Chronic Pain & Opioid Addiction: The Role of Integrated Care

12:00 – 12:10 p.m.      Welcome and Introductions

• Sarah Dash, @AllHealthPolicy
  Alliance for Health Policy
• Sherry Dubester
  Anthem, Inc.
• Mark Hayes
  Ascension
• Kirsten Thistle
  Health is Primary

12:10 – 12:45 p.m.      Presentations

• Ben Miller, @miller7
  Well Being Trust
• Eric Schoomaker
  Uniformed Services University
• William Morris
  Palo Alto Medical Foundation (Sutter Health)
• Andrea Gelzer
  AmeriHealth Caritas

12:45 – 1:30 p.m.        Question and Answer Session

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#FutureOfHealthCare

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PLEASE NOTE: This is an unedited transcript. Please refer to the video to confirm exact quotes. SARAH DASH: My name is Sarah Dash and I’m President and CEO of the Alliance for Health Policy. We are really thrilled to be hosting this conversation today. We’ve heard so much, as many of you know, about the opioid epidemic but not as much about the underlying issues around pain and how to manage it, and so we have a fantastic panel today that’s going to explore these issues with us. Before we get started with the panel, just a couple of words about today’s event. This is the third event in a series on the future of chronic care, and you can follow along on Twitter at hash tag future of healthcare. We are extremely pleased and grateful to have three annual sponsors who have been supporting this series, as well as an earlier series that we did on the future of health insurance, and a series that we will do this fall on the future of the healthcare workforce. And those are Anthem, Ascension, and Health is Primary, and I want to thank them. And we’re going to hear remarks from them in just a couple of minutes. I also want to thank the sponsors of the chronic care series specifically: CAPG, DaVita, Express Scripts, and Genentech. So, without further ado, we’re just going to hear a couple of words, first beginning with Sherry Dubester, who is Vice President of Behavioral Health and Clinical Programs at Anthem. Sherry. SHERRY DUBESTER: Thanks very much, Sarah. Well, it’s a pleasure to be here today and I can’t imagine a more timely topic, so I can see from the attendance that there’s a lot of interest and that’s wonderful. Just a word about Anthem. Anthem Blue Cross is the Blues in 14 states, we’re in 20 Medicaid markets as well, and we insure one in eight Americans, so are very invested in working on the opioid crisis as well as chronic care management, integrated behavioral medical care, and all the issues that I think we’ll hear more about today. I lead a clinical strategy in behavioral health and I’m a psychiatrist by training, and have been leading our company wide opioid strategy work. The importance of an integrated care approach is so fundamental to the programs that we deliver for our members at Anthem, and for the collaboratives that we are increasingly engaging with, our providers—medical, behavioral—for the care delivery that they’re engaged with as well. And the concept of integrated care really applies, whether you’re thinking about well being, or whether you’re thinking about chronic conditions such as diabetes, certainly as you’re thinking about the opioid crisis and chronic pain. So what do we mean by integration? And I’m guessing you may hear different definitions today, at the very least, integrated care involves integration of medical and behavioral care and there’s a tremendous amount of exciting work going on in this arena. Anthem is certainly very focused on it, so are many payers, the providers, and a lot of that is actually collaboratives, which is wonderful. But I want to leave you also with some thoughts about that integration should also pay attention to the social determinants of health. Do the members and the patients that providers care for have a safe place to live? Do they have access to healthy food? Do they have a safe place to move and walk? Do they have transportation to their appointments? Because when it comes to the kind of complex health issues that we’ll be talking about today, our version of holistic health and integrated care probably has to go beyond even the medical/behavioral but also really think about the full whole health concept. So with that, I’ll turn it over to the next speaker, and really look forward to the dialog today. Thank you. SARAH DASH: Great. Thank you so much, Sherry. And next I would like to introduce Mark Hayes, who is Senior Vice President for Federal Policy and Advocacy at Ascension. Mark. MARK HAYES: Thank you. Good afternoon everyone. We are just so glad to be a sponsor of the Alliance and of this event. This is such an important topic. In the midst of everything that’s going on in healthcare right now from the healthcare, the larger healthcare debate, around the direction of our healthcare system, to hurricanes, to so many issues, we can’t lose sight of this important one. It is crucial that we crack the code on how to deliver pain management in a better way that isn’t fueling the opioid crisis, so I’m so excited to hear what our speakers have to say today. I’m very glad that you all are here, and we’re very glad to be a sponsor. If you’re not already familiar with Ascension, we are the largest Catholic and nonprofit health system in the United States. We’re in 22 states around the country and on behalf of our caregivers and clinicians, we welcome you, and thank you for being here. SARAH DASH: Thank