Precedents and Prospects for Success

Jennifer Christian, MD, MPH, FACOEM

Spine 10 x 25 Research Summit

July 18, 2015 Burr Ridge Illinois

Conflict of Interest

President and major stakeholder of Webility Corporation which provides:

System, program, and case management consulting to healthcare delivery organizations, managed care companies, large employers, disability & workers comp insurers, and government agencies.

Non-medical (BPSE) services directly to patients.

Education: MD, MPH Univ. of Washington (Seattle).; Board cert. in occupational medicine. Expertise: Leadership, outcomes improvement (health & function, disability), innovation & pilot programs.

Relevant Experience:

Former public health officer for Anchorage, Alaska. – 300,000 pop.

Former state medical association president (Alaska)

Former CMO, VP of Managed Care company, building provider networks and “report cards” for physicians in 7 state.

Chair, ACOEM’s Work Fitness & Disability Section

Founder, The non-profit 60 Summits Project

Member, SAW/RTW Policy Collaborative, US Dept. of Labor, Office of Disability Employment Policy

Developer and Lead Guide, Maze-Masters Program – non-medical tutoring and coaching to help individuals chronic pain who are “lost in the system” get their lives back on track.

Precedents Successful transformations: Turning private tragedies into public health goals, new professionals, programs, and initiatives.– Maternal/fetal death, domestic violence, drunk

driving, HIV prevention (all blood-borne pathogens), hospice (now occurring)

Unsuccessful healthcare transformations (so far)– C-section rate, antibiotic use for viral

infections, low back disability, etc.

Changes that make doctors more money are easier and move faster.

Prospects of Success: Guarded

Insanity is doing the same thing and expecting a different result.

This initiative has to be DIFFERENT.

If we are going to do research, it has to be DIFFERENT in a profound way.

If we are going to try to change things, we have to take a DIFFERENT approach.

What does DIFFERENT look like?

Potential Context for Action: Part I

Reducing spine disability 10 x 25 will require a multi-stakeholder approach.

E.O. Wilson – Harvard “Consilience”– As we have become more specialized, we have moved

further away from the big problems at the center. Example: the world’s oceans

Problems that the 20th century left unsolved for the 21st century to tackle tend to be ones that cross disciplines and social sectors.

Our society currently lacks powerful mechanisms that allow and foster inter-disciplinary and inter-sector collaboration.

Success will require our establishing it.

Fundamental purpose of healthcare / helping services is to allow people to participate fully in human life.

Michael Porter NEJM: Value of healthcare is delivered when: – People stay alive with minimized impairment.– Duration of life disruption is minimized.

Worklessness among working age adults has many toxic consequences: increased morbidity, mortality, mental and social dysfunction, poverty, multi-generational impact.

Potential Context for Action: Part 2

ALL healthcare/helping professionals earn more money when their patients have bigger (fancier) problems and they suffer more.

Overall, our society has: – Over-medicalized common everyday life

experiences;– Created iatrogenic impairment through

health care – Created system-induced work disability. – Which has increased their cost and worsened

their impact on life.

Potential Context for Action: Part 4

Acknowledge powerful role of economics.

Revise the term “biopsychosocial” (BPS) to bio-psycho-socio-economic (BPSE).

The failure to re-unite mind / body and to focus on healing the multi-dimensional life of a whole person is producing sub-optimal outcomes in all health conditions known to be influenced by BPSE factors.

It is time to exploit the THERAPEUTIC implications of the BPSE model.

Potential Context for Action: Part 3

All stakeholders have incentives:– Patients / people with pain– Healthcare professionals– Healthcare, workers’ comp and disability

insurers– Employers– Taxpayers / government

Why are we not holding ALL stakeholders accountable for the role they play?

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Potential Context for Action: Part 5

What Will Look DIFFERENT

Once We Are Successful?

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3 Sets of Mechanisms in PlaceIncreasing the frequency with which the right things happen when working age adults develop low back pain.

Reducing the frequency with which the wrong things happen.

Driving things forward - A multi-stakeholder organization consistently advocating for and making things happen.

