Advertisement

Overcoming Barriers to the Implementation of Integrated Musculoskeletal Pain Management Programs: A Multi-Stakeholder Qualitative Study

Open AccessPublished:January 09, 2023DOI:https://doi.org/10.1016/j.jpain.2022.12.015

      Highlights

      • IPM programs are highly variable in funding, structure, services offered, and populations served.
      • IPM programs have innovative ways to overcome payment, care coordination and regulatory hurdles.
      • Lessons learned from existing programs can inform efforts to expand implementation of IPM.
      • Program success is dependent on imparting meaningful benefits to a broad range of stakeholders.
      • Payers and health systems need “proof of concept” examples that support IPM return on investment.

      Abstract

      Integrated pain management (IPM) programs can help to reduce the substantial population health burden of musculoskeletal pain, but are poorly implemented. Lessons learned from existing programs can inform efforts to expand IPM implementation. This qualitative study describes how health care systems, payers, providers, health policy researchers, and other stakeholders are overcoming barriers to developing and sustaining IPM programs in real-world settings. Primary data were collected February 2020 through September 2021 from a multi-sector expert panel of 25 stakeholders, 53 expert interviews representing 30 distinct IPM programs across the United States, and four original case studies of exemplar IPM programs. We use a consensual team-based approach to systematically analyze qualitative findings. We identified four major themes around challenges and potential solutions for implementing IPM programs: navigating coverage, payment, and reimbursement; enacting organizational change; making a business case to stakeholders; and overcoming regulatory hurdles. Strategies to address payment challenges included use of group visits, linked visits between billable and non-billable providers, and development of value-based payment models. Organizational change strategies included engagement of clinical and administrative champions and co-location of services. Business case strategies involved demonstrating the ability to initially break even and potential to reduce downstream costs, while improving non-financial outcomes like patient satisfaction and provider burnout. Regulatory hurdles were overcome with innovative credentialing methods by leveraging available waivers and managed care contracting to expand access to IPM services. Lessons from existing programs provide direction on to grow and support such IPM delivery models across a variety of settings.

      Perspective

      Integrated pain management (IPM) programs face numerous implementation challenges related to payment, organizational change, care coordination, and regulatory requirements. Drawing on real-world experiences of existing programs and from diverse IPM stakeholders, we outline actionable strategies that health care systems, providers, and payers can use to expand implementation of these programs.

      Keywords

      Introduction

      Musculoskeletal pain is the most common pain condition in the US, the leading cause of health care spending
      • Dieleman JL
      • Cao J
      • Chapin A
      • Chen C
      • Li Z
      • Liu A
      • Horst C
      • Kaldjian A
      • Matyasz T
      • Scott KW
      • Bui AL
      • Campbell M
      • Duber HC
      • Dunn AC
      • Flaxman AD
      • Fitzmaurice C
      • Naghavi M
      • Sadat N
      • Shieh P
      • Squires E
      • Yeung K
      • Murray CJL
      US Health Care Spending by Payer and Health Condition, 1996-2016.
      , and a frequent reason for opioid initiation.
      • Brands B
      • Blake J
      • Sproule B
      • Gourlay D
      • Busto U
      Prescription opioid abuse in patients presenting for methadone maintenance treatment.
      ,
      • Callinan CE
      • Neuman MD
      • Lacy KE
      • Gabison C
      • Ashburn MA
      The Initiation of Chronic Opioids: A Survey of Chronic Pain Patients.
      ,
      • Dieleman JL
      • Cao J
      • Chapin A
      • Chen C
      • Li Z
      • Liu A
      • Horst C
      • Kaldjian A
      • Matyasz T
      • Scott KW
      • Bui AL
      • Campbell M
      • Duber HC
      • Dunn AC
      • Flaxman AD
      • Fitzmaurice C
      • Naghavi M
      • Sadat N
      • Shieh P
      • Squires E
      • Yeung K
      • Murray CJL
      US Health Care Spending by Payer and Health Condition, 1996-2016.
      ,
      Institute of Medicine (US) Committee on Advancing Pain Research
      Care, and Education: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research [Internet].
      Musculoskeletal pain has complex psychological, social, and behavioral factors that drive disability and risk for chronic pain development.
      National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division
      Board on Global Health; Board on Health Sciences Policy; Global Forum on Innovation in Health Professional Education; Forum on Neuroscience and Nervous System Disorders: The Role of Nonpharmacological Approaches to Pain Management.
      However, current approaches to caring for musculoskeletal pain are frequently unimodal (i.e., use of single treatments like medication), focused on addressing the physiological aspects of the condition. As a result, current pain management approaches often provide limited benefit
      • Buchbinder R
      • Underwood M
      • Hartvigsen J
      • Maher CG
      The Lancet Series call to action to reduce low value care for low back pain: an update.
      ,
      • Dieleman JL
      • Cao J
      • Chapin A
      • Chen C
      • Li Z
      • Liu A
      • Horst C
      • Kaldjian A
      • Matyasz T
      • Scott KW
      • Bui AL
      • Campbell M
      • Duber HC
      • Dunn AC
      • Flaxman AD
      • Fitzmaurice C
      • Naghavi M
      • Sadat N
      • Shieh P
      • Squires E
      • Yeung K
      • Murray CJL
      US Health Care Spending by Payer and Health Condition, 1996-2016.
      ,
      • Humphreys K
      • Shover CL
      • Andrews CM
      • Bohnert ASB
      • Brandeau ML
      • Caulkins JP
      • Chen JH
      • Cuéllar M-F
      • Hurd YL
      • Juurlink DN
      • Koh HK
      • Krebs EE
      • Lembke A
      • Mackey SC
      • Ouellette LL
      • Suffoletto B
      • Timko C
      Responding to the opioid crisis in North America and beyond: recommendations of the Stanford–Lancet Commission.
      and leave missed opportunities to improve the lives of people with pain.

      U.S. Department of Health and Human Services: Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations [Internet]. 2019. Available from: https://www.hhs.gov/ash/advisory-committees/pain/reports/index.html. Accessed September 28, 2022.

      Inadequate pain management also has implications for the ongoing opioid crisis in the United States (US).
      • Manchikanti L
      • Helm S
      • Fellows B
      • Janata JW
      • Pampati V
      • Grider JS
      • Boswell MV
      Opioid epidemic in the United States.
      For the last several years, policymakers and health systems have taken steps to reduce the societal impact of opioid use, largely through the implementation of guidelines that restrict opioid prescribing. While these efforts have reduced opioid prescriptions
      • Goldstick JE
      • Guy GP
      • Losby JL
      • Baldwin G
      • Myers M
      • Bohnert ASB
      Changes in Initial Opioid Prescribing Practices After the 2016 Release of the CDC Guideline for Prescribing Opioids for Chronic Pain.
      ,
      • Scherrer JF
      • Tucker J
      • Salas J
      • Zhang Z
      • Grucza R
      Comparison of Opioids Prescribed for Patients at Risk for Opioid Misuse Before and After Publication of the Centers for Disease Control and Prevention's Opioid Prescribing Guidelines.
      , they have not accompanied an increase in the availability of safe, alternative pain management options. The result is a “silent epidemic” of poorly controlled pain, with many individuals seeking pain management outside the health care system.
      • Adams K
      • Guerra M
      Unintended consequences of United States chronic pain guidelines.
      ,
      Center for Drug Evaluation and Research
      FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual.
      ,
      • Chiarello E
      Where Movements Matter: Examining Unintended Consequences of the Pain Management Movement in Medical, Criminal Justice, and Public Health Fields.
      ,
      • Pergolizzi JV
      • Rosenblatt M
      • LeQuang JA
      Three Years Down the Road: The Aftermath of the CDC Guideline for Prescribing Opioids for Chronic Pain.
      Due to the many personal, public health, and financial consequences of poorly managed musculoskeletal pain, health care systems and payers have a strong interest in finding better approaches to treatment. Integrated Pain Management (IPM) incorporates evidence-based treatments across disciplines to address patients’ biopsychosocial and functional needs.

      Lentz T, Goertz C, Sharma I, Gonzalez-Smith J, Saunders R: Managing Multiple Irons in the Fire: Continuing to Address the Opioid Crisis and Improve Pain Management during a Public Health Emergency. NEJM Catal Innov Care Deliv [Internet], 2020. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371322/. Accessed February 27, 2021.

      IPM prioritizes evidence-based interventions, such as psychological and behavioral health management, physical and occupational therapy, chiropractic care, and integrative approaches like acupuncture and yoga. Many IPM programs also incorporate pharmacologic interventions (mostly non-opioid) and resources to address social determinants of health.

      Effective Health Care Program, Agency for Healthcare Research and Quality: Research Protocol: Integrated Pain Management Programs. [Internet]. 2020. Available from: https://effectivehealthcare.ahrq.gov/products/integrated-pain-management/protocol. Accessed June 13, 2022.

      The U.S. Department of Health and Human Services Pain Management Best Practices Inter-Agency Task Force

      U.S. Department of Health and Human Services: Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations [Internet]. 2019. Available from: https://www.hhs.gov/ash/advisory-committees/pain/reports/index.html. Accessed September 28, 2022.

