PRIMARY CARE & HEALTH SERVICES SECTION

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1 Pain Medicine 2015; 16: Wiley Periodicals, Inc. PRIMARY CARE & HEALTH SERVICES SECTION Original Research Article Economic Analysis of a Comprehensive Pain Rehabilitation Program: A Collaboration Between Florida Blue and Mayo Clinic Florida Christopher D. Sletten, PhD,* Svetlana Kurklinsky, PhD,* Vijit Chinburapa, PhD, CPHQ, and Salim Ghazi, MD* *Department of Pain Medicine, Mayo Clinic Florida, Jacksonville, FL 32224, USA; Health Care Economics, Florida Blue, Jacksonville, FL 32246, USA Reprint requests to: Svetlana Kurklinsky, PhD, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA, Tel: ; Fax: ; kurklinsky.svetlana@mayo.edu. Clinical Research Fellowship Financial Support Provided by St. Jude Medical (S.K.) Funding sources: The study was approved by the Mayo Clinic s Institutional Regulatory Board (IRB) # VC 2015 The Authors Pain and Medicine Published by Wiley Periodicals, Inc. This is an open access article under the terms of the Creative Commons Attribution-Non-Commercial- NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Abstract Objective. The cost of caring for patients with chronic pain conditions poses a significant burden to both the healthcare system and patients. We were interested in analyzing the financial costs and benefits of treating these patients in a comprehensive outpatient pain rehabilitation program. Design. All participants completed the 3-week outpatient Mayo Clinic Florida Pain Rehabilitation Program (PRC) between October 2011 and September Healthcare costs were compared during the 3-, 6-, 12-, and 18-month periods pre- and post-treatment. Patients. The sample included 53 patients. Results. Medical costs decreased by 86, 68, 64, and 90% in the 3-, 6-, 12-, and 18-month post-treatment periods, respectively, when compared with the same pretreatment periods. Conclusions. The appropriate use of a comprehensive outpatient rehabilitation program for chronic pain patients can result in a significant reduction in medical costs. Key Words. Chronic Pain; Multidisciplinary Chronic Pain Rehabilitation Program; Cost Benefit Analysis Background Chronic pain is a prevalent and expensive health problem affecting between 20% and 40% of the population at any point in time [1]. The financial burden of chronic pain on the health care system is staggering. In a study by Gaskin and Richard [2], the combined cost of health care expenses and decreased productivity ranged from $560 to $635 billion dollars annually (2,010 dollars). This estimate is considered conservative as the authors did not include nursing home patients, children, military personnel, and incarcerated individuals. Several studies have been completed to catalog the costs and potential economic benefits of various treatments for chronic pain. The majority of these studies have focused on low back pain. Studies from both Europe and the United States have shown that this specific type of chronic pain is costly from a health care utilization and worker productivity perspective [1 4]. As reported previously [3], there are significant limitations in the generalizability of these reports. The definition and comprehensiveness of the treatments vary widely as do 898

2 Economic Analysis of a CPRP the health economics of the particular country in which the studies were conducted. Many of these studies have also relied on economic modeling vs true monetary costs. There are no recent studies that have used actual cost data from health care insurers. In an earlier study, Simmons et al. [5], showed that a comprehensive pain rehabilitation program (CPRP) reduced real health care costs by 59.2%. These authors compared pretreatment and post-treatment costs for patients that completed a 2-week outpatient pain rehabilitation program. It has been well-established that CPRPs have a significant therapeutic impact on patients with chronic nonmalignant pain [6 11]. These programs use a multidisciplinary approach with an emphasis on physical reconditioning, cognitive behavioral interventions and weaning of opiate analgesic medications. Typically there is active involvement from physicians, psychologists, physical therapists, occupational therapists, and nurses. Patients are instructed and encouraged to regain independence and increase self-care. Patients treated in CPRPs have a long history of chronic pain, with an average duration of 8 years [9]. With the long duration of pain and significant levels of disability and comorbidity, come significant medical costs, and expenditures. Turk [11] thoroughly defined the relative costs and benefits of typical pain interventions including drug therapies, interventional pain management, surgery, and pain rehabilitation. He concluded that CPRPs have a broader base of benefits and fewer overall costs relative to the other interventions reviewed. The economic issues surrounding the treatment of chronic pain have continued to escalate. In the past decade, the proliferation of interventional pain clinics, backed by newer technology, and procedures with additional classes of drugs have led to even greater costs for patients and insurers [12 14]. We were interested in evaluating how effective