you. Finally, I’d like to introduce Kirsten Thistle, who is here joining us from the Health is Primary campaign. KIRSTEN THISTLE: Thank you. Good afternoon. As Sarah said, I’m Kirsten Thistle and I am, along with my colleague, Ann Saybolt, the campaign director for Health is Primary. First, a quick poll. How many of you guys have actually heard of the Health is Primary Campaign? Not bad. We have been running ads in the Hill and then Roll Call and hoping to raise awareness about our program. It was launched a couple years ago by eight family medicine organizations, most notably the American Academy of Family Physicians, and our goal really has been to focus on raising awareness around the value of primary care in America and how a country with a strong foundation of primary care can deliver better health, better quality at a lower cost. A big part of what we’ve been talking about is this idea of integration—integrating behavioral health, mental health, nutrition—all of these other clinical services into the primary care setting. We have a long way to go. A big hurdle to clear in order to be successful is to change payment models so that we can move away from the fee for service model and move to value-based payment where we’re looking more holistically at patients. We’ve been traveling the country and finding case studies of where this is working and, again, we have a long way to go, but I think we’re seeing some bright spots around the country in different models of how this is delivering success for patients. If you go to our website, healthisprimary.org, you can see case studies of specific examples of practices that have been successful and really looking at data-driven metrics of how they’ve succeeded and what that success looks like. So again, we’re thrilled to be sponsors of the Alliance, and of this really important event. It’s obviously clearly timely and the opioid epidemic, I know, keeps us both up at night because it’s just staggering, the impact that it’s having on this country. So we’re thrilled to hear what the speakers have to say today and look forward to a lively discussion. SARAH DASH: Great. Thank you so much to all of you, and I’ve moved over here so we can go ahead and get started with the panel. So we’re really lucky to have an excellent panel here today that represents individuals who are really on the front lines of this epidemic, who are dealing with real patients with real pain, and looking at the evolving guidelines for treating pain, and how that intersects with this national epidemic. So I’m going to go ahead and introduce them now and then we’ll hear their presentations and then do a Q&A and discussion. All the way to my right is Ben Miller, who is Chief Policy Officer for the Well Being Trust, a national foundation committed to advancing the mental, social, and spiritual health of the nation. And prior to joining the Well Being Trust, Dr. Miller spent eight years as Associate Professor in the Department of Family Medicine at the University of Colorado School of Medicine, and he was also the founding director of the Eugene S. Farley, Jr. Health Policy Center. Eric Schoomaker, and I should say Dr. Eric Schoomaker, also is a Professor and Vice Chair for Leadership, Centers, and Programs in the Department of Military and Emergency Medicine at the Uniformed Services University. Prior to his retirement, after 32 years of active service, and he is a Lieutenant General Doctor, Lt. Gen. Dr. Schoomaker served as the 42nd U.S. Army Surgeon General and Commanding General of the U.S. Army Medical Command. We are so thrilled to have you here today. To my left, Dr. William Morris, is a clinician at the Dominican Hospital in Santa Cruz, California where he is Medical Director of the Utilization Management Department. He is also the medical director of the Community Clinic of Janus, the local methadone and suboxone treatment clinic, as well as medical director of the Driftwood Skilled Nursing Facility. And then, after the panel, maybe you can tell us how to be in three places at once. Finally, Dr. Andrea Gelzer is the Senior Vice President and Corporate Chief Medical Officer for AmeriHealth Caritas. Previously Dr. Gelzer served as the Chief Medical Officer for Boston Medical Center Health Net Plan. She also served multiple roles, including Senior Vice President of Clinical Public Affairs at Cigna Corporation and, for 16 years, worked in private practice in internal medicine, so a wealth of experience and we’re thrilled to have all of you here, and without further ado, I’ll turn it over to Dr. Miller. DR. BEN MILLER: Thank you Sarah. Good afternoon everyone. Okay. This is not a trick question. How many of you have experienced pain? Alright. Everybody’s hand in this room should go up because at some point in your life everyone in this room has experienced pain. Now, your pain might have varied from ouch, I slammed my hand in the door, or ouch, I had a car accident and now my neck hurts all the time, or it might be something as like, my goodness, it’s Friday morning and I’m sitting here listening to this Miller guy talk. I mean, there’s a lot of different ways to classify pain. My important point here, which I want to make repeatedly here, is that this is all of us. And our inability to design solutions to meet the population need on something as basic as pain is causing us problems. If you look at the data you can see, and I don’t need to repeat these facts, a lot of individuals daily suffer from pain. What type of