President's Message: Summer 2005

Benjamin Johnson, MD, MBA

Musings of a Frustrated Multidisciplinary Clinician

Being an indirect clinical descendant of John Bonica, via my mentor and former anesthesiology chairman, Dr. John Allen Dekrey, I am a committed multidisciplinary pain specialist. In spite of directing multidisciplinary pain centers in both academic and now private practice environments, I find myself frustrated at the inability to obtain the behavioral component of pain care that many of my patients need. Having discussed this issue with many of you and other pain specialists, I know that obtaining behavioral health benefits for chronic pain patients is a matter familiar to many, if not all, of the states in the Southern Pain Society.

From discussions with behavioral health providers, such as psychiatrists and psychologists in our SPS, several problems are at the root of the lack of access to needed behavioral health benefits coverage:

1. The lack of parity between medical and behavioral benefits coverage
2. The lack of understanding of the importance of behavioral therapy by patients
3. The paucity of pain-oriented behavioral practitioners
4. The failure of insurance providers to recognize the cost-benefit advantages to including behavioral modification in pain treatment strategies.

In my many discussions with pain-oriented behavioral health providers within the SPS, there is a long history of a lack of parity between medical and behavioral health benefits coverage. In some, if not all, instances, the behavioral health benefits management is outsourced to a separate behavioral health management firm; while the medical benefits are managed by the primary insurer. My personal explanation is the lack of appreciation for the beneficial effects of behavioral modification on chronic disease management such as chronic pain. Insurers and practitioners seem to give greater credence to “objective” medical pathology than to “subjective” behavioral pathology; even in an environment such as chronic pain, where a high percentage of patients are known to have psychiatric co-morbidity. Therefore it is easier to get a lumbar transforaminal injection approved than a series of psychological interventions.

As profit-maximizing entities, insurance firms should be the first to mandate behavioral evaluations and interventions if they realized the cost-savings inherent in a multidisciplinary therapeutic strategy. Estimated savings for such a strategy range up to 20%, according to the prevailing medical literature, when behavioral interventions are utilized. The cost savings result from:

• Identifying patients who have nonmedical reasons for “keeping” their pain complaints
• Identifying contraindications for opioid usage
• avoiding unnecessary procedural interventions in patients with behavioral problems such as somatization disorder
• identifying patients at risk for adverse experiences with procedural interventions, such as history of physical abuse, dissociative disorders, etc.
• increasing patient compliance regarding medication usage
• optimizing medical treatment expectations in regard to surgical and pain-related interventional procedures
• preparation of patients for return-to-work

As pain specialists, we must continue to advocate the cost-effectiveness of behavioral interventions, in order to give our patients the best chance of obtaining benefits coverage for this service. I especially emphasize this service to our workers' compensation carriers, because of the tight relationship of return to work issues with pain management and disability issues.

Another obstacle that we typically encounter is the reluctance of the patient to consider behavioral interventions as a vital part of their pain therapy. This reluctance is manifested in several ways:

• patients may refuse to pay a copay for psychological therapy, yet pay the same amount for a “medical” visit
• patients may be a “no-show” for psychological appointments, yet show up promptly for a medical visit
• patients may object to being evaluated by a behavioral practitioner on the grounds that their pain is “real”, and not “in my head”.

The root problem in each of these scenarios is the lack of importance placed on the psychological aspect of pain management. A part of the blame may be on the pain specialist, who might not emphasize the importance of behavioral evaluation and intervention as much as emphasizing the treatment expectations of a procedural intervention. However, our society also denigrates the patient with pain and/or behavioral problems, therefore such a person may be reluctant to seek skilled help. It is socially more acceptable to have headaches and low back pain, than it is to have depression and somatization or abuse issues. As we well know, it is not uncommon for a person with psychosocial morbidity to wander through the medical system with needless interventional diagnostic and therapeutic interventions, until finally obtaining a psychological evaluation which reveals the relevant psychological or psychiatric problem.

The final problem that I want to bring to light is the paucity of pain-oriented behavioral specialists. One certain cause of this is the lack of demand for these specialists. Since many of our pain management colleagues practice without our behavioral colleagues' expertise, the demand is low for these valuable practitioners. I have had the pleasure of working among superb behavioral consultants such as Janice Livengood, Robert Jamison, Stan Chapman, Dan Doleys, Jeannie Koestler, and others. As a result, I've made a conscious effort to include behavioral intervention as a part of my multidisciplinary strategy, having witnessed some of the near-misses of trying to practice pain medicine without the expertise of my behavioral colleagues. Another approach to creating demand for additional pain-oriented behavioral specialists is to encourage psychology externs to visit our practices. In this way, they can become familiar with the challenges and even conduct research projects for us in our field of pain medicine.

In summary, I remain committed to advocating the beneficial aspects of the behavioral components of pain medicine; and I look forward to hearing from my SPS colleagues regarding other strategies to enhance behavioral health benefits coverage and patient compliance.

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