a CPRP would be at reducing medical costs in real dollars spent. Like other CPRPs, the targeted goals at the Mayo Clinic Florida Pain Rehabilitation Center (PRC) include: physical reconditioning, improving emotional and behavioral functioning, reduction and elimination of pain medications, and educating patients about being better health care consumers. Patients referred to the PRC are evaluated by a Pain Psychologist to establish the patient s candidacy for the program. The program is a 3-week day treatment program that runs Monday to Friday from 8:00 to 4:30. On a daily basis patients engage in physical therapy (PT) that focuses on gradual physical strengthening, proper body mechanics, and cardiovascular conditioning. Patients participate in three 1 hour group therapy sessions per day. The topics of these groups include, stress management, sleep strategies, and cognitive behavior therapy. The patients have three sessions of biofeedback during the course of their treatment and 1 hour of occupational therapy groups per day. One of the explicit goals of the program is to encourage the patient to use primary health care as the mainstay of their medical team. Related to this, patients are encouraged not to pursue further specialty care for their chronic pain conditions. The Mayo Clinic PRC is one of the oldest and largest of its kind in the country. Since its creation in 1974, at the Mayo Clinic in Rochester, Minnesota has treated more than 5,000 patients. In October of 2011, Mayo Clinic PRC expanded to the Florida campus in Jacksonville, Florida with a current capacity of 400 patients annually. This study was based on a joint collaboration between the Mayo Clinic Florida and Florida Blue. The goal of this study was to analyze health care costs in actual dollars spent by a large health insurance provider. We analyzed pre- and post-treatment data for the patients who completed the PRC between October 2011 and September Objective The study evaluated the impact of participation in comprehensive outpatient rehabilitation program on health care services utilization and associated costs and utilization outcomes. Methodology The study used a retrospective cohort with pre- and postintervention analysis to compare health care services utilization and associated medical and pharmacy costs. We examined whether Florida Blue patients who participated in the PRC had a significant reduction in medical and pharmacy costs. We analyzed costs associated with selected classes of medications. Medical costs were analyzed for primary care, speciality care, emergency room visits, durable medical equipment (DME) claims, PT, occupation therapy (OT), and chiropractic claims. The analysis was done at four intervals: 3-, 6-, 12-, and 18- months before and after the PRC treatment. Participants Data from Florida Blue patients who participated in the PRC in Mayo Clinic Florida between October 2011 and September of 2013 were analyzed. Patients were referred by physicians from a broad range of specialties who are members of a large tertiary care practice. These patients were evaluated by a pain psychologist prior to admission. Criteria for admission included, chronic pain that was refractory to usual interventions, impairment in daily functioning, deconditioning, and interest/acceptance of the need for pain rehabilitation. Only patients with severe psychiatric impairment and/or cognitive impairment were excluded. Data sources included medical and pharmacy claims, eligibility/enrollment, and encounter records. We used the following inclusion criteria: 899

3 Sletten et al. 1. Continuously enrolled with Florida Blue during the specified 3-, 6-, 12-, or 18-month period before and after the last date of PRC participation. 2. Pharmacy benefits for the analysis of pharmacy services utilization and costs were available. Data Total medical and pharmacy costs included costs paid by the health plan, coinsurance, copay, and deductibles paid by patients. As costs for different patients were analyzed in different years, the Bureau of Labor Statistics medical services and medical care components of the consumer price index was used to adjust medical and pharmacy costs for inflation. All costs were reported in August 2013 dollars representing the end of the study time period. The Florida Blue professional and institutional claims data were assigned to various categories of services based on the current procedural terminology (CPT) codes, revenue codes, provider type, and physician specialty. Primary care visits and specialist visits were identified from professional claims based on Florida Blue assigned indicator from evaluation and management CPT codes and physician specialty. Emergency room visits were identified from institutional claims based on revenue codes. Emergency room visits that were associated with inpatient admissions were not included. DME usage was identified from professional and institutional claims and was classified based on a combination of CPT codes based on Berenson Eggers type of service classification, Florida Blue assigned indicator for DME, and provider type. PT, occupational therapy, and chiropractic claims were identified from professional and institutional claims based on a combination of CPT