pain is it? Well, I’ll get into that in just a second. But this is a substantial need that is oftentimes going unmet in our society. Some of those reasons really are how we define what pain is, and so you can look at the literature and we could spend probably six hours talking about this, there’s a variety of different ways to classify pain. You can have tissue damage, you can have nerve damage, or you can have, what we call – I love this word – psychogenic. No, it is not something that you take and go to a concert. Psychogenic is really kind of how you believe your pain to be, or what you think about yourself or believe about yourself and how that influences your physical behavior or your pain. As I just described, most classification systems, however, really kind of quickly gloss over what we mean when we talk about pain. So we can have acute pain, like a bee sting, or we can have more chronic pain which is pain that we live with consistently throughout our lives. Underlying all of this, though, is a need to look at the whole. In 1977, one of the most seminal articles came out by George Engle on the biopsychosocial model. And I want to mention that in this context because as you hear today, a lot of the solutions that we’ve created to address pain have not necessarily taken into account the whole biopsychosocial continuum of care. They’ve taken on a piece of that. We’re going to focus on the biological, okay, but they haven’t necessarily talked about, well, how are you doing with this and what are the things that we might be able to do at a social level to influence how you are better addressing your pain? And it comes down to this one main true fact, which is why I’m so glad to see integration in the title of today’s talk, we are a fragmented society in a fragmented culture that has treated pieces of health and not necessarily taken into account the whole of health. Pain is one of the best examples of this that I can give you. If I only addressed your physical symptoms how is that really helping you cope with this new change in your life that’s decreasing the quality of your life? These are substantial issues that fragmented care really do force us to kind of say, well, no wonder we have problems like opioid epidemics. We have seen a dramatic increase in the use of opioids in this country, and it doesn’t take a rocket scientist to figure this out. Why is the U.S. prescribing more opioids for pain than anyone else in the entire world? Well, it takes us back to the reason that we have so many discussions in places like this because healthcare fundamentally is broken, and in our brokenness and our fracturedness we have let people down. So what do we do to solve those problems? Well, we integrate. And we have to integrate by putting the person first. So I have three points that I want to make here with my limited time. Number one, when we talk about pain, we have to come up with solutions that are actually around the person in the community. I’m going to give you two examples of this. First of all, it’s important that you know your data, know who you’re actually talking about when you stand up on stages like this and you talk about, well, here’s the program that we’re actually advocating for. You need to know the people that you’re trying to serve. You need to know what their needs are and design the program to their needs. An example this is in northeast Colorado. A good friend and colleague, Dr. Jack Westfall, has done a program where he’s actually gone out to folks in the farming community. He’s gone out to folks that just live in rural areas of the state and said, “How can we best address the opioid crisis in northeast Colorado, but most importantly, how can we also talk about your pain and let you know that there is a team of individuals that are here to help you.” These are beer coasters. These are beer coaster, okay? How novel is it to think about taking a message and putting it on a beer coaster that is sitting in your local bar, or that you’re handing out at your local farm feed store and your farmers take home and put their beverage on. You have to take the message to the audience in the places that they are. You can’t expect them to come to you and just say, “Okay. I now have pain,” or “I’m addicted to this substance. What is it that you’re going to do to help me?” Another example of this is that they’ve got these really wonderful flyers that normalize not only pain but what happens when you might actually become addicted to the medications that you’re taking to manage your pain. You normalize it, and you let people know that there is hope. That beyond just kind of this fact that you’re facing every day that you are in pain and you are suffering, there is a team of people that are here to help you and to listen to you and not judge you. And so there’s little caveats at the bottom of each of these posters that say things like, listen, this is not a moral failing when you take another pill. This is not really a moral failing when you can’t show up at work because you’re in so much pain. This is about how can we now create a solution that targets what you need and what is best for you. Another example, here—second point here, actually. How do we create programs that are actually in response to the systematic problem? So what we need now are more systematic solutions to address pain and less programs that take on a piece of that. And so, the bumper sticker for this one is that systems are greater than programs. We have to