Pauline Anderson

March 23, 2017

ORLANDO — An intensive outpatient pain management program incorporating both psychiatric care and pain management slashed about 45% in costs incurred annually by high utilizers of the healthcare system, a new study shows.

Steven D. Prakken, MD, director, Medical Pain Service (MPS), Duke University, Durham, North Carolina, who is dually trained in psychiatry and pain medicine, discussed the results with the program during the American Academy of Pain Medicine (AAPM) 2017 Annual Meeting.

In general, 21% of medical costs are consumed by 1% of the patient population. That population includes many patients with chronic pain, who often have psychiatric comorbidity and tend to be underinsured, Dr Prakken told Medscape Medical News.

"High utilizers are a really difficult population to deal with and they take up a good deal of our time," he said. "Traditional care models are not doing well in terms of this population."

Dr Prakken called his service a "deep dive" into "functional pharmacology."

"It's a process by which we look at all the medications these patients are taking, in detail, figuring out what kind of effects and side effects they have, in detail."

The new study included 31 patients referred to the MPS team and treated for an average of 12 months. Dr Prakken leads the five-member team, which also includes a nurse practitioner and physician assistants.

Researchers looked at 14 different cost points, including inpatient and outpatient services, emergency department, nursing, surgery, laboratory, and pharmacy. They compared healthcare utilization before and after initiation of treatment at the MPS.

They found that the intervention led to a 45% reduction in costs; changes in costs per year went from $508,707 to $277,989.

"Nearly $9000 a year for each high utilizer was actually saved," said Dr Prakken. A 45% cost savings is huge, he added. "It's the size of a planet in a healthcare system."

Less Depression

The mechanism of the savings was multipronged. "These high utilizers are not showing up in the ER [emergency room] as often; they're not making as many impulsive decisions; they're not as depressed; they're not as anxious," said Dr Prakken. "All of these things we know are comorbid with pain and a whole lot of other medical diseases."

A psychiatric approach to this patient population is proving to be key, said Dr Prakken. "I can sort out whether this is addiction, whether it's diversion, whether it's depression, and whether it's anxiety."

High utilizers may have complex issues, including depression and personality problems, and may impulsively take pain medicines.  

"There's much less in the way of questions about what to do with the patient sitting in front of you who is having a bad response to an antidepressant and, at the same time, needs to have their opioid adjusted because their pain is worse."

Still, high utilizers "are not going to go away," stressed Dr Prakken.

He and his colleagues have "crunched" numbers for a larger group of high utilizers, about 600, and found even more savings.

"It came out to $30,000 per high utilizer per year," said Dr Prakken. "That means millions and millions and millions of dollars a year that the hospital doesn't have to worry about in terms of utilization from this underinsured group."

On the basis of their success, the Duke team plans to expand the service, he said.

Commenting on the research, Miroslav Backonja, MD, a neurologist and pain specialist in Seattle, Washington, said it's another illustration that multidisciplinary and interdisciplinary pain management programs are effective.

Research showing cost savings in the field of pain management is especially important, added Dr Backonja. "A lot of times, these types of programs are denied out of concern that they're too expensive."

American Academy of Pain Medicine (AAPM) 2017 Annual Meeting. Poster 181. Presented March 17, 2017.

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