codes, Florida Blue assigned indicator, and physician specialty. Prescriptions for psychotherapeutic drugs, sedative hypnotic drugs, and analgesic drugs were identified from pharmacy claims based on American Hospital Formulary Service (AHFS) therapeutic drugs classification system. Analysis Generalized estimating equations statistical model were used to model correlated data to compare health care costs and utilization outcomes comparing the pre- and post-treatment periods of the program. Study outcomes were compared within the same individuals over time and were not adjusted for other characteristics. The generalized linear model based on a gamma distribution was used to model medical costs, total pharmacy costs, and pharmacy costs for psychotherapeutic drugs, sedative hypnotic drugs, and analgesic drugs. The generalized linear model based on a negative binomial distribution was used to model rate of primary care visits, specialist visits, emergency room visits, DME use, PT/OT and chiropractic claims, and number of prescriptions for psychotherapeutic drugs, sedative hypnotic drugs, and opiate analgesic drugs. All statistical analyses were performed using SAS version 9.3. The results were considered marginally significant at 0.1 level and statistically significant at 0.05 level. Results Data for 53 patients were available. Three patients did not have eligibility/enrollment data and were excluded. Of 50 remaining patients, nine with a 3-month posttreatment period beyond the cutoff date of August 31, 2013 were excluded. Three patients were considered outliers as they had pre- or postend period medical and pharmacy costs greater than three standard deviations from the mean. In these three cases, there were high medical costs for nonpain medical conditions and were thus beyond the focus of our treatment. These costs included chemotherapy, pulmonary interventions, and hospitalization for severe lung disease, and neurosurgery for mononeuritis. After excluding these, a total of 33, 25, 16, and 5 patients met the criteria and were included in the comparative analysis of the 3-, 6-, 12-, and 18-month pre- and post-treatment periods, respectively. For the analysis of pharmacy costs and utilization, 16, 11, 10, and 3 patients met the criteria with pharmacy benefits and were included in the analysis of 3-, 6-, 12-, and 18-month pre- and post-treatment periods, respectively. Patients included in the analysis were continuously enrolled during the pre- and post-treatment periods, and none of the periods extended beyond August 31, The admitting pain categories in order from most to least frequent were; back pain, headache, chronic pain syndrome, joint pain, neck pain, fibromyalgia, and abdominal pain. These diagnoses and their frequency are consistent with previous reports from Mayo Clinic PRC [9,10]. The results indicated a statistically (P < 0.05) or marginally (P < 0.1) significant decrease in medical costs during the 3-, 6-, 12-, and 18-month post-treatment periods compared with the 3-, 6-, 12-, and 18-month pretreatment periods. Medical costs decreased by 86, 68, 64, and 90% during the 3-, 6-, 12-, and 18-month post-treatment periods compared with the 3-, 6-, 12-, and 18- month pretreatment periods (Table 1). Rates of primary care visits were statistically unchanged during the 3-, 6-, and 12-month post-treatment periods, but were marginally decreased (33%; P < 0.1) during the 18-month posttreatment period relative to the 18-month pretreatment period (Table 2). The number of specialist visits was not significantly decreased (17%) during the 3-month posttreatment period, but was significantly decreased (34, 39, and 51%) during the 6-, 12-, and 18-month post-treatment periods compared with the 3-, 6-, 12-, and 18- month pretreatment periods, respectively (Table 2). Frequency of emergency room visits, DME claims, and PT/ OT/chiropractic claims decreased comparing each of the 900

4 Economic Analysis of a CPRP Table 1 Healthcare costs 3-Months pre- and 3-months post-program end date 6-Months pre - and 6-months post-program end date Average medical cost 33 $13,557 $1, **** 25 $21,481 $6, ** Average total pharmacy cost 16 $1,702 $1, NS 11 $4,265 $3, NS Average cost for psychotherapetic drugs 16 $262 $ NS 11 $487 $ NS Average cost for sedative-hyptonic drugs 16 $66 $ NS 11 $164 $ NS Average cost for analgesic drugs 16 $191 $ NS 11 $358 $ * 12-Months pre- and 12-months post-program end date 18-Months pre- and 18-months post-program end date of patients Pre- Post- Average medical cost 16 $46,886 $16, * 5 $106,528 $9, * Average total pharmacy cost 10 $9,376 $5, ** 3 $12,546 $3, NS Average cost for psychotherapetic drugs 10 $1,456 $1, NS 3 $1,252 $ NS Average cost for sedative-hyptonic drugs 10 $307 $ NS 3 $441 $ NS Average cost for analgesic drugs 10 $675 $ ** 3 $903 $ NS Unadjusted comparison of 3-, 6-, 12-, and 18-month pre- and postend date study outcomes associated with participating in PRC NS 5 not statistically significant; NA 5 due to zero Emergency department visit (ER) visits in the 3-month post-period, statistical test result was not available. *Ratio of observed outcome in the 3-, 6-, 12-, and 18-months postprogram end date relative to 3-, 6-, 12-, and 18-months preperiod, respectively. ****P < 0.001, ***P < 0.01, **P < 0.05, *P <