have systematic solutions to talk about pain. You’ll hear a lot of these in just a minute, examples of these. This slide simply shows you what people have to experience and go through to try and get help for care. Now the example that I’m using here is mental health. So if you’re identified with some type of mental health need you are churning throughout the system, constantly trying to find a place to land. What happens if you’re an individual that experiences pain and someone says, “Well, we don’t do that here. You have to go over there for that.” You stigmatize, you don’t necessarily normalize, and most importantly, folks, people that are suffering have to wait to get help for their suffering. There is something fundamentally wrong about that in our society. Integration allows for us to be in those places where people are addressing their needs in the time that they need them. It might be the fact that you were just told that your back pain is so substantial that you’re not going to be able to go back to work. It might be that someone just said, well, you know what, it’s the combination of your diabetes, your depression, and now your diabetic neuropathy that has led us to this place of not being able to figure out what we’re going to do next. How are you going to cope with that? These are conversations that people have every day and what we’ve done, because of the fragmentation, is that we’ve made it really hard for people to get help for those problems. One study that came out recently looked specifically at what happens when you provide some type of substance use treatment around opioid use in primary care, hence, the integration. We give people momentary, instantaneous access for that problem and, you can see here, the data are quite clear, that individuals, when given access to mental health services or some type of substance use treatment, they use it. They use it because it’s a timely intervention for their need. Other examples of this, the state of Virginia, currently through what they call their ARTS waiver, which is Addiction and Recovery Treatment Services, has looked at this systematic continuum of care and said we know that the solutions are much broader than just creating another buprenorphine prescriber for opioid abuse, or just putting another mental health clinician practice. This is a system issue and we need to tackle that. They’ve increased provider training and education and they’ve looked specifically at ways that they can not only have medicine interventions but they can also have counseling to help individuals with that pain. Almost done here. Quickly on Virginia, though, you can look at the number of prescribers and the number of individuals that are entering into the system because of what the state has done at a policy level to be able to increase the number of folks that can help with pain and substance use. Last point. In order to ultimately do everything that I’m talking about, we have to have a different culture around payment. We’ve got to be able to create some type of comprehensive payment strategy that supports a continuum of care; not pay for another piece of care, pay for a continuum of care. That’s our team. Right now, the dominant culture in our healthcare system is that we pay for services in discreet categories and there’s not more egregious example of this than how we pay for mental health and physical health. If you incorporate pain here into that equation and you say, I want to be able to provide a team-based approach to you in my primary care practice, in my hospital setting, and yet I tell you that you’re going to have to figure out some type of really creative workaround to pay for that, most people are not going to do it. So we have to have really comprehensive and strategies on addressing payment. Skip to the end here. Recommendations for payment are really basic. If we want to tackle pain and tackle it in the moment that people actually need that care, we’ve got to have some type of incentive for a team approach to care. This is not about figuring out another code. This is not about paying another provider more. This is about paying for that team to take care of the person. We’ve got to figure out a way to incentivize this and to support the quality and the outcomes that people are actually needing right now. Thank you. SARAH DASH: Thank you, Ben. So we’ll turn next to Dr. Eric Schoomaker. DR. ERIC SCHOOMAKER: Thank you. Thank you. It’s a privilege to be here today and I especially appreciate all of you coming out today and seeing so many of you in the audience because I think, to echo what everyone of the folks have said from the dais today, this is a crippling problem for the nation as a whole and it begins with pain. I want to endorse and embrace everything that Ben has said here—can I call you Ben? DR. MILLER: Yeah, please. DR. SCHOOMAKER: You can call me Eric. Because fundamentally, to go back to what he started off with, this emanates from pain. We know from the Centers of Disease Control that the problems with opioids in the country today emanate, in the main, from pain, and inaccurately and improperly treated pain. Pain is at the source of this epidemic and I usually, when talking to audiences like, this start off by talking about the example of John Snow, an epidemiologist – father of epidemiology – and an anesthesiologist in London in 1853, who first realized that you can’t solve the problem of a cholera epidemic by just treating cholera victims. You have to go and find