      , the National Academy of Sciences
      National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division
      Board on Global Health; Board on Health Sciences Policy; Global Forum on Innovation in Health Professional Education; Forum on Neuroscience and Nervous System Disorders: The Role of Nonpharmacological Approaches to Pain Management.
      , and the Interagency Pain Research Coordinating Committee (through the National Pain Strategy
      • Von Korff M
      • Scher AI
      • Helmick C
      • Carter-Pokras O
      • Dodick DW
      • Goulet J
      • Hamill-Ruth R
      • LeResche L
      • Porter L
      • Tait R
      • Terman G
      • Veasley C
      • Mackey S
      United States National Pain Strategy for Population Research: Concepts, Definitions, and Pilot Data.
      ) have called for better implementation of comprehensive care for musculoskeletal pain, including IPM programs.
      • Humphreys K
      • Shover CL
      • Andrews CM
      • Bohnert ASB
      • Brandeau ML
      • Caulkins JP
      • Chen JH
      • Cuéllar M-F
      • Hurd YL
      • Juurlink DN
      • Koh HK
      • Krebs EE
      • Lembke A
      • Mackey SC
      • Ouellette LL
      • Suffoletto B
      • Timko C
      Responding to the opioid crisis in North America and beyond: recommendations of the Stanford–Lancet Commission.
      New opioid prescribing guidelines released by the US Centers for Disease Control and Prevention strongly promote the consideration of “the whole person” in pain treatment, making IPM implementation a high priority.
      • Dowell D
      • Ragan KR
      • Jones CM
      • Baldwin GT
      • Chou R
      CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022.
      Pain care advocates have even called for investment of recent opioid settlement funds into efforts that improve IPM implementation.
      • Bicket MC
      • McQuade B
      • Brummett CM
      Opioid Settlement Funds—Do Not Neglect Patients With Pain.
      A recent Stanford-Lancet Commission strongly reinforced the need for such initiatives, concluding that “as long as pain is prevalent and poorly managed, overuse of opioids and attendant harms are more likely.”
      • Humphreys K
      • Shover CL
      • Andrews CM
      • Bohnert ASB
      • Brandeau ML
      • Caulkins JP
      • Chen JH
      • Cuéllar M-F
      • Hurd YL
      • Juurlink DN
      • Koh HK
      • Krebs EE
      • Lembke A
      • Mackey SC
      • Ouellette LL
      • Suffoletto B
      • Timko C
      Responding to the opioid crisis in North America and beyond: recommendations of the Stanford–Lancet Commission.
      However, despite interest in IPM programs and considerable evidence for the effectiveness of treatments they deliver
      • Chou R
      • Deyo R
      • Friedly J
      • Skelly A
      • Hashimoto R
      • Weimer M
      • Fu R
      • Dana T
      • Kraegel P
      • Griffin J
      • Grusing S
      • Brodt ED
      Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline.
      ,
      • Donahue ML
      • Dunne EM
      • Gathright EC
      • DeCosta J
      • Balletto BL
      • Jamison RN
      • Carey MP
      • Scott-Sheldon LAJ
      Complementary and integrative health approaches to manage chronic pain in U.S. military populations: Results from a systematic review and meta-analysis, 1985-2019.
      ,
      • Foster NE
      • Anema JR
      • Cherkin D
      • Chou R
      • Cohen SP
      • Gross DP
      • Ferreira PH
      • Fritz JM
      • Koes BW
      • Peul W
      • Turner JA
      • Maher CG
      Lancet Low Back Pain Series Working Group: Prevention and treatment of low back pain: evidence, challenges, and promising directions.
      ,
      • Huang J-F
      • Zheng X-Q
      • Chen D
      • Lin J-L
      • Zhou W-X
      • Wang H
      • Qin Z
      • Wu A-M
      Can Acupuncture Improve Chronic Spinal Pain? A Systematic Review and Meta-Analysis.
      ,
      • Rubinstein SM
      • de Zoete A
      • van Middelkoop M
      • Assendelft WJJ
      • de Boer MR
      • van Tulder MW
      Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials.
      ,

      Skelly AC, Chou R, Dettori JR, Turner JA, Friedly JL, Rundell SD, Fu R, Brodt ED, Wasson N, Kantner S, Ferguson AJR: Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020. Available from: http://www.ncbi.nlm.nih.gov/books/NBK556229/. Accessed September 30, 2021.

      , adoption of IPM has lagged as a result of widespread barriers to implementation.
      IPM programs have historically faced numerous challenges to implementation
      • Hobelmann JG
      • Huhn AS
      Comprehensive pain management as a frontline treatment to address the opioid crisis.
      ,
      • Levy RM
      The extinction of comprehensive pain management: a casualty of the medical-industrial complex or an outdated concept?.
      , including poor reimbursement, lack of provider buy-in, and concerns about cost-effectiveness.
      • Coulter ID
      • Hilton L
      • Walter J
      • Brown KS
      Integrative Pain Management Centers in the Military: The Challenges.
      ,
      • Donovan MI
      • Evers K
      • Jacobs P
      • Mandleblatt S
      When there is no benchmark: designing a primary care-based chronic pain management program from the scientific basis up.
      ,
      • Hurstak E
      • Chao MT
      • Leonoudakis-Watts K
      • Pace J
      • Walcer B
      Wismer B: Design, Implementation, and Evaluation of an Integrative Pain Management Program in a Primary Care Safety-Net Clinic.
      ,
      • Roth IJ
      • Tiedt MK
      • Barnhill JL
      • Karvelas KR
      • Faurot KR
      • Gaylord S
      • Gardiner P
      • Miller VE
      • Leeman J
      Feasibility of Implementation Mapping for Integrative Medical Group Visits.
      ,
      • Znidarsic J
      • Kirksey KN
      • Dombrowski SM
      • Tang A
      • Lopez R
      • Blonsky H
      • Todorov I
      • Schneeberger D
      • Doyle J
      • Libertini L
      • Jamie S
      • Segall T
      • Bang A
      • Barringer K
      • Judi B
      • Ehrman JP
      • Roizen MF
      • Golubić M
      Living Well with Chronic Pain”: Integrative Pain Management via Shared Medical Appointments.
      Many of these challenges are well documented
      • Coulter ID
      • Hilton L
      • Walter J
      • Brown KS
      Integrative Pain Management Centers in the Military: The Challenges.
      ,

      Lentz T, Goertz C, Sharma I, Gonzalez-Smith J, Saunders R: Managing Multiple Irons in the Fire: Continuing to Address the Opioid Crisis and Improve Pain Management during a Public Health Emergency. NEJM Catal Innov Care Deliv [Internet], 2020. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371322/. Accessed February 27, 2021.

      ,
      • Levy RM
      The extinction of comprehensive pain management: a casualty of the medical-industrial complex or an outdated concept?.
      ; however, existing literature lacks direction on how to overcome these challenges, especially as health care delivery, policy, and payment have changed over time. To make meaningful progress in IPM implementation, we must address knowledge gaps that will inform program implementation in the current health care environment. This paper builds on our prior work to identify contemporary challenges to IPM adoption

      Lentz T, Goertz C, Sharma I, Gonzalez-Smith J, Saunders R: Managing Multiple Irons in the Fire: Continuing to Address the Opioid Crisis and Improve Pain Management during a Public Health Emergency. NEJM Catal Innov Care Deliv [Internet], 2020. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371322/. Accessed February 27, 2021.

      , drawing on qualitative interviews with IPM stakeholders to outline how programs are addressing key barriers to growth. The overarching goal is to provide practical guidance on the development, implementation, and sustainability of IPM programs in real-world settings.

      Methods

      We employed a sequential multi-method qualitative approach to collect and analyze different types of data. We used a consensual team-based qualitative research approach
      • Hill C
      • Knox S
      • Thompson B
      • Williams EN
      • Hess S
      • Ladany N
      Consensual Qualitative Research: An Update.
      and followed recommendations for complex qualitative reasoning, alternating between inductive and deductive approaches, to build from theory while also synthesizing themes from new data.
      • Creswell JW
      Qualitative Inquiry and Research Design: Choosing Among Five Approaches.
      The first step employed a deductive reasoning approach—reviewing extant literature to identify the state of knowledge about peer-reviewed evidence on IPM programs followed by web searches to identify policy-relevant grey literature and unstudied IPM programs. This focused literature review was used to gain insight that would guide discussion in the second step of convening an expert stakeholder panel. Specifically, the focused literature review helped to craft a priori topics important for advancing IPM progress in addition to identifying a diverse set of experts to advise our research. The discussion and meeting notes from this convening

      Lentz T, Goertz C, Sharma I, Gonzalez-Smith J, Saunders R: Managing Multiple Irons in the Fire: Continuing to Address the Opioid Crisis and Improve Pain Management during a Public Health Emergency. NEJM Catal Innov Care Deliv [Internet], 2020. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371322/. Accessed February 27, 2021.

      fed into the third step of developing a semi-structured interview guide and list of potential key informant interviewees and exemplar IPM programs for case studies. Key informant interviews and case studies comprised the fourth step, occurring in parallel to accomplish complementary goals. Key informant interviews represented single interviews with different organizations to capture the breadth of experiences on challenges and solutions to progress in IPM programs, whereas case studies on diverse exemplar IPM programs allowed us to capture the rich, contextual depth of “real-world” IPM examples. Finally, data from the preceding steps were synthesized and debriefed through a rigorous team-based approach to develop themes of new knowledge within a priori categories (deductive reasoning) as well as emergently developed new categories (inductive reasoning).
      • Creswell JW
      Qualitative Inquiry and Research Design: Choosing Among Five Approaches.
      ,
      • Hill CE
      • Knox S
      • Thompson BJ
      • Williams EN
      • Hess SA
      • Ladany N
      Consensual qualitative research: An update.
      Below, we describe stages of data collection and analysis in more detail.

      Expert stakeholder panel

      At the outset of the project, we convened a panel of 25 IPM stakeholders in February 2020 to guide our research approach and provide expert opinion on the topic. We conducted a focused literature review to identify major topics for discussion at the meeting and to develop a briefing packet for participants on the state of knowledge on IPM programs. Participants were selected to represent key perspectives on designing, implementing, and evaluating IPM programs, including health care payers, providers, policymakers, researchers (with pain management, complementary and integrative health, rehabilitation, health services research, and health policy backgrounds), patient representatives and more. The meeting included brief presentations from attendees to spark reflection on specific topics, followed by moderated discussion (Supplementary File 1). Topics included the current landscape of IPM programs, major factors challenging or facilitating the success of IPM programs (e.g., regulatory context), the payment landscape, and building a business case for IPM implementation.

      Lentz T, Goertz C, Sharma I, Gonzalez-Smith J, Saunders R: Managing Multiple Irons in the Fire: Continuing to Address the Opioid Crisis and Improve Pain Management during a Public Health Emergency. NEJM Catal Innov Care Deliv [Internet], 2020. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371322/. Accessed February 27, 2021.

      The research team took detailed notes used for de-briefing and interview guide development.

      Developing an interview guide

      Interview content was informed by our expert stakeholder panel. Interviews followed a semi-structured guide (Supplementary File 2) for soliciting insight into IPM program structure and operation, barriers to and facilitators of success, performance measurement, business and organizational change cases for delivery reform, and local policy context.
      • Adams WC
      Conducting Semi-Structured Interviews. Handbook of Practical Program Evaluation [Internet].
      Interview questions were tailored to different stakeholder types.

