Welcome to the Integrative Pain Care Policy Congress Blog!
Brought together by their collective agreement that comprehensive integrative pain management is the best approach to caring for people with pain, and that none of us can properly advance this kind of care alone, the Integrative Pain Care Policy Congress is made up of leaders from more than 50 organizations (and growing!) representing the full scope of licensed and certified health care providers, public and private payers, policy experts, and pain research and patient advocacy organizations.
Are you or your organization interested in joining the Policy Congress, or would you like to receive email updates when this blog is updated? Contact Amy Goldstein for more information.
Posted By Omar Manejwala, M.D.,
Wednesday, April 25, 2018
We have no right to help one set of patients while harming another. With media attention on the opioid overdose crisis and widespread efforts to reduce opioid prescribing implemented across systems of care, there is a real risk that people who are suffering from chronic pain are being forgotten—or worse—vilified. In the chaos of competing ideas about how to address these twin crises, the Academy of Integrative Pain Management launched an ambitious effort—a “policy congress” in October 2017 that invited the ideas and active participation of the major stakeholders—even including those experiencing chronic pain themselves. The group was tasked to answer one question: what is comprehensive integrative pain management? This deceptively simple question led to several more. Is it medical or psychological? What is the role of spirituality in recovery? What about complementary approaches?
Among other areas of consensus, policy congress participants generally seemed to agree with the idea that behavioral drivers play a key role. In my recent article, How Behavioral Conditions Worsen Chronic Pain, I explore how behavioral conditions worsen chronic pain and how we might better integrate behavioral healthcare in our approaches to managing this challenging condition.
Interest in comprehensive, integrative pain management continues to skyrocket. In the past month, we have seen many related opportunities arise that have the potential to truly shift the state of pain care in the United States.
Helping clinicians to understand the need to utilize comprehensive, integrative pain management
Reframing the Primary Care Management of Chronic Pain on April 23rd
Caring for our Military: Considering Non-drug Therapies for Pain on June 4th
Improving government funding for pain research
The National Institute on Drug Abuse and National Center for Complementary and Integrative Health have announced a funding opportunity titled Exploring Epigenomic or Non-Coding RNA Regulation in the Development, Maintenance, or Treatment of Chronic Pain. The purpose of this initiative is to encourage research that investigates the role of epigenetic or non-coding RNA regulatory pathways in the development, maintenance, or treatment of chronic pain, ultimately providing foundational knowledge that can be used to develop novel and non-addictive pain medications or to develop biomarkers that predict chronic pain progression or treatment response.
The National Institutes of Health has launched the HEAL Initiative. Toward this effort, NIH is nearly doubling funding for research on opioid misuse/addiction and pain from approximately $600 million in fiscal year 2016 to $1.1 billion in fiscal year 2018. In part, the initiative will: define and support best practices for pain management using nondrug and integrated therapies for specific pain conditions; pursue public-private partnerships to develop new non-addictive pain medicines; and, launch a longitudinal study to follow patients 1) after acute onset of musculoskeletal pain, and 2) after surgery to identify biomarkers that might predict which individuals are more likely to transition from acute to chronic pain.
Moving legislation forward to improve coverage of integrative care
The ACE Research Act (HR 5002/S 2406) aims to provide NIH with the necessary tools and flexibility to support innovative medical research. It would enable the Director of NIH to more quickly and efficiently support research on new, non-addictive treatments for pain. Further, NIH will be able to more easily partner with innovative companies with cutting-edge technology to address the opioid overdose epidemic and other public health concerns. Multiple members of the Integrative Pain Care Policy Congress recently signed on in support of this bill.
Many state legislatures are currently considering legislation that would improve coverage of comprehensive, integrative pain management. You can find pain-related legislation sorted by state and by issue in AIPM’s legislation trackers. Some of the many bills of interest include:
RI S 2537, an act that would require health insurers to provide coverage for physical therapy, occupational therapy, massage therapy, and the healing art of acupuncture and oriental medicine.
VT S 224, an act that would allow health insurers to subject health care services provided by a chiropractic physician to co-payments, but only so long as those co-payments are not greater than the amount of the co-payment applicable to care and services provided by a primary care provider under the plan.
MO SB 597, an act that would expand MO HealthNet payments to include up to twenty (20) visits per year for services limited to examinations, diagnoses, adjustments, and manipulations and treatments of malpositioned articulations and structures of the body provided by licensed chiropractic physicians practicing within their scope of practice.
NY SB 5764, an act that would prohibit insurers from imposing co-payments for physical or occupational therapy greater than the co-pay for similar services provided by a physician.
As a result of feedback from the participants of the Integrative Pain Care Policy Congress, we are beginning three new workgroups to implement focused action steps to advance comprehensive, integrative pain care and address our nation’s challenges with pain, opioid misuse, and mental health.Below you will find a summary of each workgroup’s first goal, the co-facilitators, and the monthly meeting schedules. If you are interested in participating in one of these workgroups and have not yet signed up, please contact Amy Goldstein.
