ACOEM, Chronic Pain and Functional Restoration - 1

Saturday, December 3, 2005 | 0

During the last year there have been significant changes in medical treatment for California injured workers as a result of SB 899 which became law in January 2005. SB 899 has a strong focus on medical treatment perspectives. The focus is on differentiated services and providers need to be technologically savvy and sophisticated, especially in relation to chronic pain. This focus is creating significant confusion within the industry as many do not understand what is termed "Functional Restoration"; "What kind of treatment is Functional Restoration?"; and "Who has this specialized training to provide Functional Restoration?"

Lets look backwards towards SB 899, to summarize the treatment issues, and ACOEM. For clarification of the ACOEM guidelines or administrative director-adopted treatment guidelines shall have the presumption of correctness relative to extent and scope of medical treatment for all injury dates. We know that SB 899 was conceived to tackle many of the primary cost drivers and related issues regarding the state workers compensation system. The goal with SB899 was to create a greater structure around the medical care provided to injured workers, and improve the quality of care while reducing the cost of care. No longer was treatment by the physician solely dependent on the opinion of that physician who may or may not have been familiar with treating the specific body part. SB 899 addressed over-treated workers with unproven treatments. As of January 2005, Medical Provider networks were to be utilized in referrals and treatment. Further, rebuttal of the guidelines can only occur with scientific medical evidence. This was to provide the basis for utilization review certification of treatment. The treatment recommended must be accepted as reasonable by American College of Occupational and Environmental Medicine. In other words, the doctor must provide the treatment that has been determined by his peers as being the most beneficial.

This brought to light questions relative to whether or whether not ACOEM addressed Chronic Pain. ACOEM definitely addresses the issue of chronic pain. Are you aware, the word chronic pain exists in the guidelines a minimum of 263 times? That in each chapter related to a body part, the treatment algorithm addresses chronic pain? The American College of Occupational and Environment Medicine indicates pain becomes chronic anywhere from 1 month to 6 months post injury. The International Association for the Study of Pain has stated that three months is the definitional time frame, while the American Psychiatric Association uses a six month limit. The most clinically useful definition is that 'chronic pain persists beyond the usual course of healing of an acute disease or beyond a reasonable time for an injury to heal.' * (ACOEM page 107). Taking all these factors into consideration, ACOEM treatment guidelines begin to address chronic at the 4-6 weeks period of treatment. The recommendation is implementation of a pain assessment for workers not responding according to guidelines.

Research demonstrates that: "Over treatment often results in irreparable harm to the patient's socioeconomic status, home life, personal relationships, and quality of life in general. However, because opioids are 'easy' and represent a path of little resistance, they may prevent the patient, the physician, or both from vesting in a difficult and uncomfortable rehabilitation course. A physician's choice to palliate and not rehabilitate is a profound clinical, ethical, and medico-economic decision not to be taken lightly or be based on new changes in treatment unfounded dogma". *(ACOEM Chapter 6 page 106). ACOEM recommends, to avoid overtreatment, interventions should begin at this point of the treatment, 4-6 weeks. In reviewing the algorithms within ACOEM for treatment guidelines, you will find that all body areas demonstrate this same intervention at this same time period.

The result is that the guides of ACOEM, which direct treatment towards Chapter 6 are directing a change in this manner of treatment. There is now a focus on the restoration of function and a reintegration into the work force, which is aggressive multidisciplinary/interdisciplinary treatment and not passive modalities in one location (interdisciplinary). Yet the treatment protocols of this treatment are not clearly defined in Chapter 6 of ACOEM. The result is that there has been a sprouting of boutique practices claiming they provide "Functional Restoration". Beware, don't be fooled into thinking that this is a new concept and new type of practice. Functional restoration is not a new concept. It has been available for decades. Functional Restoration has always been the foundation of treatment by Physical Medicine and Rehabilitation Physicians, Physiatrists.

