Program Overview | Utilization and Quality Management | Program Tools
Chronic or persistent pain is a medical condition that impacts many of our lives. It can affect people to the extent that they cannot work, participate in physical activity, or generally enjoy life. Chronic pain is debilitating. It is associated with depression, decreased productivity – or, simply put, a poor quality of life. Pain can be caused by a multitude of factors; however, musculoskeletal dysfunction is the principle reason for both acute and chronic pain. Many experts report that musculoskeletal disorders cost in excess of 100 billion dollars and continue to increase.
More than 100 million people suffer from some type of chronic pain. The lifetime prevalence of mechanical low back pain (LBP) in the United States is 60-80%. Recently, the rate of spinal surgery has increased to 19.8/100,000 surgeries a 15 fold increase in the last 5 years and is expected to accelerate as the boomer population ages. The rapid growth of pain and musculoskeletal management has been fueled by the expansion of treatment options and modalities. Because acute and chronic pain involves all aspects of a person’s life, the most effective treatment is a multidisciplinary approach that may include rehabilitative services, behavioral health support, interventional pain therapy, or surgery to improve outcomes.
Interventional pain management – the treatment of pain with image-guided injections – was virtually non-existent 30 years ago. While the American College of Graduate Medical Education (ACGME) has developed recognized standards of training, not all pain management specialists are credentialed. Moreover, clinical standards of care for interventional pain treatment are not well defined. There has been a marked increase in the rate of interventional and surgical treatment for chronic pain which, apart from joint replacement procedures, has increased costs without conclusively demonstrating associated improvements in quality of life measures for patients who suffer with chronic pain conditions.
Medicare recently conducted an investigation of interventional pain practices. The Office of the Inspector General’s audit of facet block procedures released in August 2008 showed a 76 percent increase in the number of procedures performed from 2003 to 2006. The cost to Medicare for these procedures doubled. Moreover, the audit found that almost 70 percent of claims either did not conform to published Medicare guidelines or had coding errors.
Trends related to back pain spinal surgery and joint surgery are on the rise. Joint replacement surgery has doubled in the last 10 years and is expected to continue to grow as the active boomer population ages. CMS reports that the cost of hip and knee replacement is in excess of 5 billion dollars a year and rising; surpassing coronary surgery. The fastest growing joint replacement procedures involve the shoulder. Back surgery procedures too have trended exponentially for the last 10 years.
CareCore Musculoskeletal Management Program utilizes research-driven clinical expertise to improve quality and manage the appropriateness of care. We employ innovative information technology, data management systems, evidence-based clinical pathways and operational processes to deliver clinical and financial value to payors, patients and providers.
Helmick, C., Felson, D., Lawrence, R., Gabriel, S., et all. Estimates of the Prevalence of Arthritis and Other Rheumatic conditions in the United States. Arthritis & Rheumatism 58(1), 15-25. 2008
MMWR 2006;55(40):1089-1092. [Data Source: 2003–2005 NHIS
Dubois, MY, Gallagher, RM, Lippe, PM. Pain Management Position Paper. Pain Medicine. Volume 10 • Number 6 • 2009
IHA Orthopedics Data Compendium, Use, Cost, and Market Structure for Total Joint Replacement, August 2006
OEI-05-07-00200 Medicare Payments for Facet Joint Injection Services September 2008
OEI-05-09-00030 Inappropriate Medicare Payments for Transforaminal Epidural Injection Services, August 2010
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