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Moving Beyond the Buggy Whip

Why CPT codes may be irrelevant in a functional restoration program

October 23, 2017 Photo

With growing momentum in workers compensation toward value-based care, an advocacy model, and the BioPsychoSocialSpiritual treatment paradigm, a question arises: When it comes to the #CleanUpTheMess effort—addressing the overuse, misuse, and abuse of opioids—are CPT codes for a functional restoration program (FRP) irrelevant? Could they be the health-care equivalent of the buggy whip?

While the concept of paying for outcomes instead of procedures (fee for service) is not new, it has generated significant discussion in the past decade. The Centers for Medicare and Medicaid Services (CMS) has increasingly focused on bundled payments and risk sharing as it manages Medicare benefits. From Accountable Care Organizations (ACO) to Hospital Value-Based Purchasing (HVBP), CMS has launched a strategic march toward quality improvement, transparency, and accountability. According to CMS.gov, the goal of an ACO is to coordinate care among providers “to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.”

This approach is logical. If medical care is paid by each service performed, then the result will likely be more services billed. If medical care is paid based on the clinical outcomes, then the result will likely be a more strategic and holistic approach. A fee-for-service model could promote a premature MRI, a lumbar fusion surgery that is not clinically indicated, or a prescription painkiller dispensed by a physician.

In contrast, paying for outcomes can lead to a different decision tree where what’s best for the ultimate disposition of the patient is at the core of every choice. This model encourages constant consideration for the best long-term outcome rather than short-term gains or treatments to appease the patient. While it might require more conversation and collaboration, it could promote a stronger strategy.

An ACO improves a health-care provider’s cost structure by improving both financial and clinical outcomes. Promoting goals like zero readmissions helps keep the focus on process efficiencies, better communication, more transparency, and adherence to treatment guidelines. Making outcomes, not transactions, the prime directive requires a holistic approach that may not be easily organized into separate billing codes. Creativity within the framework of evidence-based medicine and proven business practices is needed to achieve those kinds of outcomes.

The same is true for helping patients find better treatment options for chronic pain than dangerously inappropriate polypharmacy regimens and invasive interventions (i.e., injections, implanted devices, and surgery). ACOs would provide the additional benefit of higher employee satisfaction within the health-care organization, stemming from the ability to do the right thing from treatment, frequency, and duration standpoints. More satisfied employees, working with purpose, help achieve better results.

FRPs are important components of helping patients recover functions that have often been dramatically reduced by inappropriate treatments and polypharmacy regimens for chronic pain. The FRPs that have the best repeatable positive clinical outcomes—defined as reduction in medications, increase in function, and limited recidivism—utilize an inter-disciplinary, team-oriented, strategic treatment model.

There are obviously no guarantees when it comes to a human being making changes. Ultimate success is based on that person knowing there are better choices, internalizing the associated thought process and approach, and then making those better choices every moment of every day. Helping someone reduce or remove medications that are causing more harm than good while adding resiliency and coping mechanisms to better control pain (physical, psychological, and emotional) requires a coordinated effort between a doctor and other members of the medical team, psychologist, and physical therapist. The patient’s support network (family, friends, and co-workers) can be one of the biggest influencers, and if that support network believes the patient’s long-term benefits are at the center of all treatment choices, then its support will be easier to secure.

Enacting a life-long change in attitudes and activities requires dealing with the whole person—otherwise known as the BioPsychoSocialSpiritual model. The treatment plan and modalities require individualization and evidence-based trial and error. All of that means every human being will require a customized plan that is less about a scripted journey (the treatment modalities) and more about the ultimate destination (true pain management focused on improved function; not pain control through sedation).

The best way to facilitate this kind of care is to not force the provider to account for every 15-minute increment of treatment during the day. Allowing for customization and creativity, within a philosophical structure that strategically follows evidence-based medicine, will yield the best results. Clinicians at successful FRPs bring expertise, experience, and evidence-based medicine to the treatment plan. Every single activity is a component of that overall plan, has been thoughtfully considered, and is carefully monitored to accrue data not only for that patient, but also for the overall program. The ability to tailor the various modalities specific to an individual patient, and adjust as time goes on, is incredibly important to overall success.

Examples of clinical flexibility that are best when not tied to billing codes include:

• Medication-assisted treatment (the use of buprenorphine, methadone, or naltrexone to facilitate tapering of complex drug regimens) or a more methodical and organic step-therapy reduction.

• Cognitive behavioral treatment (CBT) should fit within the flow of a day without detailed time, duration, and place, and should be reinforced by the entire treatment team and support network.

• Physical activity, with pacing encouraged, should ebb and flow based on stamina.

• Mindfulness training (and reminders) should be embedded into every activity throughout the day and night (when there is less structure).

• Activities to accept reality and instill hope may include canoeing, bicycling, use of a treadmill, riding horses, or swimming in the pool.

• Instilling confidence by taking part in daily-living activities—such as going to a movie or the grocery store, or mentoring new patients—is important, but difficult to pre-plan.

Bundled payments, capitation, and daily stipends grant the necessary flexibility for the clinicians to meet the patients where they are that day. Connecting every activity to a CPT code can be counter-productive to the end-goal of more efficacious, less dangerous methods for managing chronic pain. If the payer has confidence in the FRP then it should not micro-manage the process. As with the ACO, the decision on which FRP to use in the future is based on historical performance. If chosen well, this provides better clinical and financial outcomes.

There were manufacturers of buggy whips that felt their industry would last forever. Horses and buggies had been the primary mode of transportation for centuries. However, the automobile quickly put them out of business. It is a classic tale of not adapting to change. When it comes to the use of an FRP to #CleanUpTheMess and effect the best possible treatment that will last a lifetime, the fee-for-service model that is billed via CPT codes is quickly becoming the new buggy whip.

About The Authors
Mark Pew

Mark Pew is senior vice president for PRIUM. He has been a CLM Fellow since 2011 and can be reached at  mpew@prium.net

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