BOSTON – A patient care process initiated to ensure that opioid prescriptions adhere to high standards of appropriate use and safety has potentially improved the quality of pain management while increasing revenue, according to a detailed analysis of the initiative presented at the International Conference on Opioids.

The process, started 2 years ago in a pilot program, involves a series of steps to evaluate pain patients for their suitability for opioids and then monitor their course of care, said Dr. William G. Brose, an adjunct clinical professor at Stanford (Calif.) University and chief executive officer of the HELP Pain Medical Network.

The process, called the Analgesic Adherence Program (AAP), was constructed out of published guidelines and standards of care, particularly those issued for opioid use by the medical board of the state of California, where the for-profit HELP Pain Medical Network has more than 30 locations. Concern about liability from prescribing opioids was a major impetus for development of the AAP.

“I wanted to try to keep myself safe, to try to keep my patients safe, and to try to keep my practice secure,” Dr. Brose explained.

The process begins with initial risk stratification for which the Medical Board of California specifies the tools. Other states might specify different tools or no tools, although every state has now established recommendations for the use of opioids, except Alaska and Illinois, Dr. Brose said. He said 18 of those guidelines have been updated in the last 4 years, and those following his lead should adhere to state-specific standards.

Subsequent steps include educating patients about the risks and benefits of opioids, seeking informed consent, and then selecting a monitoring program suitable to the patient’s circumstances. Throughout each process, the AAP includes detailed decision trees, including the option to refer patients to specialists if a risk level exceeds the comfort level of the clinician or institution.

Most of these steps, such as risk assessment and seeking informed consent, are billable and performed by nonphysicians. This was captured in an evaluation of 192 new patients and 662 established patients entered into the AAP process over the past 12 months. Relative to usual management, physician time was essentially unchanged, even though time spent by nonphysician clinicians, coders, and billers, rose.

As a result of the AAP, the tasks of the pain specialists have shifted. According to Dr. Brose, his job and the job of other pain specialist physicians in his network is “basically exception management.” This means that Dr. Brose focuses his attention on “the people who are not doing what they are supposed to be doing.”

Those patients, Dr. Brose said, are the more interesting ones, and this approach results in the most efficient use of physician time.

The AAP was created by Dr. Brose for the HELP Pain Medical Network to address growing concern about the medicolegal risks from prescribing opioids. Dr. Brose reported that increased revenue for the network has been a byproduct. Although the implementation of AAP has been associated with some increased costs, average per-year billing for new chronic pain patients evaluated for opioid prescriptions has climbed from $900 to $1,950 per year. For established patients, per-year billing climbed from $600 to $1,300.

“If you go through the effort to establish this kind of process, you’ll increase your revenue and you will be delivering safer, more effective, consistent monitored care,” Dr. Brose said.

Dr. Brose is a stockholder in the HELP Pain Medical Network.


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