These new boutique practices are not a sprouting a new treatment development , but that of an intervention which has been " Gold Standard of physiatry " . The boutiques have put a new high tech look to the treatment, and in most cases they are repackaging their services under this title. Many of these boutique practices do not have the specialized knowledge and training, including the interdisciplinary staff in one location and case management routine meetings all require a functional restoration program. These boutique practices are diverting these patients from the level of care that ACOEM recommends.

Overall , a majority of these boutique practices are just providing past negative treatment under a new name. They are attracting payors due to their offer of reduced payments. These payors, who are trying to shortcut with costs, are losing the main focus of SB 899 quality of treatment vs. cost of treatment. What may seem less in cost with these programs in all reality could increase the treatment costs significantly. Boutique facilities can offer fees that are less than the long established facilities, due to the lack of presence of professionals with the training and specialization of these long standing facilities, thus affecting the ability to achieve an improved quality living for the injured worker.

ACOEM states: "Research has shown that an interdisciplinary approach to pain management is significantly more effective than either no treatment or conventional, unimodal intervention in treating patients with chronic pain and improving their quality of life". For many injured workers, pain is short-lived, lasting a few weeks or months, and becoming a faded distant memory. Why is it not for others, the pain never goes away, it lingers like a specter, affecting a persons ability to work, have fun, and live?

After an extensive review of the literature available, not only literature utilized by ACOEM, but that of the Physical Medicine and Rehabilitation Specialty, Pain Management Associations, and published works on Pain Management by Wall, Melzack, Losser, Turk, Weiner, Tollinson, this article presents a summary of what is provided as implementation guidelines to treatment of chronic pain within a functional restoration concept as described in Chapter 5 and Chapter 6 of ACOEM guidelines.

Most primary care physician and payers are unsure as how to :
* From a PCP, how to perform a pain assessment, or even have the time.
* Interpret the results of the assessment.
* How is a pain assessment coded for payment?
* What is functional restoration?
* Where are these programs ?
* What should we expect relative to treatment and costs?

ACOEM with its accepted guidelines recognizes chronic pain and the need for specialization to treat this diagnosis, although it does not provide guides for implementation. ACOEM indicates: "For chronic pain sufferers the pain will remain for life. For these individuals they require education and treatment that teaches them that this pain does not have to affects their ability to function. They require a treatment that is tailored to their physical needed and is of a psychosocial basis. Successful pain management hinges on appreciating the dynamics of each patient's case and on proactively managing factors that might delay return to work or restoration of function. The immediate focus should be on functional improvement rather than on abolishing pain." *(ACOEM page 107)

Result studies are beginning to demonstrate that the payers in the workers compensation system are applying the ACOEM guidelines inconsistently. There are physicians who are not appropriately following the guidelines relative to the extent of assessment, the pain assessment, if recovery does not occur.

The Pain Assessment: How many primary care physicians can perform this assessment? Not many have the training or the time. The assessment is detailed, time consuming, a commodity that many physician do not have to dedicate to this assessment. The reimbursement for the assessment is not consistent with the time required. The Pain Assessment is hinder by two factors: The injured worker requires a pain assessment by an practioner who understands the process, the reasoning behind many of the questions, and what the results demonstrate; The reimbursement does not offset the costs in both monetary costs and time.

With the above factors considered, you now have an overall shortage of specialized trained practitioners who understand the pain assessment, and are willing to accept the reimbursement. There is a further complication with the number of functional restoration pain management facilities declining over the years. They are costly to operate, require specially trained personal, and with reductions in reimbursement it has been difficult for many Centers to remain viable. Currently, (demonstrated by studies of Market Data Enterprises), the number of U.S. pain management practitioners appears to be leveling off, after growing strongly through 2001. The number estimated by Market Data Enterprises has dropped slightly, from 3,800 two years ago to an estimated 3,549 programs operating today in the United States. Their research demonstrates that due to the shortage, there are facilities currently with a waiting list of 600 patients that equals approximately a two year wait. All of this makes it extremely difficult to implement the appropriate treatment.

Part 2 orf this series will review what functional restoration is and why there is a need for specialization.

Article by Brenda Klass, Care Center Rehab and Pain Mgmt. She can be reached at 818 784-0990, or by e-mail at BKlass@CareCtr.com.



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