      Conducting key informant interviews

      The list of interviewees was developed from our review of publicly available information (e.g., internet searches for programs accredited by the Commission on Accreditation of Rehabilitation Facilities), from discussion at the stakeholder meeting, and through snowball sampling, where interviewees were asked for suggestions on other key informants in the IPM field. From April 2020 through September 2021, we interviewed 53 diverse stakeholders from different organizations across the US. Of the 53 interviewees, 38 represented 30 distinct IPM programs. Interviewees were typically program administrators, lead clinical staff, or a person otherwise familiar with the development and operation of the program. We considered IPM programs to be those that deliver care consistent with the biopsychosocial model, integrating two or more psychological, physical, or integrative services to address musculoskeletal pain within a structured program. We aimed to study a diverse sample of programs that were implemented in a variety of settings and geographic areas, used different care delivery models, and leveraged different staff types and configurations. The remaining 15 of the 53 interviewees were not affiliated with a specific IPM program but rather represented public and private payers, pain and health services researchers who are active in IPM research, patient advocates, and policymakers. These interviews were intended to help us better understand challenges and opportunities related to payment, research, and regulatory issues in the delivery of IPM. Interviews lasted between 45 and 60 minutes each. Interviewees provided verbal consent for participation and our research protocol was reviewed and deemed exempt by the Duke University Institutional Review Board,

      Conducting case studies

      Separately, we conducted interviews with 42 different stakeholders as part of four in-depth case studies of exemplar IPM programs. These programs had not been extensively studied; were considered exemplars within the IPM community; provided different mixes of services; used different staff types and configurations; and were diverse in geographic region, size, and structure. We used these cases to understand the rich, contextual depth of real-world experiences associated with implementing IPM programs. We worked with leadership from each program to select interviewees with knowledge of one or more of the following: historical context and change process; financial change and operations; care delivery; and data collection and program monitoring. Case study interviewees included executive leadership, program leaders and staff, care providers, finance and operations staff, researchers, and affiliated payers.
      Table 1 lists the characteristics of participants in the expert stakeholder panel, key informant interviews, and case study interviews. Table 2 summarizes the characteristics of the four case studies, including their geographic context, organizational type, program features, and key results.
      Table 1Characteristics of Participants
      Expert Stakeholder Panel (n=25)Key Informant Interviews (n=53)Case Study Interviews (n=42)
      Stakeholder TypeResearcher973
      Payer4106
      Provider42821
      Advocate/Policymaker450
      Other4012
      SettingAcademic health system51526
      Non-profit health system099
      Government agency590
      Private payer166
      Public payer140
      Payer organization120
      Research organization820
      Advocacy organization360
      Employer100
      U.S. Geographic RegionNortheast4714
      South162117
      Midwest2120
      West31011
      Table 2Overview of Case Study IPM Programs
      Case Study IPM ProgramSetting and ContextKey Program FeaturesKey Results and Outcomes
      West Virginia University Center for Integrative Pain ManagementAcademic medical center in Morgantown, WVCo-location of pain services; central case managers to navigate patients through the program; pain assessment measuresHigh patient satisfaction; increased patient demand; growth in services offered
      University of Vermont Medical Center Comprehensive Pain ProgramAcademic medical center in Burlington, VTPayment model that bundles pain management services; central role of group visits and group supportImprovements in patient satisfaction, well-being, chronic pain acceptance, ability to recover from stress, self-compassion, physical function, and depression; reductions in health care costs and utilization
      People's Community Clinic Integrative Pain Management ProgramFQHC in Austin, TXImplementation in a safety net context; approach focuses on relational health; medical-legal partnership; group medical visits; community-based partnershipsImprovements in patients’ quality of life, stress, self-efficacy, and coping skills; increased patient demand
      University of New Mexico Pain CenterAcademic medical center in Albuquerque, NMConnections to primary care providers; extending pain management care for medically underserved communities; commitment to provider educationDownstream reductions in health care utilization and costs; high patient satisfaction

      Data abstraction and analysis

      Key informant interviews were recorded and transcribed verbatim. Theme abstraction strategies from our consensual, team-based qualitative approach included a variety of recommended rigorous approaches: drafting thematic memos for each interview, team debriefing on memos to reconcile differences in interpretation, distilling themes that cross-cut memos, and collaborating with researchers from different fields (health policy, pain management, public health, and social sciences).

      Guba EG: ERIC/ECTJ Annual Review Paper: Criteria for Assessing the Trustworthiness of Naturalistic Inquiries. Educational Communication and Technology Springer; 29:75–91, 1981.

      ,
      • Hill CE
      • Knox S
      • Thompson BJ
      • Williams EN
      • Hess SA
      • Ladany N
      Consensual qualitative research: An update.
      ,
      • Silverman D
      Interpreting Qualitative Data: Methods for Analysing Talk, Text and Interaction.
      Our cross-cutting thematic analysis for this paper drew from findings from the expert stakeholder panel (25 participants), key informant interviews (53 interviews), and case studies (42 interviews plus standalone case reports, freely available online

      Gonzalez-Smith J, Huber K, Saunders RS, Goertz CM, Lentz TA: Exemplary Integrated Pain Management Programs: University of Vermont Medical Center Comprehensive Pain Program [Internet]. 2021. Available from: https://healthpolicy.duke.edu/publications/exemplary-integrated-pain-management-programs-university-vermont-medical-center. Accessed October 4, 2022.

      ,

      Huber K, Gonzalez-Smith J, Bleser WK, Saunders RS, Goertz CM, Lentz TA: Exemplary Integrated Pain Management Programs: People's Community Clinic Integrative Pain Management Program [Internet]. 2021. Available from: https://healthpolicy.duke.edu/publications/exemplary-integrated-pain-management-programs-peoples-community-clinic-integrative. Accessed October 4, 2022.

      Huber K, Gonzalez-Smith J, Saunders RS, Goertz CM, Lentz TA: Exemplary Integrated Pain Management Programs: University of New Mexico Pain Consultation and Treatment Center [Internet]. 2021. Available from: https://healthpolicy.duke.edu/publications/exemplary-integrated-pain-management-programs-university-new-mexico-pain-consultation. Accessed October 4, 2022.

      Huber K, Gonzalez-Smith J, Saunders RS, Goertz CM, Lentz TA: Exemplary Integrated Pain Management Programs: West Virginia University Center for Integrative Pain Management (WVUCIPM) [Internet]. 2021. Available from: https://healthpolicy.duke.edu/publications/exemplary-integrated-pain-management-programs-west-virginia-university-center. Accessed October 4, 2022.

      ). As aforementioned, we used complex qualitative reasoning to develop themes using both deductive reasoning (new knowledge within a priori categories) as well as inductive reasoning (new knowledge within emergently-developed new categories).
      • Creswell JW
      Qualitative Inquiry and Research Design: Choosing Among Five Approaches.

      Results

      We identified four major themes around strategies to overcome IPM implementation challenges: navigating coverage, payment, and reimbursement; enacting organizational change; making a business case to stakeholders; and overcoming regulatory hurdles. We discuss these themes in detail below.

      Current Fee-for-Service Reimbursement Greatly Limits IPM Payment and Adoption While New, Innovative Value-based Payment Models Hold Promise

      Program interviewees stated that current fee-for-service (FFS) models pose significant challenges to IPM adoption for two main reasons. First, reimbursement of services is often misaligned with the value conferred by those services. For example and as representatives of one program mentioned, prescription pain medications, surgery, and injections are generally well-reimbursed despite evidence of limited effectiveness as solutions for chronic pain.
      • Blom AW
      • Donovan RL
      • Beswick AD
      • Whitehouse MR
      • Kunutsor SK
      Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence.
      ,
      • Tucker H-R
      • Scaff K
      • McCloud T
      • Carlomagno K
      • Daly K
      • Garcia A
      • Cook CE
      Harms and benefits of opioids for management of non-surgical acute and chronic low back pain: a systematic review.
      Conversely, other treatments with evidence of a more favorable impact on chronic pain, like acupuncture, spinal manipulation and cognitive behavioral-based therapies, are inconsistently covered.
      • Heyward J
      • Jones CM
      • Compton WM
      • Lin DH
      • Losby JL
      • Murimi IB
      • Baldwin GT
      • Ballreich JM
      • Thomas DA
      • Bicket MC
      • Porter L
      • Tierce JC
      • Alexander GC
      Coverage of Nonpharmacologic Treatments for Low Back Pain Among US Public and Private Insurers.
      ,
      National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division
      Board on Global Health; Board on Health Sciences Policy; Global Forum on Innovation in Health Professional Education; Forum on Neuroscience and Nervous System Disorders: The Role of Nonpharmacological Approaches to Pain Management.
      ,

      Skelly AC, Chou R, Dettori JR, Turner JA, Friedly JL, Rundell SD, Fu R, Brodt ED, Wasson N, Kantner S, Ferguson AJR: Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020. Available from: http://www.ncbi.nlm.nih.gov/books/NBK556229/. Accessed September 30, 2021.

      Payers reported less familiarity with some IPM services (e.g., acupuncture, yoga) and their impact, which made them less likely to reimburse for these treatments.
      Second, program interviewees also stated that IPM services are often subject to an array of utilization management tools, including prior authorization, utilization reviews, or visit limits, which restrict access and increase administrative burden. Payers argued such tools are necessary due to uncertainty regarding standard best practices for IPM services. Further, reimbursement is often restricted for multiple visits on the same day as payment is intended to cover all evaluation and management services for related conditions. Many providers expressed frustration with utilization management because it required programs to split up visits to different providers, reducing the efficiency of coordinated care and placing added burden on patients due to increased transportation time and costs.
      Interviewees offered several potential solutions. Some health care systems have developed ways to subsidize non-reimbursed or under-reimbursed IPM services by “linking” medical visits, wherein a billable practitioner provides services alongside a non-billable practitioner. In one program, exercise physiologists (who are non-billable when providing services independently) function as chiropractic assistants, billing for biomechanical evaluations and functional rehabilitation under the supervision of chiropractors. In this case, the model is possible because state laws provide chiropractors with broad powers to identify, train, assess for competence, and approve for duty chiropractic assistants from a variety of clinical backgrounds. However, it is not scalable to states that do not allow for this level of flexibility in oversight. In other instances, health systems have used revenue from facility fees or interventional services to indirectly subsidize non-reimbursed services.
      Another approach used by numerous programs is group visits where multiple patients, typically with a mix of insurance types, simultaneously see a provider. Program administrators viewed group visits as an effective method to scale up in a financially sustainable way and extend care to individuals with differing coverage for IPM services. Across the programs we interviewed, examples of services delivered in a group format include nutritional counseling, psychological therapies, and exercise training. Beyond the financial benefits, programs reported that group visits facilitate peer support, which helps to improve engagement in the program and empowers self-care. One program launched an alumni network to enable patients to remain engaged with group members after they finished the program.
      While most programs operated within a FFS model, we observed a few innovative examples of value-based payment (VBP) models where payment is uncoupled from the volume of services delivered and instead linked to the value of care received. These models are designed to overcome many FFS challenges, such as misalignment between reimbursement and value of services, difficulty defining units of IPM services, and utilization management. One notable example is a collaboration between the University of Vermont Medical Center Comprehensive Pain Program (CPP) and BlueCross BlueShield Vermont (BCBSVT) to develop “Partners Aligned in Transformative Healing” (PATH), an intensive 13-week outpatient program that includes an array of integrative therapies. The PATH program is supported by bundled payments that allow BCBSVT members to access a variety of CPP services, with patients paying a fixed number of co-pays (2-3) during the program.