the source of the epidemic. And he found the Broad Street pump, realized that it was the common source of water for almost every victim of cholera in London at that time. They had washed a contaminated diaper in a small depression about three feet from the pump, it became contaminated and that was the source of the epidemic. We are in an epidemic of opioid addiction, but the solution is not just to attack opioids, it’s to attack pain. I want to also reinforce something that Ben said. We now know something we didn’t know maybe 30 years ago, that acute pain and chronic pain are two different states. Chronic pain is not a symptom of another problem, it is a brain disease. When we’ve had pain for a period of weeks to months and we go through a process called “chronification,” and when we do that, the pain is not sighted in tissue disruption and no susceptive nerve injury, it’s sighted in the brain. And it interacts between the emotional basis of the brain, the limbic system, sources of memory and it’s as idiosyncratic and fingerprinted across different patients as much as fingerprints are different across patients. And so every patient, as Ben said, has to be treated in a patient-centric way that addresses the individual needs of that patient. Their memories of pain, their experience with pain, their sources of pain and the like. I’m going to talk about changing this culture of how we approach pain, and I use that term deliberately because all of the major studies that have been done, whether it was done by the military that we are a part of, or by the Institute of Medicine, now the National Academy of Medicine, have highlighted the fact that we have to change the culture of how we approach pain. This is just an image to kind of blend together the complexity of where pain comes from in our soldiers and our veterans to include the psychological and emotional impacts of being separated from family, their loss of friends, the exposure to, what I think is, the signature weapon of these wars, which is blast. I don’t endorse a signature wound, but certainly the signature weapon and then how we’ve been approaching this in the form of complementary approaches. I’m obliged to say I have these disclosures and disclaimers. The second point is pretty important. We only embrace, and through the help of the Congress, are compelled within the DOD only to adopt standards of practice that have evidence behind them that have FDA approval and the like, and so nothing I’m going to talk about today is smoking mirrors; I’m talking today about good evidence based practices. And I don’t know who speaks for the DOD in my university, but I’m certainly not that person. These are all my personal thoughts. Okay. We knew that you wouldn’t have any difficult identifying the fact that combat wounds and injuries in combat, which by the way, exceed the number of wounds, it’s always illnesses and injuries that get our soldiers, sailors, airmen, Marines and Coast Guardsmen, are the source of much of the pain that they experience, but I wanted you also to be aware, ignore the complexity of this slide. Look not at the lyrics but at the melody, and the melody here is over the course of a decade or more from actual data drawn from ambulatory visits, you can see while the prevalence and incidence of cardiovascular disease, kidney disease and others remain pretty static, the incidence of musculoskeletal complaints and of mental health disorders rose dramatically starting about mid odds. And those musculoskeletal complaints are not because of combat wounds necessarily, although they’re related, they’re because we are stressing a force, unlike we ever have before, light infantrymen in the Marines or the Army, and Air Force targeter, are carrying on average 120 pounds and often operating above 8,000 or 10,000 feet and that are doing this on multiple rotations and so they get injuries. Sports injuries are still the most common problem that we face, and so we’re not unlike any other force. This is just to emphasize something that also Ben brought up, and that is, this is a study in the VA but it’s been duplicated with tens of thousands of patients since then, that if you look at the prevalence of pain in intersection with post traumatic stress disorder and traumatic brain injury of concussive form, mild traumatic brain injury, what you find is, chronic pain rarely exists alone. It exists in a comorbid state with psychological problems and with TBI. The fact is, it’s a minority of the cases in which you have pain alone, or even post traumatic stress disorder or concussion alone. So we’re taking care of a very complex group of patients with very complex biopsychosocial problems. We established a task for in around 2008, 2009 that published a comprehensive pain management strategy. We realized that we were faced with an unprecedented pressure to manage chronic pain and came up with, through objective studies of both the literature and our system, of the need for a holistic multi disciplinary and multi modal approach to that that use state of the art evidence based practices that focused on optimal quality of care and function of our people, patients – both our family members and our soldiers – for managing that. About a year later, the Institute of Medicine, now the National Academy of Medicine, launched a similar study that looked at the whole nation, not just the military’s problem, and came up with a very similar set of recommendations. And among them was, we don’t need to abandon