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FORMULA FOR IMPROVEMENT Functional impairment, “invalidism,” and work disability are often preventable (thus may be needless or iatrogenic when we observe them).

“Sickness”, “pain” & “disease” are distinct and co-exist. All are real and are human problems.

A person’s functional status after a health problem occurs is often best explained by factors in NON-medical domains.

Thus, the problem has shown up in the medical domain, but the solution lies elsewhere. So let’s expand our therapeutic repetoire!

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Right Things More Often

Physicians at entry point of care: – View worklessness and social withdrawal as

poor outcomes that all patients should avoid. – View evidence-based treatment guidelines as

the route to best outcomes. – Use BPSE model of pain, sickness and disease

to UNDERSTAND problems, GUIDE treatment. – View their own words and interactions as part of

the treatment – avoid nocebo, employ placebo. – Can employ and refer for an expanded

repertoire of interventions.© Copyright Webility Corporation – reprinted with permission 14

Right Things More Often

More musculoskeletal, spine and pain specialists:– Have characteristics described on prior slide – And are even MORE expert at assessing and

weighing relative contribution of biomechanical, pathological, and BPSE factors – and discussing them with patients.

– Assure that BPSE factors are identified and addressed PRIOR TO any aggressive intervention, or when recovery is sub-optimal.

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Right Things More Often

SUNSHINE: Visibility of and accountability for functional and work outcomes and job loss / gain by: – Individual clinicians– Healthcare delivery organizations– Health payers– Employers– Workers’ comp and disability Insurers– Government agencies serving PWD

Trading patterns heavily influenced by data on life outcomes/cost.

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Right Things More OftenFrequent use of (and payment for) best practices and evidence-based interventions that are underused today:– Attention to elapsed time– Care coordination and multi-party

communication/collaboration– Education to increase health literacy– Shared medical decision-making– Behavioral medicine intervention– CBT for depression, anxiety and pain– SAW/RTW and vocational services

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Right Things More Often

Design of patient visit now includes

addressing patients’ reasonable concerns

directly:– How long am I going to be laid up? – How long do I have to take it easy?– What can I still do? What shouldn’t I do? – What should I do to speed my recovery? – When will life be back to normal? …if ever? – What does this mean about me? My job?

My livelihood? My future?– How will I pay the rent this month?

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Right Things More Often

All back surgeries are being done after evaluation by BPSE providers, and either pre-habilitation or rehabilitation in collaboration with them.

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Early Screening & Packaged Intervention Programs Can Provide Extra Support

Many evidence based screening instruments predict increased risk of poor outcomes, but no generally accepted method to evaluate all BPSE domains on a routine operational basis.

“Chronic Disease (or Chronic Pain) Self-Mgt Program” - 6 sessions

“Personal Health Improvement Program” – 6 sessions

“Progressive Goal Attainment Program” – 10 sessions

Shared medical decision-making - 1-2 sessions

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Regular Use of New Materials/Suppliers/Vendors

Community resources (ACPA, etc.)

Health education / health literacy

Instruction in self-care and self-management skills for chronic conditions

Facilitation of shared medical decision-making (“real” informed consent)

Life skills training, including workplace.

Coping / resiliency training

Multi-dimensional intervention

Function and work-oriented– Behavioral medicine practitioners– Cognitive behavioral psychotherapists

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Wrong Things Less Often

See SUNSHINE: Visibility / Accountability for outcomes on previous slide

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10th

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Hypothetical Total Resource Utilization by Percentile

Resource Use by Decile

Wrong Things Less OftenEvidence-based guidelines have been adopted by legislation and presumed to be correct (replacing presumption that treating physician is right.)

Fewer back surgeries being done for problems that are:– Caused by unacknowledged BPSE factors– Complicated by unacknowledged BPSE

factors

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Wrong Things Less Often

Revised medical / HCP board statutes and regulations allow disciplinary action against physicians with practice patterns that result in poor disability outcomes.

Good working relationships between medical boards and employers/insurers who have data re: practice patterns and outcomes.

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