Special Commission to Examine the Feasibility of Establishing a Pain Management Access Program

Special Commission to Examine the Feasibility of Establishing a Pain Management Access Program August 16, 2016

Present: Secretary Marylou Sudders, Chancellor Michael Collins, Heidi Sulman, Niels Puetthoff, David Seltz, Ray Campbell, Dr. Candace Sloane, Dr. Debra Poskanzer, Dr. Dennis Dimitri, Dr. Robert Cohen, Dr. Dan Fanselow, Dr. Paul Mendis, Alysa Veidis, Rosa Rodriguez-Monguio, Dr. Scott Sigman, Dr. Julian Robinson

Summary of the Discussion: Secretary Sudders called the meeting to order and introduced Assistant Attorney General Jonathan Sclarsic to give a presentation to Commission members on the Opening Meeting Law.

Jonathan Sclarsic gave a brief overview of the Open Meeting Law and informed members of their obligations under the law.

Secretary Sudders reviewed the legislative authority and charges of the commission: a. Review the development of a referral process to make pain management specialists accessible to primary care providers, including a process similar to the Massachusetts child psychiatry access project (MCPAP); b. Review the establishment of a pain management specialty certification through the board of registration in medicine to refer a primary care provider through MCPAP; c. Review ways to incorporate a full spectrum of pain management methods into provider care practices including non-opioid evidence-based alternative treatments; d. Review the current coverage of pain management through commercial and public insurers; and e. Reviewing ways to ensure a full spectrum of pain management interventions are covered through commercial and public insurance health plans

MCPAP PRESENTATION Secretary Sudders then introduced the first presenter, Marcy Ravech, Director of the Massachusetts Child Psychiatry Access Project (MCPAP).

Marcy Ravech gave a presentation on the history of MCPAP and how the program works.  Program’s mission: to enhance the ability of Pediatric Primary Care Providers (PCPs) to promote and manage their patients’ behavioral health as a fundamental component of overall health and wellness.  Ms. Ravech noted the goals of the program: to improve the pediatric team’s competencies in screening, identification, and assessment; treating mild to moderate cases of behavioral health disorders; making effective referrals to community service; and coordinating the care for patients who need community-based specialty psychiatric and behavioral health services. She said the overall goal is everyone has access to the right care in the right place.  MCPAP is insurance blind, which is a critical feature of the program.  Ms. Ravech reviewed the history of the program.  The program is organized into six regional teams, split up geographically and by population – the 1.5 million children in Massachusetts – which leads to close relationships with providers.  The new model, after their redesign just this year, is to have two psychiatrists on each team, so one can be in the office answering questions and the other can be in the field training providers.  There is a full-time licensed therapist in the main office to answer any questions and a full-time referral specialist focusing on care coordination and working directly with the doctors and families.  Ms. Ravech briefly discussed the MCPAP for Moms model

Questions for Ms. Ravech:  Secretary Sudders asked how the insurance coverage was distributed. Marcy Ravech answered 55% commercial, 45% public.  Ray Campbell asked how they track their data. Marcy Ravech answered they track all data through their own database.  Dan Fanselow asked what measure of success does MCPAP use. Marcy Ravech answered their measure of success is how often they are being used.  Debra Pozkanzer initiated a discussion about whether a doctor-patient relationship exists between the MCPAP specialist and the patient and how that relates to liability. Marcy Ravech said there is no doctor patient relationship. Dr. Candace Sloane noted it has never been an issue with BORIM in the two years MCPAP has been implemented. Debra Pozkanzer noted that physicians who have written recommendations could be held responsible. Dr. Candace Sloane noted the physicians are not rendering care, but advising colleagues.