opioids. I’m not an anti-opioid person. If I’m in a major traffic accident, or if I break my leg, or if I’m an IAD explosion, I’m not going to shout: “Give me acupuncture.” I’m going to ask for morphine and I want it there. The same for any major trauma. What we’re saying is, this is not the panacea that it’s been cast to be. This is a very important slide because it shows the intersection and interaction among the federal medical partners in this. On the top you’re going to see different organizations and on the bottom you’re going to see products, in the middle is the time line. It began actually with the VA, and I can’t speak for the VA, but the VA has been one of the leaders here. The VA saw this problem early, they attacked it early, they established a step care model that is multi modal, multi disciplinary, team based in its approach, and incremental in its application, and published those. Our task force resulted in a product as well. The Institute of Medicine then followed with the report I just talked about. At the same time, the National Institutes of Health had organized an Interagency Pain Research Coordinating Council, known as the IPRCC, with federal members from the services as well as the NIH and about that time, the secretary of HHS came to this coordinating committee and said, look, since you’re already working on research efforts, you come up with a national pain strategy that’s going to apply the principles that we’re outlining in the Institute of Medicine. And the results of that, as I’ll show you in just a second, were the national pain strategy. At the same time, the National Center for Complementary and Alternative Medicine, the NCCAM, now known as the National Center for Complementary and Integrative Health, this isn’t about creating an alternative universe, this is about integrating complementary practices into conventional practices, and it’s not just about medical treatments, it’s about maintaining and promoting health and well being. So many of these complementary practices need to be integrated at the self care level. They then established, through the leadership of Dr. Josie Briggs, the Director, an effort to use the platforms of the VA and the DOD to advance research in evidence based approaches of complementary practices in chronic pain. We’ve looked at this in the military health system, we now have the publication of the national pain strategy out of the IPRCC and others, which resulted in the Presidential Memorandum to start looking carefully at opioids and other approaches to pain management, the CARA Act and, of course, the CDC opioid guidelines. But I want to stress again that this isn’t about just regulating opioids, and it certainly isn’t about swinging the pendulum back to a state in which we don’t manage pain with opioids; it’s rather to look at the whole person and the whole package. If we have one thing that we would recommend, it’s that we adopt, across the country, a pain assessment tool that gets us away from the thing that every one of you – Ben had you all raise your hands if you had pain – if you’ve had pain, you know if you go to a clinic or a hospital or see a doctor or anybody, the first thing, the last thing, and everything in between is the question: Are you in pain and what number is it? Well, that has no utility. In an 11-step analog model from zero to 10 has no utility if it’s not linked to function, if it’s not linked to functional impairment. And so we have adopted, with the help of the VA, a common language. We’ve adopted the Defense and Veteran’s Pain Rating Scale. You’ll see the familiar 11-step analog scale with the faces, but you’ll also see that every one of those steps is described in terms of a functional decay, so you can’t be at 10-level pain sitting eating your lunch and watching TV. You’ve got to have a major disruption in function and, very important on the flip side of this card, begins to look at the major interference that pain causes sleep, activity, mood, and stress. Is your pain causing you stress? Is it interfering with your sleep and the like? This causes a whole different dialog to occur between the providing team and the patient because you can find patients who have stable 4-, 5-, 6-level pain but are now getting sleep, now eating, are not interfering with their activity. That’s a success. Whereas driving toward pain of zero is only accomplished by putting people to sleep and having them, you know, inactive and non conversant on the carpet. So those are my thoughts. Thank you very much. SARAH DASH: Great. Thank you very much. And before we move on to our next two presentations which I very much want to hear, I just want to ask a little bit of a clarifying question and maybe either Dr. Miller or Dr. Schoomaker can kind of jump in here, but you both made the distinction between acute pain and chronic pain. Are there distinctions in the medical literature between the different types of pain? Is there more acute pain than chronic pain? We’ve also, you know, I think, out there, probably heard the term “chronic non cancer pain,” cancer pain is perhaps different. Can you kind of just spell that out for us a little bit more and then if Dr. Schoomaker, if you could kind of tell us a little bit more about the scale on the standardized pain assessment, does that cover all those kinds of pain? Is that kind of a way to address people’s pain whether it’s in the moment, acute, or a more chronic kind of issue? DR. MILLER: Okay. We’ll make it really, really s