      Gonzalez-Smith J, Huber K, Saunders RS, Goertz CM, Lentz TA: Exemplary Integrated Pain Management Programs: University of Vermont Medical Center Comprehensive Pain Program [Internet]. 2021. Available from: https://healthpolicy.duke.edu/publications/exemplary-integrated-pain-management-programs-university-vermont-medical-center. Accessed October 4, 2022.

      One challenge of VBP models is the lack of consensus on how to define and measure quality of IPM services. As a result, payers stated they are reluctant to reimburse for IPM programs, citing limited evidence showing which treatments work and which should be covered as a standard IPM benefit. Many stakeholders noted that current quality measures inadequately capture all dimensions of high-quality pain management. Poor consensus on best practices for quality assessment is reflected in the wide variety of measures used across programs (Table 3). Although specific measures varied across programs, we observed commonalities in the broad domains that programs tracked. These included pain, function/disability, quality of life, patient satisfaction, mental health, and health care use (e.g., opioid and emergency department (ED) use). In the PATH program, BCBSVT and CPP mutually agreed on which domains to measure and the CPP chose which specific measures to use in consultation with clinical providers.
      Table 3Examples of Quality Domains and Measures used by IPM programs
      DomainExample MetricsSummary and Use
      Commonly Used Measures
      Pain and Function/DisabilityDoD PASTOR (Pain Assessment Screening Tool and Outcomes Registry)20-30 minute survey that produces a comprehensive report of a patient's chronic pain; built on the PROMIS tool; helps to track pain over time
      PEG (Pain, Enjoyment of life, and General activity) scaleAssesses average pain intensity, quality of life, and function
      Defense & Veterans Pain Rating ScalePain assessment tool with additional prompts to gauge pain levels, including supplemental questions on how pain interferes with function and quality of life.
      Health-related Quality of LifeHuman Flourishing MeasuresUsed to assess how pain affects human flourishing in 5 domains: happiness and life satisfaction, mental and physical health, meaning and purpose, character and virtue, and close social relationships
      PROMIS-29 or PROMIS global healthSummary from subset of PROMIS questions to gauge health-related quality of life
      Patient Experience/SatisfactionNet Promoter ScoreLikelihood to refer
      Patient satisfactionVarious measures of satisfaction with care
      Mental HealthPHQ-9 (Patient Health Questionnaire-9 item)Screening tool for depression
      GAD-7 (General Anxiety Disorder-7 item)Screening tool for anxiety
      Health care useOpioid prescribing/morphine milligram equivalent usageThe current focus on reducing opioid prescribing has meant that health care organizations view integrated pain management programs positively if they can prevent initial opioid prescriptions or be an alternative to opioids
      Utilization reductionsFor health care organizations paid through more global payments, they will have an incentive to reduce unnecessary utilization. Some sites were interested in seeing reductions in imaging, hospitalizations, or prescriptions.
      Less Commonly Used Measures
      Resilience, Self-Efficacy and Pain CopingSelf-compassion scaleMeasures various aspects of self-compassion: self-kindness, self-judgment, common humanity, isolation, mindfulness, and over-identification.
      Pain Catastrophizing ScaleAssesses catastrophic thoughts or feelings occurring when experiencing pain
      Patient activation measureValidated measure of patient's activation or readiness to engage in their health care
      Pain Resilience Scale (and related resilience scales)Ability to maintain behaviors and regulate emotions and thoughts during prolonged or intense pain
      Organizational MetricsStaff satisfactionVarious satisfaction measures used to show organizational leadership how programs can improve staff satisfaction.
      AbsenteeismReturn to workSome delivery systems and workers compensation insurers use return to work as a key outcome measure
      Quality ImprovementAdherence to programProportion of patients who complete programs

      Organizational Change to IPM Requires Strong Champions, Provider Buy-In, Incremental Scaling, and Cross-Sector Alignment to Facilitate Co-management

      IPM programs represent a paradigm shift in pain management, providing services that span a range of disciplines (e.g., nutrition, behavioral health, social services, legal aid) in addition to conventional medicine. As a result, nearly all programs reported the need to undergo substantial organizational change. Each program we interviewed had one or more deeply committed champions that spearheaded organizational change and were critical for sustained success. We interviewed two programs that were no longer operating and both attributed the closing to loss of their clinical champion. One program noted the importance of having a champion with both administrative and clinical experience who could translate the clinical vision into billing or relative value unit (RVU) language understood by those financing the program.
      A key early challenge faced by most health systems was garnering buy-in from clinical staff to deliver a different model of care. Many providers initially expressed reluctance to refer patients to other clinicians for pain management, especially if they were not familiar with the services being delivered (e.g., yoga, acupuncture). Other providers quickly recognized the benefits of having new, evidence-based pain management options that could help them better manage patients with pain. Across programs, junior faculty and trainees often adopted new approaches to pain management more readily than providers in later career stages. Programs addressed this challenge by using data to show improvements in patient satisfaction and outcomes. They also demonstrated how the model could better distribute the burden of complex pain management across providers to reduce burnout.
      Most IPM programs grew incrementally, starting with only a few services and adding care options as demand grew. Several programs leveraged low-cost community-based resources to scale up services. One program partnered with a local school of integrative medicine to expand access to acupuncture. Other programs implemented part-time or flexible contracting arrangements for lesser used services, like nutritional counseling, until demand warranted hiring full-time staff. This approach kept upfront costs low and provided flexibility to accommodate fluctuations in demand as the program grew. While many programs scaled by increasing the number of services offered over time, some programs initially offered a core set of services to a specific population segment (i.e., existing patients that needed non-opioid pain management) and expanded by increasing the number of population segments that could access those services.
      Programs reported that integrating pain services required various departments and cost centers to collaborate in unique ways with new reporting structures, new methods of cost and revenue sharing, and shared clinicians and staff. Care coordination often required collaboration among service providers that do not commonly work together. For example, in one program within a Federally Qualified Health Center (FQHC), attorneys work alongside clinicians to address health-harming legal needs like housing insecurity.

      Huber K, Gonzalez-Smith J, Bleser WK, Saunders RS, Goertz CM, Lentz TA: Exemplary Integrated Pain Management Programs: People's Community Clinic Integrative Pain Management Program [Internet]. 2021. Available from: https://healthpolicy.duke.edu/publications/exemplary-integrated-pain-management-programs-peoples-community-clinic-integrative. Accessed October 4, 2022.

      Although medical-legal partnerships are becoming more common, this program found that it took time to develop appropriate referral pathways, communication and documentation strategies, and clinical workflows to fully integrate these services. Many programs stated that physical co-location of services and providers was instrumental to care coordination as it facilitates regular communication and cross-disciplinary education, allows providers to develop rapport with one another, fosters a singular culture around pain management, and makes care more accessible. Many programs also used dedicated case managers or care coordinators to address patients’ needs related to scheduling, system navigation, referral management, and insurance.

      The Business Case for IPM Involves Identifying Financial Sustainability, Reducing Unnecessary Downstream Utilization, and Improving Important Non-Financial Outcomes

      Each program we interviewed required upfront investment, which was especially challenging for programs in less-resourced health systems. Some received upfront capital from their health system (e.g., a university provided money for a department to start a program), while others relied on charitable donations, or grants for seed funding. Incremental investments over time from these sources, and to a lesser extent revenue generated from the programs themselves, helped the programs grow. To articulate the case for start-up and recurring funding, health care systems focused on at least three things: demonstrating eventual return on investment (ROI), showing the potential for cost prevention, and highlighting non-financial returns.
      Demonstrating ROI was frequently cited as the most important factor in getting leadership buy-in to build and sustain programs. However, demonstrating ROI for IPM programs has numerous challenges. First, different stakeholders have different perspectives on what constitutes a suitable ROI. For example, hospitals and health systems stated they are especially interested in revenue generation. Workers’ compensation payers are most interested in avoiding long-term work-related disability. Commercial payers are particularly interested in reducing high-cost services, like ED visits. To demonstrate ROI potential to payers, some programs attempted to forecast the extent to which use of IPM services could reduce costly downstream services like ED visits. However, most programs reported difficulties with quantifying the value of prevention given the numerous factors that drive health care use. Many programs expressed the need for more real-world examples supporting the cost-saving potential of these programs.
      Low reimbursement rates for most IPM services create a second challenge for demonstrating ROI, specifically from the health care system perspective. To address this issue, most programs initially focused on the ability to break even and reinforce the non-financial returns of their programs. For instance, many programs highlighted improved patient satisfaction over usual care. Satisfaction is an important metric for health system leaders, given that it can show new patient volume and patient retention, and is easily assessed through surveys and proxy measures. Improved staff well-being and retention was another non-financial benefit. Managing pain can be challenging for physicians and many programs found that the introduction of IPM options reduced burnout by providing a suitable referral option for complex pain management.

      Regulatory Hurdles Affect Credentialing and Licensure for IPM

      Most programs and payers reported that state and federal regulations impacted their ability to deliver and pay for care. One major logistical issue for payers is identifying and credentialing qualified IPM practitioners, since many IPM services are commonly delivered outside of the traditional health care setting. For traditional medical services, payers rely on licensure provided by state licensure boards. This can be complicated as licensure and scope of practice for each professional varies by state. While some IPM practitioners, such as doctors of chiropractic, are licensed in every state, this is not true for many others.

      Herman PM, Coulter ID: Advancing Complementary and Alternative Medicine Professions: Practitioners Face Many Policy Hurdles to Finding Their Place in Mainstream Medicine [Internet]. RAND Corporation; 2016. Available from: https://www.rand.org/pubs/research_briefs/RB9894.html. Accessed June 13, 2022.

      ,

      Herman PM, Coulter ID: Complementary and Alternative Medicine: Professions or Modalities?: Policy Implications for Coverage, Licensure, Scope of Practice, Institutional Privileges, and Research [Internet]. RAND Corporation; 2015. Available from: https://www.rand.org/pubs/research_reports/RR1258.html. Accessed June 13, 2022.

