Chronic Pain Patients are grateful that Terri Lewis Ph.D. is one of their most eloquent spokespersons. She shared with the National Pain Report what she has submitted to HHS on the Pain Management Task Force draft report. If you want to submit your comments you must do so by Monday (April 1)
Barrier 1.0. Models of care across health delivery across federal law do not share consistent meaning across federal programs (lack of interoperability).
Recommendation 1.1. Incorporate specific terminology and criteria into the Social Security Act, Medicare section, to address palliative care, community based chronic care, hospice care, and end of life care for cancer or other severe diseases.
Recommendation 1.2. Incorporate clear definitions of models of care into systems of treatment and reimbursement that include home based care, assisted living, long term care, nursing home care, and end of life/hospice care delivered according to the needs of the person, their chosen support system care providers, and available local treatment providers.
Recommendation 1.3 Incorporate technology for hand-offs that assure continuity of care as conditions change over the life-course (e.g. pediatric to adult), or as local resources change (e.g. health care marketplace changes), as insurance contractors may change (reallocation of marketplace insurance awards or age related changes in plan participation), or as local health care providers change in composition and expertise.
Barrier 2.0. Diverse definitions exist across federal and state laws and regulations that do not have shared meaning for implementation, measurement or quality.
Recommendation 2.1. Adopt a single set of consistent terminology with shared meanings incorporated into federal law and regulations that flow down throughout all state laws and regulations, industry guidance documents, and contracted insurance plans.
Recommendation 2.2. Removal of CARA forensic criteria to descriptions of beneficiaries who may require pain management that has a controlled substance component for treatment.
Recommendations 2.3. Remove HEDIS criteria from insurance plan rating systems that (a) equate the care of persons with chronic illness reliant on controlled substances with terminology that inappropriately label them with opioid use disorder, and (b) ‘abuse’ and ‘utilization’ as quality factors in delivery of pharmacy services.
Barrier 3.0. Entire populations of health users who rely on pain supports are not included or addressed in special populations language.
Recommendation 3.1. Include persons with rare diseases into special populations criteria that may require integrated multi-modal integrated care for progressive illness over the life course.
Recommendations 3.2. Include persons with disabilities (developmental or acquired) into the special populations criteria that may require integrated multi-modal integrated care for progressive illness over the life course.
Recommendation 3.3. Include persons with multiple chronic conditions (CC/MCC, 2 or more) into the special populations criteria that may require integrated multimodal integrated care for management of progressive illness over the life course.
Barrier 4.0. Clarify what ‘access to pain supportive care’ across urban and rural environments.
Recommendation 4.1. Require state health plans to provide evidence of community capacity to serve the needs of residents within the community continuum – home, PCP, specialty care, emergency care, hospitalization, long term care, telemedicine, patient education, pharmacy services, behavioral and mental health, dental care, vision, assistive technology, medical equipment, and rehabilitation engineering.
Recommendation 4.2. Require federal plan sponsors to provide evidence of in-network provider capacity to meet the needs of enrolled beneficiaries and evaluate plan performance based on these criteria.
Recommendation 4.3. Require Medicare providers in sponsored plans to provide evidence of meeting the needs of enrolled beneficiaries, to create mechanisms for reimbursement for care coordination of chronic illness, and evaluate their performance based on participant outcomes.
Recommendation 4.4. Require plan sponsors to include behavioral and other community organizations in plan delivery and evaluate performance of these plans based on measures associated with social indicators of care, patient satisfaction, and patient outcomes.
Barrier 5.0 Align evaluation and research processes
Recommendation 5.1. Ensure that every health law, regulation and guideline adopted by the federal government is reviewed at a minimum of every 5 years to review scientific understandings and assumptions, incorporate new developments, identify adverse events and perverse incentives; to address design of federal program delivery and data functions, to ensure stakeholder participation, and review program outcomes.
Recommendation 5.2. Ensure that all end points reflect true evidence based practice (EBP), and are reviewed by representative stakeholder groups for consistent and shared meaning across federal agencies.
Recommendation 5.3. Widen exclusive reliance on billing data as the major source of quality data, by adopting endpoints that reflect desired patient outcomes and appropriate community focused impact.
Recommendation 5.4. Adopt a continuous improvement approach to data collection and management of patient health care information that is correct, secure, correctly reflected, accessible to patients, and that there is a clear relationship between effective treatment practices and services provided.
Barrier 6.0. Align minimum quality requirements for insurance awards.
Recommendation 6.1. Provide clear communication to awarded insurance plan sponsors that ensures appropriate service expectations across beneficiary groups.
Recommendation 6.2. Examine language and practices that encourage discrimination and underservicing.
Recommendation 6.3. Provide annual summaries of plan performance to enrolled beneficiaries.
Barrier 7.0. Align the provision of pain management with the biopsychosocial model of care.
Recommendation 7.1. Medical education must be realigned as a whole body, multi-systemic construct rather than simply the delivery of analgesia and anesthesia.
Recommendation 7.2. Increase health literacy about pain as a preventable health issue using cross-disciplinary pain education into a wider distribution of personnel preparation applications – psychoeducation, pharmacy education, substance misuse services, social work, community mental health counseling, rehabilitation counseling, and allied health disciplines – occupational health and physical therapy.
Recommendation 7.3. Incorporate developmentally appropriate education into public school health and science criteria that increases availability and accessibility of pain education resources that emphasize wellness, literacy, and prevention of preventable injuries and chronic illnesses.
Barrier 8.0. Reduce the influence of the Drug Enforcement Administration as an arbiter of health system operations across health care sectors.
Recommendation 8.1. Remove prescriptions issued to exempted beneficiaries from the algorithms that currently are used to target ‘over utilization.
Recommendation 8.2. Address communities that drug planning will be based on assurance of supplies of essential medications that may be listed as controlled substances for routine dispensing, perioperative supports, in hospital surgical and routine care, hospice supports, and end of life needs.
Recommendation 8.3. Encourage physicians to increase the numbers of persons served who fall into exempted categories by removing threat of arrest, civil forfeiture and other practices which create perverse incentives with abandon or provide substandard care to patients.
Barrier 9.0. Support physicians
Recommendation 9.1. Increase sponsored post practice pain education.
Recommendation 9.2. Reward effective practices and create interdisciplinary mentoring.
Recommendation 9.3. Incentivize optimization of patient outcomes and learning through pay for performance.
Barrier 10. Reward and incentivize true patient centered care.
Recommendation 10.1 Link evidence of patient choice in treatment planning to healthcare outcomes.
Recommendation 10.2. Implement media campaigns to root out misinformation.
Recommendation 10.3. Beneficiaries to federal law, regulations, guidelines, contract awards, and federal/state or provider agreements are provided with recourse and mechanisms for complaint investigation, and has the right to refuse heath care practices that may result in harm or be inconsistent with personal values and culture or health status.
Very respectfully submitted:
Terri A. Lewis PhD, NCC, Clinical Educator, Rehabilitation and Mental Health