Addressing Coverage & Constraints. This workgroup will begin with a comprehensive analysis of policy and coverage issues as they apply to pain care.Co-facilitators are Ravi Prasad, PhD, Associate Chief, Stanford University Division of Pain Medicine; and Doug Metz, DC, EVP & Chief Services Officer, American Specialty Health.
A concept outline will be shared in advance of the first meeting to be held on Tuesday, April 17, 2018 from 7-8AM PST / 8-9AM MST / 9-10AM CST / 10-11AM EST.Monthly meetings will occur at the same time on the 3rd Tuesday of each month.
Promoting Comprehensive, Integrative Pain Care. This group will begin with an analysis of successful models of comprehensive, integrative pain care, looking for common components that will inform future goals related to expanding access to this type of care.Co-facilitators are Steve Stanos, DO, President, American Academy of Pain Medicine; and Kevin Galloway, BSN, MHA, Colonel, US Army (Retired), Board member, Academy of Integrative Pain Management.
A concept outline will be shared in advance of the first meeting to be held on Wednesday, April 18, 2018 from 2-3 PST / 3-4 MST / 4-5 CST / 5-6 EST.Monthly meetings will occur at the same time on the 3rd Wednesday of each month.
Strategic Communication. This group will begin with developing easy-to-access documents with a consistent look and feel to effectively communicate and build momentum around common language and other outputs, starting with 1) further endorsements of the consensus definitionof comprehensive, integrative pain care developed at our first meeting (many of your organizations already have endorsed this); 2) creation of a more robust Integrative Pain Care Policy Congress Blog; and 3) organizing and communicating effectively around the second in-person Integrative Pain Care Policy Congress being planned for November 2018 (announcement coming soon!)Co-faciliators are Cindy Leyland, Director of Program Operations and PAINS Project Manager for Center for Practical Bioethics; and James Specker, Government & Industry Relations Director, American Massage Therapy Association.
A concept outline will be shared in advance of the first meeting to be held on Tuesday, April 10, 2018 from 11-12 PST / 12-1 MST / 1-2 CST / 2-3 EST.Monthly meetings will occur at the same time on the 2nd Tuesday of each month.
In a flurry of activity that would have shocked the integrative pain care community just a few years ago, the federal government, at both the legislative and administrative levels, continues to take a deep look at how non-opioid and non-pharmacological treatments for pain can be better utilized to treat pain and reduce reliance on opioid analgesics.
Congress Asks for Advice Related to Pain Management, Alternatives to Opioids
Following on the Senate committee’s heels, on February 27th, the House Ways and Means Committee sent a letter seeking feedback from a variety of stakeholders, asking a long list of questions related to opioids and pain management. The committee wants information related to incentives in Medicare, tools to prevent opioid abuse, medication therapy management, prescriber education, prescription monitoring programs, reimbursement, alternative options for the treatment of pain, and more. Comments are due no later than March 15, 2018.
CMS Proposes New Payment Policies, Asks for Advice re: Non-Pharmacological Interventions
Apart from the two legislative bodies responsible for overseeing CMS (both committees mentioned above), CMS itself recently asked for public comments related to their proposed payment policies for 2019. In addition to proposing new payment structures related to opioids, the proposed policy also stated that, “CMS and measure developers are exploring additional measurement concepts for future work, such as functional status, and use of non-pharmacological or non-opioid pain management interventions…” In response, AIPM submitted comments related to both limitations on opioids and the use of non-pharmacological and/or non-opioid pain management interventions.
CARA 2.0 Act of 2018
The second iteration of the Comprehensive Addiction and Recovery Act, or CARA 2.0, has been introduced by the Senate Health, Education, Labor & Pensions (HELP) Committee. The legislation is intended to make improvements to the original CARA, and while the bill-as-introduced is lacking in certain pain provisions, Senate leadership from HELP and Finance Committees have expressed their openness to the inclusion of pain-related provisions. Forty-two organizations, including numerous members of the Integrative Pain Care Policy Congress, have signed on to a document outlining what they would like to see included in the legislation related to pain. The House is also working on their own version of this legislation, and there will be a few substantive hearings later this month. More details to come soon.
Application Deadline for CMS Bundled Payments is March 12
As shared in a previous update, if you are interested in applications for the Bundled Payments for Care Improvement Advanced (BPCI Advanced) model, the application deadline is March 12, 2018.More information about this process can be found here.