5 Sletten et al. Table 2 Frequency of healthcare utilization 3-months pre- and 3-months post-program end date 6-months pre- and 6-months post-program end date of patients Pre- Post- of patie nts Pre- Post- Average number of primary care visits NS NS Average number of specialist visits NS ** Average number of ER visits NA NA NS Average number of DME claims NS ** Average number of PT/OT/Chiropractic claims *** NS Average number of prescriptions for psychotherapeutic drugs NS NS Average number of prescriptions for sedative-hypnotic drugs * NS Average number of prescriptions for analgesic drugs * NS 12-months pre- and 12-months post-program end date 18-months pre- and 18-months post-program end date Average number of primary care visits NS * Average number of specialist visits ** ** Average number of ER visits NS NS Average number of DME claims ** NS Average number of PT/OT/Chiropractic claims NS NS Average number of prescriptions for psychotherapeutic drugs NS NS Average number of prescriptions for sedative-hypnotic drugs NS NS Average number of prescriptions for analgesic drugs ** NS Unadjusted comparison of 3-, 6-, 12-, and 18-month pre- and postend date study outcomes associated with participating in PRC. NS 5 not statistically significant; NA 5 due to zero ER visits in the 3-month post-period, statistical test result was not available. *Ratio of observed outcome in the 3-, 6-, 12-, and 18-months postprogram end date relative to 3-, 6-, 12-, and 18-months preperiod, respectively. ****P < 0.001, ***P < 0.01, **P < 0.05, *P <

6 Economic Analysis of a CPRP post-treatment periods with the equal-length pretreatment periods, although the decrease was not statistically significant across all time periods (Table 2). Average pharmacy cost per member with pharmacy benefits was not significantly decreased during the 3-, 6-, and 18-month post-treatment periods, but was significantly decreased (42%; P < 0.01) during the 12- month post-treatment period compared with the 12- month pretreatment period (Table 1). Overall, the average costs and number of prescriptions for sedative hypnotic and analgesic drugs decreased during each of the four studied post-treatment periods compared with the pretreatment periods, although the decrease was not statistically significant across all time periods. For the 3- and 6-month time periods, not all costs and utilization of the studied outcomes decreased during the post-treatment periods compared with the pretreatment periods. However, during the 12- and 18-month posttreatment periods of the program, all of the health care costs and utilization of studied outcomes decreased in the 12- and 18-month postend period of the program, although the decrease was not statistically significant across all measures. Discussion The clinical efficacy of CPRP s has been wellestablished [6,10,11]. There is also good evidence indicating the economic benefits of such an approach [7,11]. Patients have demonstrated less health care utilization and better functioning following participation in these programs [5,11]. This study represents a novel approach to assessing health utilization behavior and costs for this patient population (in real dollars) before and after a 3-week CPRP. The results of this study support the hypothesis that treating patients in a CPRP does reduce medical utilization behavior and costs to the health care system. While there was limited data available for the full 18-month analysis, these results demonstrate specific decreases in medical utilization and the costs of medical care. Patients treated in the PRC are medically complex, physically deconditioned, and often exhibit high levels of emotional distress [10,11]. They were treated with a comprehensive, multidisciplinary approach that included physical reconditioning, withdrawal from psychoactive medications, and health behavior interventions. It was, therefore, expected that successful outcomes of the program would include not only less distress and daily impairment but also a change in health care utilization. These results offer good support for the success of the treatment goals both in behavior change and the cost of care. When health care utilization was evaluated, patients demonstrated successful, and durable decreases in seeking specialty care. They also were consistent in their use of primary care for their health care needs. This change in behavior is a specific target of the program. One additional advantage not directly assessed in this study is the impact on the cost incurred by specialty care: not only did these patients have fewer visits, but also decreased the frequency of more costly diagnostic tests, and interventions (Table 2). Overall, pharmacy costs and utilization did not consistently decrease at a statistically significant level. There was an average decline in prescriptions of approximately 50% for sedative hypnotic drugs, and 60% for analgesic drugs over the length of the study, resulting in cost reduction for these medications. The rate and cost of psychotherapeutic drugs was stable. These results are expected as their use is consistent with chronic pain management strategies. Another facet of the use of psychotherapeutic