      Payers have taken two approaches to overcome licensure challenges. The first approach, outlined previously, is paying a physician or other existing billing provider to supervise integrative service delivery. For example, acupuncturists can provide services to traditional Medicare beneficiaries for low back pain, but they must practice under the supervision of a physician, physician assistant, or nurse practitioner. Second, some payers credential and contract directly with integrative medicine practitioners, which may require developing new payer processes for screening practitioners. This approach is more common in some states, such as Washington, that have so-called “Every Category” laws requiring health plans to cover all categories of practitioners licensed, registered, or certified by the state.
      • Herman PM
      • Coulter ID
      Mapping the Health Care Policy Landscape for Complementary and Alternative Medicine Professions Using Expert Panels and Literature Analysis.
      This also requires the integrative medicine practitioner to manage challenging logistical and administrative processes for health plan contracting, requiring substantial administrative overhead (including billing systems, documentation, and additional staffing), which integrative medicine practitioners may not be used to handling.
      Payers stated that they are also challenged by various regulatory restrictions impacting how they can pay for IPM services. For instance, services covered by Medicaid programs are specified by federal law, although states can provide additional services using waivers or managed care contracting. Further, private payers, including employer-sponsored insurance, Medicaid managed care plans, and Medicare Advantage plans, are limited in what can be covered as a medical expense (versus an administrative cost), and plans must spend a certain percentage of their premiums on medical expenses (what is called a medical loss ratio). Payers in some states, like Oregon, reported using Section 1115 Medicaid waivers to directly pay for some IPM services, allowing those services to be included as medical expenses in the medical loss ratio calculation.

      Oregon Health Authority: HealthRelated Services Guide for CCOs [Internet]. 2021. Available from: https://www.oregon.gov/oha/HPA/dsi-tc/Documents/Health-Related-Services-FAQ.pdf. Accessed February 10, 2022.

      Discussion

      This study focused on strategies that health care systems, payers, and providers across the U.S. are using to address challenges to the development and sustainability of IPM programs (Table 4 and Table 5). Our work addresses a key literature gap in that most existing studies of adult musculoskeletal IPM programs focus on implementation barriers (versus potential solutions)
      • Coulter ID
      • Hilton L
      • Walter J
      • Brown KS
      Integrative Pain Management Centers in the Military: The Challenges.
      ,

      Lentz T, Goertz C, Sharma I, Gonzalez-Smith J, Saunders R: Managing Multiple Irons in the Fire: Continuing to Address the Opioid Crisis and Improve Pain Management during a Public Health Emergency. NEJM Catal Innov Care Deliv [Internet], 2020. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371322/. Accessed February 27, 2021.

      , program outcomes
      • Oslund S
      • Robinson RC
      • Clark TC
      • Garofalo JP
      • Behnk P
      • Walker B
      • Walker KE
      • Gatchel RJ
      • Mahaney M
      • Noe CE
      Long-term effectiveness of a comprehensive pain management program: strengthening the case for interdisciplinary care.
      ,
      • Skelly AC
      • Chou R
      • Dettori JR
      • Brodt ED
      • Diulio-Nakamura A
      • Mauer K
      • Fu R
      • Yu Y
      • Wasson N
      • Kantner S
      • Stabler-Morris S.
      Integrated and Comprehensive Pain Management Programs: Effectiveness and Harms. Comparative Effectiveness Review No. 251. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 75Q80120D00006.) AHRQ Publication No. 22-EHC002.
      , or report on single case examples
      • Donovan MI
      • Evers K
      • Jacobs P
      • Mandleblatt S
      When there is no benchmark: designing a primary care-based chronic pain management program from the scientific basis up.
      ,
      • Hurstak E
      • Chao MT
      • Leonoudakis-Watts K
      • Pace J
      • Walcer B
      Wismer B: Design, Implementation, and Evaluation of an Integrative Pain Management Program in a Primary Care Safety-Net Clinic.
      ,
      • Roth IJ
      • Tiedt MK
      • Barnhill JL
      • Karvelas KR
      • Faurot KR
      • Gaylord S
      • Gardiner P
      • Miller VE
      • Leeman J
      Feasibility of Implementation Mapping for Integrative Medical Group Visits.
      ,
      • Shojaei H
      • Lakha SF
      • Lyon A
      • Halabecki M
      • Donaghy M
      • Mailis A
      Evolution of a chronic pain management program in a Northwestern Ontario community: from structural elements to practical application.
      or clinical trials.
      • Znidarsic J
      • Kirksey KN
      • Dombrowski SM
      • Tang A
      • Lopez R
      • Blonsky H
      • Todorov I
      • Schneeberger D
      • Doyle J
      • Libertini L
      • Jamie S
      • Segall T
      • Bang A
      • Barringer K
      • Judi B
      • Ehrman JP
      • Roizen MF
      • Golubić M
      Living Well with Chronic Pain”: Integrative Pain Management via Shared Medical Appointments.
      These resources lend important insight but provide limited guidance on opportunities to address common challenges across various delivery settings in the current healthcare environment. Comparing our findings to prior work, some challenges are widespread and have persisted over time, like poor reimbursement and coordination obstacles, while other challenges are new, like value-based purchasing. Our work complements initiatives (e.g., National Pain Strategy
      • Von Korff M
      • Scher AI
      • Helmick C
      • Carter-Pokras O
      • Dodick DW
      • Goulet J
      • Hamill-Ruth R
      • LeResche L
      • Porter L
      • Tait R
      • Terman G
      • Veasley C
      • Mackey S
      United States National Pain Strategy for Population Research: Concepts, Definitions, and Pilot Data.
      ) which call for improved access to integrated, multimodal pain care and greater interdisciplinary collaboration, by providing guidance on how to operationalize these strategies.
      Table 4Major challenges facing implementation of IPM programs, current strategies used to overcome those challenges, and opportunities for further work
      ThemeMajor ChallengesCurrent Strategies UsedWhere Is More Help Needed
      Navigating Coverage, Payment, and ReimbursementReimbursement not aligned with value

      How to define standard IPM benefit

      Utilization management tools and out of pocket costs limit access to IPM services

      Lack of consensus on which quality measures should be used to evaluate individual and program performance

      Use group visits to improve access, which enable peer support and empowerment, while requiring fewer providers

      Partnerships between payers and health care systems to develop VBP models

      Link visits between billable and non-billable providers

      Offset costs of providing non-billable care through revenue from facilities fees or interventional services, and appropriate insurer case mix
      More “proof of concept” models showcasing value-based payment arrangements

      Develop a consensus on how to measure quality measures to use in IPM programs

      Develop standardized definitions of IPM services
      Enacting Organizational ChangeHealth care delivery is deeply rooted in the medical model, which does not often meet the need of people with pain

      Pain care is siloed and often not well coordinated

      Many integrative health providers are not familiar with working inside the traditional health care system

      Many traditional health care system providers (e.g., doctors, nurses) are not used to working alongside integrative health providers

      General lack of knowledge about integrative services in health care systems and among patients
      • Enlist or engage clinical and administrative champions to spearhead IPM development
      • Generate provider buy-in by showing improvements in patient satisfaction, outcomes, care decisions and provider burnout
      • Start incrementally and scale-up based on need
      • Consider part-time or flexible contracting arrangements to for lesser used services
      • Partner with community resources (e.g., schools of integrative medicine) to expand low-cost service offerings
      • Co-locate pain management services to encourage coordination and build provider trust
      • Use care coordinators to address patients’ needs related to scheduling, system navigation, referral management, and insurance
      • Identify best strategies to improve public and stakeholder awareness of IPM programs and their benefits
      Making a Business Case to StakeholdersNeed for upfront capital to start programs

      Difficulties with accurately estimating ROI

      Difficult to deliver care in rural and underserved communities
      Explore opportunities for grant funding and/or charitable donations for upfront and early capital

      Demonstrate potential to break even or generate cost savings

      Demonstrate non-financial benefits such as improved patient satisfaction with care and reduced provider burnout and attrition
      Determine which patients would benefit from IPM compared to less intensive options

      Studies demonstrating cost-effectiveness and return on investment of IPM programs across a variety of settings

      Program examples in rural and underserved communities
      Overcoming Regulatory Hurdles
      • Significant variation in local laws and regulations, workforce availability, and other idiosyncratic reasons why some treatments are included/excluded in various IPM programs
      • Identifying and credentialing qualified IPM practitioners
      Joint Commission standards around non-pharmacologic approaches for pain management were incentive for some systems to expand their pain management offerings

      Pay physician or other billing provider to supervise delivery of the integrative service

      Payers credential and contract directly with integrative medicine practitioners

      Consider 1115 Medicaid waivers to cover some IPM services
      • Understanding how to navigate limitations on telehealth delivery of IPM services
      Table 5A sample of stakeholder quotes representing each theme
      Navigating Coverage, Payment, and Reimbursement
      On misaligned incentives within FFS models:

      Anesthesiologists stopped sending patients [to the IPM program] because the patients improved so much they did not need interventions anymore.”

      On the need for more standardization of IPM programs:

      “It would also help to have evidentiary criteria that is operational and can be standardized….For instance, though cognitive behavioral therapy [CBT] seems to be promising, it is hard from a coverage standpoint to define what CBT is and who performs it. It feels like sifting through sand; not as clear as it needs to be.”

      On overcoming high copays that restrict access to care:

      “High out-of-pocket costs are barriers to access. Benefit design plans can help eliminate patient co-pays for certain services, but this requires a lot of patient and provider education to enforce.”
      Enacting Organizational Change
      On the paradigm shift needed to support IPM programs:

      “[We] had a clinical system that was designed in a biomedical find-it-fix-it paradigm. And so initially… the barrier was simply the clinical construct.”

      “Really to do it right is a big paradigm shift, and… specialists have been trained and enculturated in doing stuff to people and then getting paid well for it. Empowering individual clients to live out their fullest life, coaching them in that, that's a totally different skillset.”

      “Integrated pain management and this whole health system approach to care… it's really a paradigm shift in the way that we view health care and our role in health care, and it can be a little bit of a challenge to adapt to that mindset.”

      On the importance of securing buy-in of leaders and champions:

      “[We] tried to pitch program for years, but only once right leadership fell in place did the program get support”

      On garnering physician support:

      “One way [to gain support] was to build referral pathways and make physicians’ lives easier so that they were motivated to refer their patients to the IPM program.”

      On the importance of co-location:

      “Because providers are collaborating with other clinicians they trust, they grow comfortable recommending certain therapies they may not usually recommend. Providers are co-located and usually are someone the physicians know and trust to manage the patient.”
      Making a Business Case to Stakeholders
      On setting early expectations:

      Our initial goal was to break even and then build up from there.

      On the challenges of expanding IPM in rural areas and underserved communities:

      “The academic medical center coalesced a range of different practices/disciplines but this will be harder in rural areas… data aggregation at rural site will be harder”

      On the importance of non-financial outcomes:

      “A big quality indicator for [this payer] was the fact that patients loved the program.”
      Overcoming Regulatory Hurdles
      On a common regulatory hurdle:

      We would be able to implement telehealth more if there weren't licensing requirements holding them back

      “An issue [with Medicare] is that more than half of the therapists out there cannot serve Medicare because only licensed social workers and psychologists can. That creates a capacity issue. It creates hiring challenges.”