Integrative Pain Care Policy Congress Next Steps
The Integrative Pain Care Policy Congress continues to make progress in working together to advance integrative pain care. Based on survey results, the Congress is launching three new workgroups: (1) Coverage and Constraints, (2) Promoting Comprehensive, Integrative Pain Care, and (3) Strategic Communication. In the surveys that helped to form these workgroups, participants also indicated their interest in helping above and beyond meeting participation and with the strategic direction of these workgroups.On that note, Workgroup leadership will be meeting by phone on March 19-20, so you can expect to hear more about these workgroups next month!
The inaugural Integrative Pain Care Policy Congress was an invitation-only meeting that brought together approximately 70 leaders from 50+ organizations representing the full scope of licensed and certified health care professionals involved in pain care, along with insurers, regulators, people with pain, researchers, and policy experts (see roster).
The expertise, effort, and resources required to develop effective plans and interventions that address the public health crises of inadequate pain treatment and opioid-related harms are far beyond the capacities of any one organization (see: Why We Came Together), so it is essential that we find ways to work together to develop areas of consensus and strategies for collaboration.
Focusing on meaningful future action for the Congress by working towards consensus policy and advocacy goals for 2018, Congress participants identified many exciting potential strategies for achieving our shared goals. Workgroups based on some of the many ideas below are currently being developed—more on these to come soon!
If you or your organization has a particular interest in any of the below ideas, or if you have other ideas that should be considered, contact Amy Goldstein.
Consistent messaging to policymakers, public, etc. (Example—one-pager re: CARA 2.0 with 38 sign-ons and growing!)
Decrease competition and confusion between the messages developed between various pain groups represented at the conference by synchronizing our respective messages.
Ensure patients are consistently represented on pain initiatives.
Develop core set of Talking Points, Position Statements, and other materials to better define the opioid epidemic and required solutions that involve pain (so that conversation not limited to addiction and to decrease competition and confusion among various groups)
Ask for a commitment from each organization that we will use common language (the consensus definition at the very least, common talking points if possible)
Data Collection / Measurement
Keep and mine data
Agreement on collection methods
Organize trials (e.g., DoD, CMS, payors)
Metrics that talk to plans (what are healthcare leaders responsible for and how can we also meet their needs (e.g., HEDIS, NCQA)
Identify minimum package of services that might be included in a comprehensive/integrative package
Pitch to Medicare new quality improvement measures related to pain
Collaborate with largest purchasers of healthcare plans
Identify high risk/complex/ high cost patient populations and allow for bundled payment options and collect outcomes
Cultural shift towards measurement-driven care
Data that crosses companies
Algorithm for how to choose modalities across pain disciplines/services
Clinical financial QOL factors
Comparative effectiveness studies
Create a spectrum of patient centric pathways to address care
Identify specifics around coverage challenges and provider network challenges to better understand current system’s failings
Education / Training
Large scale education
Comprehensive, integrative pain management
Earlier treatment / prevention for pain
Approach COE, graduate schools for pain education
Target pediatric population
Get more people with pain engaged in care
Networks and support groups for people with pain
Promoting Quality Pain Care / Outcomes
Identify exemplar programs
Identify suggested/recommended standards for outcome profiles/measurements adopted
Health related quality of life
Pilot programs (e.g., CMMI, PCORI, model studies)
Scale up successful pilots to address scaling concerns in real-life care
Identify existing demonstrations for extending kinds of care (e.g., Project ECHO, telepain, U of WA, Healing Place)
Recognition of various specialties as part of the team
Look to successful models for ideas (e.g., patient-centered medical home, palliative care, oncology care model, integrated behavioral health, collaborative care, interdisciplinary consultation)
Explore outcomes for who and what, considering biomarkers
Algorithm for choosing modalities across pain disciplines/services
Paying for outcomes
Demand VA demonstrations report out
Need outcomes to develop better coverage (e.g., PROMIS, PASTOR)
Monitor for better quality of life, functionality
Identify high risk/complex/ high cost patient populations and allow for bundled payment options and collect outcomes
Shift focus to developing and implementing pain treatment guidelines vs. opioid treatment guidelines
Consensus outcome measures
Seek telehealth modalities (when practical) to extend care to rural/underserved areas
Quality and outcomes (start with ADLs, lower pain, improve sleep, ER visits, decrease specialist not intervention)
Make it easy for frontline providers to implement (critical)
The inaugural meeting of the Integrative Pain Care Policy Congress began with 70 leaders representing 50+ organizations having dinner with one another as they thoughtfully discussed their respective concerns and shared goals related to advancing individualized care for people with pain. Attendees represented the full scope of licensed and certified health care professionals involved in pain care, along with insurers, people with pain, researchers, policymakers, and policy experts.
At dinner, each table was carefully designed to bring together diverse stakeholder viewpoints to ensure rich and balanced conversations. At one such table, for example, was a researcher, a person with pain, a policy expert, a nurse, a pharmacist, an integrative health physician, a pediatrician, a payer, and an orofacial pain specialist.