Further discussion about MCPAP:  Secretary Sudders noted that MCPAP’s pilot was initially funded as a special project by DMH as an appropriation in the budget.  Robert Cohen asked how individual providers find a fair compensation value. He followed that up by asking if care could cost less as a result of a MCPAP program for pain management. He noted he wanted a process they can use to determine fair market value.  Dennis Dimitri noted he thinks MCPAP worked because all parties involved were so committed.  Secretary Sudders explained that the fact that there were six academic medical centers with strong commitments to psychiatry, especially child psychiatry, helped MCPAP immensely. She noted that being insurance blind was a key piece of MCPAP’s success. She also highlighted the American Academy of Pediatrics adding screens to their list of requirements assisted with advocacy.  Julian Robinson noted that child psychiatry at the time was a burgeoning field when MCPAP was being developed. He also noted that MCPAP for Moms was effective because it was very specific.  Angela Veidis asked what Ms. Ravech foresees in the future with the new model. Marcy Ravech answered more practice-based consultations.  Debra Pozkanzer asked, with the restructuring of Medicaid going towards a more ACO system, how coordinating care will change. She noted the resource and referral process would become more complex. Marcy Ravech noted that the MassHealth restructuring was the impetus for MCPAP’s review. She noted, moving forward, MCPAP will train teams in different ACOs. She noted MCPAP is now focusing on helping providers access resources they have in their ACO through their network, and working with practices on a closer basis. She noted they will focus on collaborating with health plans and ACO systems to make the system work more efficiently.  Paul Mendis asked if Ms. Ravech thinks the MCPAP system can be broadened to pain management. Marcy Ravech noted it could.  Debra Pozkanzer asked, with MCPAP being payer blind, do they have to acknowledge insurance coverage in the referral process? Marcy Ravech noted that MCPAP educates families on what is available in their networks.  Paul Mendis asked if MCPAP has noticed a reduction in psychotropic medications. Marcy Ravech answered definitely; pediatricians do not want to touch them now.

MMS PRESENTATION Secretary Sudders introduced Dr. Dimitri

Dennis Dimitri began the Massachusetts Medical Society’s Presentation on their Massachusetts Access Program for Pain (MAP for Pain) (MAPP). He noted back in 2014, when the Massachusetts Medical Society had their Opiate Task Force, they were consulting with pain specialists, but there were not many around, so they thought to use a model such as the MCPAP or Project ECHO model as a model for pain management.

Brendan Abel continued the presentation.  Doctors need references for referrals to pain management for two populations – those patients approaching the 90-day mark with opioid prescriptions and those over 100 milligrams of morphine equivalent dose (MED) per day.  PCPs see many similar patients, and if they were able to consult with a pain management specialist, they would not have to be in the dark with receiving advice.  MMS’s proposal is addresses adult patients with no addiction history and non-palliative and non-cancer care. This is about keeping PCP patients in the PCP’s office. He said it would be set up on a regional basis – as MCPAP works better because of geographical and professional connections to the community and PCP.  Training and education in the field would be very effective, with Continuing Medical Education (CME) on pain management taught regionally.

Candace Sloane noted the proposal was terrific, doctors are scared of prescribing; this accomplishes taking care of ill patients and providing doctors with professional advice. She said she just heard from three doctors yesterday who were concerned. Doctors are worried due to time commitments to patients and over prescribing of opioids.

Alysa Veidis noted that the dependence piece is the elephant in the room – 50%-70% of her patients who have chronic pain are opioid dependent.

Debra Pozkanzer noted as a practicing physiatrist in a rehab setting that is moving away from prescribing, there needs to be some way to catch patients before they become chronic pain patients.

Scott Sigman noted that this is a fantastic idea – the 90-day window is what we need to dovetail, chronic pain patients should be separate. He noted many of his patients are going through major orthopedic surgeries without opioids – we need to help doctors with training on alternative treatments.

Paul Mendis noted we need to figure how to manage pain in those with addictive disorders. Rosa Rodriguez-Monguio asked about outcomes and costs of the MMS proposal. Brendan Abel answered the Massachusetts Medical Society has not gotten there yet. Dennis Dimitri noted that outcomes would be reduction in opioid deaths and dependence.

Heidi Sulman noted that we need a solid clinical basis if we are going to implement this.

Candace Sloane said we have six AEGME pain management centers in Boston. She noted this must be a multi-model approach which has to be reimbursed.

David Seltz noted that it seems like MCPAP or Project ECHO could be utilized in this setting, and asked Mr. Abel if MCPAP is the priority. Additionally, he asked how they arrived at this proposal – whether there were stakeholders , focus groups, etc. Brendan Abel answered that the guidelines from last summer helped generate this when many physicians have reexamined and reevaluated their prescribing practices, this has led to all these new questions; inheriting patients on high levels of opioids has become more common; a confluence of factors led us here. No survey work to date.

Chancellor Collins noted that the consensus is it seems like a MCPAP-like program would benefit the Commonwealth, asking how funding would be obtained. Brendan Abel noted a fair amount of details still need to be addressed prior to asking for funding. Debra Pozkanzer asked would it be a regional team approach, possibly a pilot – could be entirely consistent with this approach.

Presentations Concluded. Secretary Sudders adjourned the meeting.