      “This issue of direct access permission [for physical therapists] and if it is permitted for what time and what kind of oversight - I think it can't be overstated how important that is.”

      “If we can't credential [yoga therapists], because there's not a formal certification or licensure, how do you build the network? How do you bring that to consumers?”
      Perhaps the most promising opportunity echoed across several themes was leveraging national progress in VBP health care transformation to overcome obstacles around IPM care delivery. Beyond bringing greater flexibility to pay for IPM services, value-based contracts can facilitate more flexible and collaborative utilization management options, such as prior authorization bundling.
      • Psotka MA
      • Singletary EA
      • Bleser WK
      • Roiland RA
      • M Hamilton Lopez
      • Saunders RS
      • Wang TY
      • McClellan MB
      • Brown N
      • null null
      Streamlining and Reimagining Prior Authorization Under Value-Based Contracts: A Call to Action From the Value in Healthcare Initiative's Prior Authorization Learning Collaborative.
      However, there are challenges to expanding IPM through VBP. The most significant challenge is that IPM is largely concentrated within specialty care. Specialty care has not been widely integrated into population health VBP models, creating few precedents for benefit design. That said, some specialty care fields have successfully engaged in VBP. One example is in the management of heart failure, where leaders outlined how to adjust model specifications in a heart failure “sub-track” of widespread population-based VBP models.
      • K Joynt Maddox
      • Bleser WK
      • Crook HL
      • Nelson AJ
      • M Hamilton Lopez
      • Saunders RS
      • McClellan MB
      • Brown N
      • null null
      Advancing Value-Based Models for Heart Failure.
      Key delivery elements for heart failure closely parallel core components of IPM, including longitudinal, multidisciplinary care and standardized outcomes assessment; thus lessons from these designs may inform similar models for IPM.
      A recent white paper identified musculoskeletal care as one of six specialty fields well-positioned for integration into population health VBP models, noting pain management as a key opportunity.
      • Japinga M
      • Jayakumar P
      • De Brantes F
      • Bozic K
      • Saunders R
      • McClellan M.
      Strengthening Specialist Participation in Comprehensive Care through Condition-Based Payment Reforms.
      Notably, the Centers for Medicare & Medicaid Services (CMS) is proposing to count certain chronic pain management service codes when attributing patients to VBP models.

      Centers for Medicare & Medicaid Services (CMS), Health and Human Services (HHS): Medicare and Medicaid Programs; CY 2023 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicare and Medicaid Provider Enrollment Policies, Including for Skilled Nursing Facilities; Conditions of Payment for Suppliers of Durable Medicaid Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); and Implementing Requirements for Manufacturers of Certain Single-Dose Container or Single-Use Package Drugs To Provide Refunds With Respect to Discarded Amounts [Internet]. 2022. Available from: https://www.federalregister.gov/documents/2022/07/29/2022-14562/medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other. Accessed November 18, 2022.

      This would not only include some pain management clinicians in VBP, but also may expand access of VBP to people with chronic pain.

      Bleser WK, Tchuisseu YP, Shen H, Thoumi A, Kaye DR, Saunders RS: Advancing Equity Through Value-Based Payment: Implementation And Evaluation To Support Design Goals. Health Affairs Forefront [Internet] Available from: https://www.healthaffairs.org/do/10.1377/forefront.20221103.813959/full/. Accessed November 18, 2022.

      Another challenge is that, to-date, widespread VBP models are structured to improve population health but not explicitly focused on equity. While these models allow for flexibility in care delivery to improve equity (e.g., through care coordination, or addressing social needs), historically-marginalized populations and their providers are disproportionately excluded from VBP.

      Hughes DL: CMS Innovation Center Launches New Initiative To Advance Health Equity. Health Affairs Forefront [Internet] Available from: https://www.healthaffairs.org/do/10.1377/forefront.20220302.855616/full/. Accessed November 18, 2022.

      However, these issues are top priority for CMS, which in January 2023 will launch the first ever equity-focused national VBP model.

      Bleser WK, Tchuisseu YP, Shen H, Thoumi A, Amin C, Kaye DR, McClellan MB, Saunders RS: ACO REACH And Advancing Equity Through Value-Based Payment, Part 1. Health Affairs Forefront [Internet]. Available from: https://www.healthaffairs.org/do/10.1377/forefront.20220513.630666/full/. Accessed November 18, 2022.

      ,

      Bleser WK, Tchuisseu YP, Shen H, Thoumi A, Amin C, Kaye DR, McClellan MB, Saunders RS: ACO REACH And Advancing Equity Through Value-Based Payment, Part 2. Health Affairs Forefront [Internet]. Available from: https://www.healthaffairs.org/do/10.1377/forefront.20220517.755520/full/. Accessed November 18, 2022.

      We identified innovative thinking on business case development. Business case examples for value-based care from other specialty fields reinforce these approaches and offer additional lessons for IPM. For example, business case arguments for development of accountable serious illness care strongly resemble arguments we identified in our study.
      • Bleser WK
      • Saunders RS
      • Winfield L
      • Japinga M
      • Smith N
      • Kaufman BG
      • Crook HL
      • Muhlestein DB
      • McClellan M
      ACO Serious Illness Care: Survey And Case Studies Depict Current Challenges And Future Opportunities.
      Like individuals with chronic pain, seriously ill patients (many of whom have coexisting chronic pain conditions)
      • Lillie AK
      • Read S
      • Mallen C
      • Croft P
      • McBeth J
      Musculoskeletal pain in older adults at the end-of-life: a systematic search and critical review of the literature with priorities for future research.
      ,
      • Maxwell CJ
      • Dalby DM
      • Slater M
      • Patten SB
      • Hogan DB
      • Eliasziw M
      • Hirdes JP
      The prevalence and management of current daily pain among older home care clients.
      ,
      • Smith AK
      • Cenzer IS
      • Knight SJ
      • Puntillo KA
      • Widera E
      • Williams BA
      • Boscardin WJ
      • Covinsky KE
      The epidemiology of pain during the last 2 years of life.
      account for substantial health care costs, are at high risk for procedures that confer low value
      • Bleser WK
      • Saunders RS
      • Winfield L
      • Japinga M
      • Smith N
      • Kaufman BG
      • Crook HL
      • Muhlestein DB
      • McClellan M
      ACO Serious Illness Care: Survey And Case Studies Depict Current Challenges And Future Opportunities.
      , and often require poorly reimbursed services.
      • Bleser WK
      • Saunders RS
      • Winfield L
      • Japinga M
      • Smith N
      • Kaufman BG
      • Crook HL
      • Muhlestein DB
      • McClellan M
      ACO Serious Illness Care: Survey And Case Studies Depict Current Challenges And Future Opportunities.
      To address ROI challenges for the seriously ill, organizations tracked reductions in use of costly services such as hospitalizations and ED visits, a strategy used by some programs we interviewed. Two other examples from outside our work highlight additional opportunities for business case arguments in IPM. In one bundled payment program for orthopedic surgery, leadership focused on ‘non-financial’ returns in the short term, arguing that commitment to professional and clinical excellence would translate into long-term business success (e.g., improved reputation, better payer relations, and increased market share).
      • Liao JM
      • Holdofski A
      • Whittington GL
      • Zucker M
      • Viroslav S
      • Fox DL
      • Navathe AS
      Baptist Health System: Succeeding in bundled payments through behavioral principles.
      In another example, a chronic pain management program used ‘transactional cost economic analysis’ to model how changes in costs and care delivery would differ based on adoption of various workflows and technologies.
      • Theodore BR
      • Whittington J
      • Towle C
      • Tauben DJ
      • Endicott-Popovsky B
      • Cahana A
      • Doorenbos AZ
      Transaction cost analysis of in-clinic versus telehealth consultations for chronic pain: preliminary evidence for rapid and affordable access to interdisciplinary collaborative consultation.
      Beyond our key themes, we also identified several takeaways cross-cutting our themes. The first is that payers, providers, health system administrators, policymakers, and patients all have different perspectives on how to define program success. Programs are more likely to be successful if they can develop delivery and financing models that impart meaningful benefits to a broad range of stakeholders. A second takeaway is the high heterogeneity across programs, reflecting the many ways programs have adapted to provider availability, financial constraints, delivery settings, state regulations, and populations served. While this variability results in lessons learned that can help programs scale, it also reflects a lack of consensus on how to standardize IPM delivery, which most payers say is necessary for consistent and appropriate IPM coverage. Future efforts should focus on defining core IPM components as well as flexible components that can be included based on availability and need.
      A third takeaway is the considerable challenge in implementing and scaling IPM services in rural and medically underserved communities. Many services like acupuncture and chiropractic care are unavailable in these communities, exacerbating current disparities in pain care.
      • Saper R
      Integrative Medicine and Health Disparities.
      Most of the programs we identified and interviewed were affiliated with academic institutions or large health care systems, perhaps highlighting the importance of these environments for building and sustaining IPM programs. More proof of concept examples in rural settings and outside of large health care systems, such as in FQHCs, are needed to demonstrate how IPM services can be equitably extended across populations. Telehealth was used by some programs to extend services to patients in rural and underserved areas. Many programs leveraged reduced regulatory restrictions on telehealth during the COVID-19 pandemic to increase their reach. However, not all integrative services are amenable to delivery by telehealth.
      Finally, we identified areas that need additional evidence and research. Despite solid evidence for the efficacy of many treatments delivered within IPM programs, many interviewees felt that most payer and administrative stakeholders lacked proper awareness of IPM and its benefits. Interviewees pushed for efforts to clearly define IPM services and disseminate evidence summaries directly to key stakeholders. Health care administrators and payers expressed the need for more “proof of concept” examples that would support the ROI of IPM programs across various delivery settings and health care systems. These examples are currently rare, underscoring the challenges in bringing together health systems and payers to develop collaborative payment arrangements for IPM services.
      A few limitations of our project are worth noting. This work focused on adult musculoskeletal pain programs, so findings may not be relevant to other types of pain management programs (e.g., neuropathic pain, pediatric populations). Our IPM program sampling strategy, although intended to be comprehensive, may have biased the sample toward more well-known, well-resourced programs. As a result, our findings may not fully reflect strategies used by smaller or lesser resourced programs. Finally, we used a broad definition to define IPM programs that didn't distinguish between multidisciplinary, interdisciplinary, and transdisciplinary designs. Each featured services that were “integrated”, but this too was not operationally defined and the degree of integration varied across programs, reflecting the diverse and unstandardized nature of current IPM practice.

      Conclusion

      Improving the implementation of safe and effective treatments for those suffering from musculoskeletal pain is critical. Evidence supporting the benefits of non-pharmacological approaches to pain management is clear and compelling, yet programs that integrate these approaches to address the biopsychosocial needs of patients with musculoskeletal pain are not widely implemented. This work is intended to inform payers, health care systems, and other stakeholders of the real-world experiences of programs that have experienced success delivering IPM services.