In an effort to ensure our Policy Congress advocates for the best possible policies related to integrative pain care, Congress attendees took time at dinner to discuss what other stakeholders should and/or must be included in the collective conversation as the Congress moves forward. In addition to those who were already at the table (see roster), attendees suggested a number of stakeholders that should be engaged.
Feedback could be grouped in the following ways:
Areas of interest (e.g., dental, health care educators, sleep, nutrition, food health, homeopathic medicine, yoga)
Payors (e.g, workman’s compensation, state Medicaid directors, CEO private insurance)
Government—Federal (e.g., NIH, HRSA, FDA, CMMI, White House Opioid Commission, SAMSHA, NIDA, Congresspeople)
Government—State (e.g., NAAG, NGA, state health departments, state insurance commissioners, legislators)
Patient advocacy (e.g., professional athletes, voting block, AARP, consumer organizations)
Provider organizations (e.g, family physicians, naturopathic physicians, public health association, herbalist guild, college of nutrition, addiction, pediatrics)
Pain team representatives (e.g., chaplain, first responders, orthopedic surgeons, oral surgeons, surgeons, gynecologist, rheumatologists, mentors, coaches, behavorial health, family practice, AARP dental educators)
National associations (e.g., AHIP, AHA, ASTHO, NQF, NRHA, state EMS officials)
Provider education (e.g., ACGME)
Purchasers of health care (e.g., large employer coalitions, purchaser coalition, public and private sector, employee assistance)
Who are we missing? If you know of other organizations/agencies/institutions that should be involved in developing and implementing policies related to comprehensive integrative pain management, please send your thoughts to Amy Goldstein.
What is comprehensive integrative pain management?
For years, there has been a growing consensus by a wide variety of stakeholder groups that optimal pain care is patient-centered and brings together all evidence-informed therapeutic approaches to reduce pain and achieve optimal health and healing, the health care team working in a coordinated, team-based approach on behalf of the patient. However, until the inaugural Integrative Pain Care Policy Congress, there was never a definition that varied stakeholders agreed upon to that explain precisely what this care is and what it should be called.
To best empower our collective to advocate for policies that will help all of those people whom Policy Congress attendees represent, we first needed to define what, exactly, we were advocating for by addressing the lack of a consensus definition for optimal pain management: achieving a definition was the first priority for the inaugural meeting.
Using information gleaned from pre-Congress surveys, followed up by in-person discussions and many revisions, approximately 70 leaders from 50+ participating organizations agreed on a consensus definition for “comprehensive integrative pain management”.
Comprehensive integrative pain management includes biomedical, psychosocial, complementary health, and spiritual care. It is person-centered and focuses on maximizing function and wellness. Care plans are developed through a shared decision-making model that reflects the available evidence regarding optimal clinical practice and the person’s goals and values.
Held in San Diego, California, from October 21-22, 2017, the inaugural Integrative Pain Care Policy Congress was an invitation-only meeting that brought together approximately 70 leaders from 50+ organizations representing the full scope of licensed and certified health care professionals involved in pain care, along with insurers, regulators, people with pain, researchers, and policy experts (see roster).
Our nation is facing two inter-related public health crises—chronic pain and prescription opioid misuse. To address these intertwined health crises, there is an ever-growing number of guidelines and policies intended to reduce opioid use at both the state and federal levels. While well-intentioned, these policies are impacting the health care that is available to those in need of acute and chronic pain management. Yet, often missing from the conversation surrounding the development of these policies is any talk of how to improve patient access to effective and affordable non-opioid treatments for pain, whether pharmacological or non-pharmacological.
The expertise, effort, and resources required to develop effective plans and interventions that address the public health crises of inadequate pain treatment and opioid-related harms are far beyond the capacities of any one organization, so it is essential that we find ways to work together to develop areas of consensus and strategies for collaboration. Facilitated by Academy of Integrative Pain Management and State Pain Policy Advocacy Network, in partnership with Alliance for Balanced Pain Management, Integrative Health Policy Consortium, and PAINS, the inaugural Integrative Pain Care Policy Congress provided us with the opportunity to do just that by:
Gathering, for the first time, leaders and experts representing the full scope of licensed and certified health care professionals involved in pain care, along with insurers, regulators, people with pain, researchers, and policy experts who believe that integrative pain care is essential. We aimed to highlight current successes and barriers and to discuss opportunities to jointly promote optimal models to provide this kind of care.
Connecting the dots related to past and current efforts to find quality evidence supporting reimbursement for comprehensive integrative pain management. To discuss the current state of coverage and constraints for payment, along with the most current data available on the effectiveness of these therapies for pain, the Congress facilitated conversations between CMS and private payers; clinical, policy, research leaders; health care providers; and patients.
To help kick off the inaugural in-person meeting and help each attendee understand the perspectives of the other attendees, we produced a short video. This piece included statements shared in advance by attendees and intended to answer the question: What brings us together?