ 16 min= $235/hr)
90834
(90806)
Psychotherapy, 45 minutes
(38 to 52 minutes) with patient and/or
(occasionally a) family member
$80.63 (69)
90837
(90808)
Psychotherapy, 60 minutes
(53 minutes or longer) with patient
and/or family member
$118 (83)
90853
Group psychotherapy
$25 (39)
$62.60 (39)
The psychotherapy codes should not be billed for any sessions lasting less than 16 minutes.
Capitated Systems and
Accountable Care Organizations
ACO/ Capitated Systems
• You have $X dollars to spend on your
population
– Under ACA, pain is one of the highest priority
conditions
• Will adding psych services for pain
– Increase costs?
– Or reduce costs?
✔
What is the evidence that
adding psych services
provides better care
at less cost?
Colorado Biopsychosocial
Law Study
Legislative Natural
Experiment
Legislative act creates
treatment and control groups
1992: Colorado Biopsychosocial Law
1. Law mandated use of evidence-based biopsychosocial
guidelines for work-related illness or injury
2. MDs must be trained in the guidelines
3. Mandated psych assessment
1.
For all with delayed recovery or chronic pain
2.
Prior to numerous surgeries and procedures
4. Mandated psych treatment
5. Insurers had to pay for listed treatments
6. Regulatory and judicial oversight
2011
We obtained 15 years of
cost data on
every injured worker under
every payor in 45 states
What Happens When you Mandate The
Biopsychosocial Model?
• 15 years of cost data
• Colorado
• Rest of USA
N = 520,314
N ≈ 28.6 million
– Bruns, Mueller and Warren, 2012
Hypotheses
• Colorado’s biopsychosocial approach will
contain inflation in medical costs
• Colorado’s biopsychosocial approach will
contain inflation in disability costs
• Provide better care
Nation
202%
Colo
68%
Nation
109%
Colo
28%
Estimated Cost Savings of
Colorado’s Biopsychosocial Model
in 2007 alone:
$859,000,000
Bruns, Mueller and Warren, 2012
Colorado Study Conclusion
• At a population level, this produces better
care at reduced cost
Psych Assessment And Cost Offset
• Helpful in IPC
– Who is good candidate for group treatment?
– Predicting patients at risk for nonadherence, etc
• More helpful in ACOs
– Cost of IPC + hospital + specialty + more on same
spreadsheet
– 1 surgery can blow the budget
• Patient selection can help to control specialty costs,
reduce hospital re-admits
Psych Assessment Cost Offset
• Some medical treatments are extremely
expensive
– Some surgeries can cost > $100K
– Many payers require presurgical psych evals
• Surgeons wouldn’t do surgery without an MRI
– But psych assessments are more predictive of
outcome than MRI for many pain procedures
– Very high return on investment of clinical time
Brief Standardized Psych Evals
• The only published method of pain assessment
with a 10 minute assessment method that is
– Standardized
– Evidence of validity and reliability
– No gender or race bias
– Identifies factors associated with poor response to
surgical and nonsurgical (TBI, PT) treatments
– Bruns, D., & Disorbio, J. M. (2009)
Psych Treatment Cost Offset
• For many patients behavioral treatments are
much better choices than surgical ones
– For some conditions behavioral treatment
outcome = that of surgery
– Surgery is 156X more expensive
– Surgery has serious risks
• 3/1000 chance of death
– Bruns et al, 2012
For ACOs to meet their
financial targets
They will have to find a better means of
selecting patients for high-cost, high risk
procedures for painful conditions.
Since pain is the most expensive condition, and it
is a biopsychosocial disorder, that means more
psych assessment and treatment
References
Bruns, D., & Disorbio, J. M. (2009). Assessment of biopsychosocial
risk factors for medical treatment: a collaborative approach. J Clin
Psychol Med Settings, 16(2), 127-147.
Bruns, D., & Disorbio, J. M. (2013). The Psychological Assessment
of Patients with Chronic Pain. In T. R. Deer (Ed.), Comprehensive
Treatment of Chronic Pain: Medical, Interventional, and
Behavioral Approaches (pp. 805-826). New York: Springer
Colorado Division of Workers' Compensation. (2012). Rule 17,
Exhibit 9: Chronic Pain Disorder Medical Treatment Guidelines.
Colorado Department of Labor and Employment: Division of
Worker Compensation
Questions
Additional Information:
www.healthpsych.com/handouts/cfha2013.zip
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!