      Disclosures

      This project is part of the Duke School of Medicine Opioid Collaboratory portfolio, a grant funded by the Duke Endowment and administered through the Duke Department of Population Health Sciences. The collaboratory's mission is to save lives and reduce the harmful impact of opioids in North Carolina through the development, implementation, and/or evaluation of sustainable, system-level interventions. Dr. Goertz serves on the Advisory Committee for the Alliance to Advance Comprehensive Integrative Pain Management and is a member of the Interagency Pain Research Coordinating Committee (IPRCC). All other authors report no conflicts of interest.

      Appendix. Supplementary data

      References

        • Adams K
        • Guerra M
        Unintended consequences of United States chronic pain guidelines.
        Int J Clin Pharm. 2021; 43: 313-317
        • Adams WC
        Conducting Semi-Structured Interviews. Handbook of Practical Program Evaluation [Internet].
        John Wiley & Sons, Ltd, 2015: 492-505 (pageAvailable from) (Accessed August 15, 2022)
        • Bicket MC
        • McQuade B
        • Brummett CM
        Opioid Settlement Funds—Do Not Neglect Patients With Pain.
        JAMA Health Forum. 2021; 2e211765
        • Bleser WK
        • Saunders RS
        • Winfield L
        • Japinga M
        • Smith N
        • Kaufman BG
        • Crook HL
        • Muhlestein DB
        • McClellan M
        ACO Serious Illness Care: Survey And Case Studies Depict Current Challenges And Future Opportunities.
        Health Affairs Health Affairs. 2019; 38: 1011-1020
      1. Bleser WK, Tchuisseu YP, Shen H, Thoumi A, Amin C, Kaye DR, McClellan MB, Saunders RS: ACO REACH And Advancing Equity Through Value-Based Payment, Part 1. Health Affairs Forefront [Internet]. Available from: https://www.healthaffairs.org/do/10.1377/forefront.20220513.630666/full/. Accessed November 18, 2022.

      2. Bleser WK, Tchuisseu YP, Shen H, Thoumi A, Amin C, Kaye DR, McClellan MB, Saunders RS: ACO REACH And Advancing Equity Through Value-Based Payment, Part 2. Health Affairs Forefront [Internet]. Available from: https://www.healthaffairs.org/do/10.1377/forefront.20220517.755520/full/. Accessed November 18, 2022.

      3. Bleser WK, Tchuisseu YP, Shen H, Thoumi A, Kaye DR, Saunders RS: Advancing Equity Through Value-Based Payment: Implementation And Evaluation To Support Design Goals. Health Affairs Forefront [Internet] Available from: https://www.healthaffairs.org/do/10.1377/forefront.20221103.813959/full/. Accessed November 18, 2022.

        • Blom AW
        • Donovan RL
        • Beswick AD
        • Whitehouse MR
        • Kunutsor SK
        Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence.
        BMJ British Medical Journal Publishing Group;. 2021; 374: n1511
        • Brands B
        • Blake J
        • Sproule B
        • Gourlay D
        • Busto U
        Prescription opioid abuse in patients presenting for methadone maintenance treatment.
        Drug Alcohol Depend. 2004; 73: 199-207
        • Buchbinder R
        • Underwood M
        • Hartvigsen J
        • Maher CG
        The Lancet Series call to action to reduce low value care for low back pain: an update.
        Pain. 2020; 161: S57-S64
        • Callinan CE
        • Neuman MD
        • Lacy KE
        • Gabison C
        • Ashburn MA
        The Initiation of Chronic Opioids: A Survey of Chronic Pain Patients.
        The Journal of Pain. 2017; 18: 360-365
        • Center for Drug Evaluation and Research
        FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual.
        2021 (individualized tapering. FDA [Internet] 2019. Available from) (Accessed December 7)
      4. Centers for Medicare & Medicaid Services (CMS), Health and Human Services (HHS): Medicare and Medicaid Programs; CY 2023 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicare and Medicaid Provider Enrollment Policies, Including for Skilled Nursing Facilities; Conditions of Payment for Suppliers of Durable Medicaid Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); and Implementing Requirements for Manufacturers of Certain Single-Dose Container or Single-Use Package Drugs To Provide Refunds With Respect to Discarded Amounts [Internet]. 2022. Available from: https://www.federalregister.gov/documents/2022/07/29/2022-14562/medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other. Accessed November 18, 2022.

        • Chiarello E
        Where Movements Matter: Examining Unintended Consequences of the Pain Management Movement in Medical, Criminal Justice, and Public Health Fields.
        Law & Policy. 2018; 40: 79-109
        • Chou R
        • Deyo R
        • Friedly J
        • Skelly A
        • Hashimoto R
        • Weimer M
        • Fu R
        • Dana T
        • Kraegel P
        • Griffin J
        • Grusing S
        • Brodt ED
        Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline.
        Ann Intern Med. 2017; 166: 493-505
        • Coulter ID
        • Hilton L
        • Walter J
        • Brown KS
        Integrative Pain Management Centers in the Military: The Challenges.
        Mil Med. 2016; 181: 1033-1039
        • Creswell JW
        Qualitative Inquiry and Research Design: Choosing Among Five Approaches.
        SAGE Publications, 2012
        • Dieleman JL
        • Cao J
        • Chapin A
        • Chen C
        • Li Z
        • Liu A
        • Horst C
        • Kaldjian A
        • Matyasz T
        • Scott KW
        • Bui AL
        • Campbell M
        • Duber HC
        • Dunn AC
        • Flaxman AD
        • Fitzmaurice C
        • Naghavi M
        • Sadat N
        • Shieh P
        • Squires E
        • Yeung K
        • Murray CJL
        US Health Care Spending by Payer and Health Condition, 1996-2016.
        JAMA. 2020; 323: 863-884
        • Donahue ML
        • Dunne EM
        • Gathright EC
        • DeCosta J
        • Balletto BL
        • Jamison RN
        • Carey MP
        • Scott-Sheldon LAJ
        Complementary and integrative health approaches to manage chronic pain in U.S. military populations: Results from a systematic review and meta-analysis, 1985-2019.
        Psychol Serv. 2021; 18: 295-309
        • Donovan MI
        • Evers K
        • Jacobs P
        • Mandleblatt S
        When there is no benchmark: designing a primary care-based chronic pain management program from the scientific basis up.
        J Pain Symptom Manage. 1999; 18: 38-48
        • Dowell D
        • Ragan KR
        • Jones CM
        • Baldwin GT
        • Chou R
        CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022.
        MMWR Recomm Rep. 2022; 71: 1-95
      5. Effective Health Care Program, Agency for Healthcare Research and Quality: Research Protocol: Integrated Pain Management Programs. [Internet]. 2020. Available from: https://effectivehealthcare.ahrq.gov/products/integrated-pain-management/protocol. Accessed June 13, 2022.

        • Foster NE
        • Anema JR
        • Cherkin D
        • Chou R
        • Cohen SP
        • Gross DP
        • Ferreira PH
        • Fritz JM
        • Koes BW
        • Peul W
        • Turner JA
        • Maher CG
        Lancet Low Back Pain Series Working Group: Prevention and treatment of low back pain: evidence, challenges, and promising directions.
        Lancet. 2018; 391: 2368-2383
        • Goldstick JE
        • Guy GP
        • Losby JL
        • Baldwin G
        • Myers M
        • Bohnert ASB
        Changes in Initial Opioid Prescribing Practices After the 2016 Release of the CDC Guideline for Prescribing Opioids for Chronic Pain.
        JAMA Netw Open. 2021; 4e2116860
      6. Gonzalez-Smith J, Huber K, Saunders RS, Goertz CM, Lentz TA: Exemplary Integrated Pain Management Programs: University of Vermont Medical Center Comprehensive Pain Program [Internet]. 2021. Available from: https://healthpolicy.duke.edu/publications/exemplary-integrated-pain-management-programs-university-vermont-medical-center. Accessed October 4, 2022.

      7. Guba EG: ERIC/ECTJ Annual Review Paper: Criteria for Assessing the Trustworthiness of Naturalistic Inquiries. Educational Communication and Technology Springer; 29:75–91, 1981.

      8. Herman PM, Coulter ID: Advancing Complementary and Alternative Medicine Professions: Practitioners Face Many Policy Hurdles to Finding Their Place in Mainstream Medicine [Internet]. RAND Corporation; 2016. Available from: https://www.rand.org/pubs/research_briefs/RB9894.html. Accessed June 13, 2022.

      9. Herman PM, Coulter ID: Complementary and Alternative Medicine: Professions or Modalities?: Policy Implications for Coverage, Licensure, Scope of Practice, Institutional Privileges, and Research [Internet]. RAND Corporation; 2015. Available from: https://www.rand.org/pubs/research_reports/RR1258.html. Accessed June 13, 2022.

        • Herman PM
        • Coulter ID
        Mapping the Health Care Policy Landscape for Complementary and Alternative Medicine Professions Using Expert Panels and Literature Analysis.
        J Manipulative Physiol Ther. 2016; 39: 500-509
        • Heyward J
        • Jones CM
        • Compton WM
        • Lin DH
        • Losby JL
        • Murimi IB
        • Baldwin GT
        • Ballreich JM
        • Thomas DA
        • Bicket MC
        • Porter L
        • Tierce JC
        • Alexander GC
        Coverage of Nonpharmacologic Treatments for Low Back Pain Among US Public and Private Insurers.
        JAMA Netw Open. 2018; 1e183044
        • Hill C
        • Knox S
        • Thompson B
        • Williams EN
        • Hess S
        • Ladany N
        Consensual Qualitative Research: An Update.
        Journal of Counseling Psychology. 2005; 52: 196-205
        • Hill CE
        • Knox S
        • Thompson BJ
        • Williams EN
        • Hess SA
        • Ladany N
        Consensual qualitative research: An update.
        Journal of Counseling Psychology US: American Psychological Association. 2005; 52: 196-205
        • Hobelmann JG
        • Huhn AS
        Comprehensive pain management as a frontline treatment to address the opioid crisis.
        Brain Behav. 2021; 11: e2369
        • Huang J-F
        • Zheng X-Q
        • Chen D
        • Lin J-L
        • Zhou W-X
        • Wang H
        • Qin Z
        • Wu A-M
        Can Acupuncture Improve Chronic Spinal Pain? A Systematic Review and Meta-Analysis.
        Global Spine J. 2021; 11: 1248-1265
      10. Huber K, Gonzalez-Smith J, Bleser WK, Saunders RS, Goertz CM, Lentz TA: Exemplary Integrated Pain Management Programs: People's Community Clinic Integrative Pain Management Program [Internet]. 2021. Available from: https://healthpolicy.duke.edu/publications/exemplary-integrated-pain-management-programs-peoples-community-clinic-integrative. Accessed October 4, 2022.

      11. Huber K, Gonzalez-Smith J, Saunders RS, Goertz CM, Lentz TA: Exemplary Integrated Pain Management Programs: University of New Mexico Pain Consultation and Treatment Center [Internet]. 2021. Available from: https://healthpolicy.duke.edu/publications/exemplary-integrated-pain-management-programs-university-new-mexico-pain-consultation. Accessed October 4, 2022.

      12. Huber K, Gonzalez-Smith J, Saunders RS, Goertz CM, Lentz TA: Exemplary Integrated Pain Management Programs: West Virginia University Center for Integrative Pain Management (WVUCIPM) [Internet]. 2021. Available from: https://healthpolicy.duke.edu/publications/exemplary-integrated-pain-management-programs-west-virginia-university-center. Accessed October 4, 2022.

      13. Hughes DL: CMS Innovation Center Launches New Initiative To Advance Health Equity. Health Affairs Forefront [Internet] Available from: https://www.healthaffairs.org/do/10.1377/forefront.20220302.855616/full/. Accessed November 18, 2022.

        • Humphreys K
        • Shover CL
        • Andrews CM
        • Bohnert ASB
        • Brandeau ML
        • Caulkins JP
        • Chen JH
        • Cuéllar M-F
        • Hurd YL
        • Juurlink DN
        • Koh HK
        • Krebs EE
        • Lembke A
        • Mackey SC
        • Ouellette LL
        • Suffoletto B
        • Timko C
        Responding to the opioid crisis in North America and beyond: recommendations of the Stanford–Lancet Commission.
        The Lancet. 2022; 399: 555-604
        • Hurstak E
        • Chao MT
        • Leonoudakis-Watts K
        • Pace J
        • Walcer B
        Wismer B: Design, Implementation, and Evaluation of an Integrative Pain Management Program in a Primary Care Safety-Net Clinic.
        J Altern Complement Med. 2019; 25: S78-S85
        • Institute of Medicine (US) Committee on Advancing Pain Research
        Care, and Education: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research [Internet].
        National Academies Press (US), Washington (DC)2011 (Available from) (Accessed April 28, 2020)
        • Japinga M
        • Jayakumar P
        • De Brantes F
        • Bozic K
        • Saunders R
        • McClellan M.
        Strengthening Specialist Participation in Comprehensive Care through Condition-Based Payment Reforms.
        Duke-Margolis Center for Health Policy, Washington, DC2022 (Available from) (Accessed November 18, 2022)
        • K Joynt Maddox
        • Bleser WK
        • Crook HL
        • Nelson AJ
        • M Hamilton Lopez
        • Saunders RS
        • McClellan MB
        • Brown N
        • null null
        Advancing Value-Based Models for Heart Failure.
        Circulation: Cardiovascular Quality and Outcomes American Heart Association;. 2020; 13e006483
      14. Lentz T, Goertz C, Sharma I, Gonzalez-Smith J, Saunders R: Managing Multiple Irons in the Fire: Continuing to Address the Opioid Crisis and Improve Pain Management during a Public Health Emergency. NEJM Catal Innov Care Deliv [Internet], 2020. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371322/. Accessed February 27, 2021.

        • Levy RM
        The extinction of comprehensive pain management: a casualty of the medical-industrial complex or an outdated concept?.
        Neuromodulation. 2012; 15: 89-91
        • Liao JM
        • Holdofski A
        • Whittington GL
        • Zucker M
        • Viroslav S
        • Fox DL
        • Navathe AS
        Baptist Health System: Succeeding in bundled payments through behavioral principles.
        Healthcare. 2017; 5: 136-140
        • Lillie AK
        • Read S
        • Mallen C
        • Croft P
        • McBeth J
        Musculoskeletal pain in older adults at the end-of-life: a systematic search and critical review of the literature with priorities for future research.
        BMC Palliative Care. 2013; 12: 27
        • Manchikanti L
        • Helm S
        • Fellows B
        • Janata JW
        • Pampati V
        • Grider JS
        • Boswell MV
        Opioid epidemic in the United States.
        Pain Physician. 2012; 15: ES9-E38
        • Maxwell CJ
        • Dalby DM
        • Slater M
        • Patten SB
        • Hogan DB
        • Eliasziw M
        • Hirdes JP
        The prevalence and management of current daily pain among older home care clients.
        Pain. 2008; 138: 208-216
        • National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division
        Board on Global Health; Board on Health Sciences Policy; Global Forum on Innovation in Health Professional Education; Forum on Neuroscience and Nervous System Disorders: The Role of Nonpharmacological Approaches to Pain Management.
        in: Stroud C Posey Norris SM Bain L Proceedings of a Workshop [Internet]. National Academies Press (US), Washington (DC)2019 (Available from) (Accessed April 28, 2020)
      15. Oregon Health Authority: HealthRelated Services Guide for CCOs [Internet]. 2021. Available from: https://www.oregon.gov/oha/HPA/dsi-tc/Documents/Health-Related-Services-FAQ.pdf. Accessed February 10, 2022.

        • Oslund S
        • Robinson RC
        • Clark TC
        • Garofalo JP
        • Behnk P
        • Walker B
        • Walker KE
        • Gatchel RJ
        • Mahaney M
        • Noe CE
        Long-term effectiveness of a comprehensive pain management program: strengthening the case for interdisciplinary care.
        Proc (Bayl Univ Med Cent). 2009; 22: 211-214
        • Pergolizzi JV
        • Rosenblatt M
        • LeQuang JA
        Three Years Down the Road: The Aftermath of the CDC Guideline for Prescribing Opioids for Chronic Pain.
        Adv Ther. 2019; 36: 1235-1240
        • Psotka MA
        • Singletary EA
        • Bleser WK
        • Roiland RA
        • M Hamilton Lopez
        • Saunders RS
        • Wang TY
        • McClellan MB
        • Brown N
        • null null
        Streamlining and Reimagining Prior Authorization Under Value-Based Contracts: A Call to Action From the Value in Healthcare Initiative's Prior Authorization Learning Collaborative.
        Circulation: Cardiovascular Quality and Outcomes American Heart Association;. 2020; 13 (e006564)
        • Roth IJ
        • Tiedt MK
        • Barnhill JL
        • Karvelas KR
        • Faurot KR
        • Gaylord S
        • Gardiner P
        • Miller VE
        • Leeman J
        Feasibility of Implementation Mapping for Integrative Medical Group Visits.
        J Altern Complement Med. 2021; 27: S71-S80
        • Rubinstein SM
        • de Zoete A
        • van Middelkoop M
        • Assendelft WJJ
        • de Boer MR
        • van Tulder MW
        Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials.
        BMJ. 2019; 364: l689
        • Saper R
        Integrative Medicine and Health Disparities.
        Glob Adv Health Med SAGE Publications Inc;. 2016; 5: 5-8
        • Scherrer JF
        • Tucker J
        • Salas J
        • Zhang Z
        • Grucza R
        Comparison of Opioids Prescribed for Patients at Risk for Opioid Misuse Before and After Publication of the Centers for Disease Control and Prevention's Opioid Prescribing Guidelines.
        JAMA Netw Open. 2020; 3 (e2027481)
        • Shojaei H
        • Lakha SF
        • Lyon A
        • Halabecki M
        • Donaghy M
        • Mailis A
        Evolution of a chronic pain management program in a Northwestern Ontario community: from structural elements to practical application.
        BMC Health Serv Res. 2022; 22: 1355
        • Silverman D
        Interpreting Qualitative Data: Methods for Analysing Talk, Text and Interaction.
        2nd edition. SAGE Publications Ltd, London2001
        • Skelly AC
        • Chou R
        • Dettori JR
        • Brodt ED
        • Diulio-Nakamura A
        • Mauer K
        • Fu R
        • Yu Y
        • Wasson N
        • Kantner S
        • Stabler-Morris S.
        Integrated and Comprehensive Pain Management Programs: Effectiveness and Harms. Comparative Effectiveness Review No. 251. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 75Q80120D00006.) AHRQ Publication No. 22-EHC002.
        Agency for Healthcare Research and Quality, Rockville, MD2021 (Oct)
      16. Skelly AC, Chou R, Dettori JR, Turner JA, Friedly JL, Rundell SD, Fu R, Brodt ED, Wasson N, Kantner S, Ferguson AJR: Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020. Available from: http://www.ncbi.nlm.nih.gov/books/NBK556229/. Accessed September 30, 2021.

        • Smith AK
        • Cenzer IS
        • Knight SJ
        • Puntillo KA
        • Widera E
        • Williams BA
        • Boscardin WJ
        • Covinsky KE
        The epidemiology of pain during the last 2 years of life.
        Ann Intern Med. 2010; 153: 563-569
        • Theodore BR
        • Whittington J
        • Towle C
        • Tauben DJ
        • Endicott-Popovsky B
        • Cahana A
        • Doorenbos AZ
        Transaction cost analysis of in-clinic versus telehealth consultations for chronic pain: preliminary evidence for rapid and affordable access to interdisciplinary collaborative consultation.
        Pain Med. 2015; 16: 1045-1056
        • Tucker H-R
        • Scaff K
        • McCloud T
        • Carlomagno K
        • Daly K
        • Garcia A
        • Cook CE
        Harms and benefits of opioids for management of non-surgical acute and chronic low back pain: a systematic review.
        Br J Sports Med. 2020; 54: 664
      17. U.S. Department of Health and Human Services: Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations [Internet]. 2019. Available from: https://www.hhs.gov/ash/advisory-committees/pain/reports/index.html. Accessed September 28, 2022.

        • Von Korff M
        • Scher AI
        • Helmick C
        • Carter-Pokras O
        • Dodick DW
        • Goulet J
        • Hamill-Ruth R
        • LeResche L
        • Porter L
        • Tait R
        • Terman G
        • Veasley C
        • Mackey S
        United States National Pain Strategy for Population Research: Concepts, Definitions, and Pilot Data.
        J Pain. 2016; 17: 1068-1080
        • Znidarsic J
        • Kirksey KN
        • Dombrowski SM
        • Tang A
        • Lopez R
        • Blonsky H
        • Todorov I
        • Schneeberger D
        • Doyle J
        • Libertini L
        • Jamie S
        • Segall T
        • Bang A
        • Barringer K
        • Judi B
        • Ehrman JP
        • Roizen MF
        • Golubić M
        Living Well with Chronic Pain”: Integrative Pain Management via Shared Medical Appointments.
        Pain Med. 2021; 22: 181-190