drugs is the type of drugs used. This issue is beyond the scope of this analysis. However, patients completing this program are weaned from benzodiazepines and stimulants and often left on their antidepressant regimen (Table 2). The analysis of health care costs is summarized in Tables 1 and 2. All of the intervals analyzed show marginal to highly significant decreases in overall medical costs. The greatest cost savings is in the first 3 months. However, even at the 18-month interval, there was still notable cost savings. At 18 months, there is nearly a $100, decrease for the five patients that remained in the analysis. Based on general reimbursement trends, the cost of the program is recovered within the first 6 months post-program. In total, this study has demonstrated that patients completing a CPRP show decreases in health care utilization behavior and medical costs. While the initial cost of such a program is significant, the long-term savings in real dollars cannot be ignored. The results of this study are also consistent with emerging models of health care that emphasize self-management and primary care for chronic conditions. Moving away from specialty care reduces cost and medical utilization in this population of patients. It should also be noted that the population studied represents a broad range of chronic pain conditions. This is in contrast with previous studies that largely focused on low back pain [3]. Finally, the collaboration between a major health insurance company, Florida Blue and the Mayo Clinic Florida represent new possibilities for addressing complex medical populations and the incorporation of real economic data into the treatment literature. In deference to the positive conclusions, there are some important limitations of this study. Because this was a preliminary financial analysis we did not include more specific patient characteristics or the specific parameters of the patient s health plans. We also intentionally focused on the economic data without incorporating specific clinical outcomes. Finally the absence of randomization and a control group created a potential for selection bias. There is a possibility of the regression 903

7 Sletten et al. toward the mean creating an appearance of reducing costs over time. However, the observed decline in medical costs was observed across all time periods and was concurrent with the decline in utilization of key service components. Finally, because of the time constraints of the study, not all patients were included in every level of analysis. We acknowledge that the decrease in sample size by the 18-month time period limits the statistical power of the analysis. However, even with a small sample there is still clear evidence that there is an enduring economic effect of this treatment approach. Future studies of this type should include the integration of clinical data with the financial analysis to better clarify patient types that may have the greatest impact on the financial outcomes. It would also be extremely valuable to include multiple payor types and health care plans in future studies. Acknowledgments The authors acknowledge Christopher M. Toby for valuable help in making this collaboration between Mayo Clinic Florida and Florida Blue functional. References 1 Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. Eur J Pain 2006;10: Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain 2012;13: Becker A. Health economics of interdisciplinary rehabilitation for chronic pain: Does it support or invalidate the outcomes research of these programs? Curr Pain Headache Rep 2012;16: Thomsen AB, Sorensen J, Sjogren P, Eriksen J. Chronic non-malignant pain patients and health economic consequences. Eur J Pain 2002;6: Simmons JW, Avant WS Jr., Demski J, Parisher D. Determining successful pain clinic treatment through validation of cost effectiveness. Spine (Phila Pa 1976) 1988;13: Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain 1992;49: Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. J Pain 2006;7: Hooten WM, Townsend CO, Sletten CD, Bruce BK, Rome JD. Treatment outcomes after multidisciplinary pain rehabilitation with analgesic medication withdrawal for patients with fibromyalgia. Pain Med 2007;8: Rome JD, Townsend CO, Bruce BK, et al. Chronic noncancer pain rehabilitation with opioid withdrawal: Comparison of treatment outcomes based on opioid use status at admission. Mayo Clin Proc 2004;79: Townsend CO, Kerkvliet JL, Bruce BK, et al. A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with opioid withdrawal: Comparison of treatment outcomes based on opioid use status at admission. Pain 2008;140: Turk DC. Clinical effectiveness and costeffectiveness of treatments for patients with chronic pain. Clin J Pain 2002;18: Caudill-Slosberg MA, Schwartz LM, Woloshin S. Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs Pain 2004;109: Manchikanti L, Falco FJ, Singh V, et al. Utilization of interventional techniques in managing chronic pain in the Medicare population: Analysis of growth patterns from 2000 to Pain Physician 2012;15: E Manchikanti L, Fellows B, Ailinani H, Pampati V. Therapeutic use, abuse, and nonmedical use of opioids: A ten-year perspective. Pain Physician 2010;13: