Welcome back to the Healing Pain Podcast with Dr. Michael Schatman
In this episode, we are discussing the impact of the health insurance industry on the effective treatment of chronic pain. This is a topic I have been wanting to create some content around for some time. When I look back at the evolution of the show, the episodes typically fall into two buckets. I’m either talking about effective treatments, trying to build, spread awareness around conservative effective treatments for chronic pain or I’m talking about the latest, or some new research that I feel is innovative.
In those two buckets, I’m also always looking for where are the problems and the barriers for us as professionals and for people living with pain to access effective pain care. When I look at the problems, there’s one big problem that is like a big flashing red light, the elephant in the room. That’s the health insurance industry.
I asked myself, “How has this changed throughout my career?” As a physical therapist, I started practicing or treating patients in 1997. In 1997, I can’t think of too many barriers for me treating a patient. When do I say that I’m talking about how much it costs a patient to access conservative pain care and then is that treatment covered? Those are the two big issues, “How much does it cost? Is it covered?” I can tell you back in 1997, I don’t remember any patient having a deductible. If there was a copay or something moderate, it’s maybe $5 or $10.
I’m not saying as citizens, professionals and people living with pain that we shouldn’t be fiscally concerned about the delivery of healthcare because that’s important, especially in the United States of America. However, I can tell you in 2021, the average American contributes to their health insurance. Meaning there’s typically an employee portion each month as an employee that contributes to your monthly premium. There’s also an annual deductible and then there are copays on top of all of that.
As people in the United States of America, this may be the most important for those of us who live in the United States but I know this impacts all of us around the world, we are paying a lot of money into our health insurance. We have to ask the question, “What are we getting back? What is the benefit that we are receiving?” The average deductible in New York City, the place where I live, is somewhere between $5,000 and $10,000 for a family plan. I have seen family plan deductibles upwards of $20,000. It’s clear that premiums have increased.
The second thing for us to consider is copays. When I first started in 1997, copays were maybe $5 or $10. It’s not uncommon now. I have seen copays that equal the cost of the PT visits. Copays that run anywhere between $40, $50, $60 and $70 upwards to $100 to receive physical therapy care. We are paying more.
However, at the same time, I have also seen visits decrease. In the United States of America, this varies depending on the diagnosis and where people live, the average length of stay for a PT session is about twelve visits. Consider you have to treat someone who has fibromyalgia and you only have two visits per week for six weeks for a total of twelve visits before the insurance company terminates care.
Effectively, what large insurance companies have done is have contracted or hired third-party medical management companies, which come in. It’s what they call they manage health insurance claims, which I would like to call what it is the aggressively deny claims for conservative care. This includes things like physical therapy, occupational therapy, speech, mental health services, as well as addiction treatment.
Not only do they manage that care but oftentimes, insurance companies will not approve a patient seeing multiple providers. For example, insurance companies often regulate if a patient is seeing both a physical therapist and chiropractor or a PT and OT. Any combination of those, they don’t like when patients are using their insurance to the fullest extent.
Let’s carry that over into what is identified as the gold standard for the treatment of chronic pain, which is multidisciplinary or interdisciplinary care. That’s when the patient can access multiple providers. In the United States of America, we have one interdisciplinary chronic pain clinic for every million people that focus on chronic pain management.
Why do we have that? Insurance companies have identified this as expensive care. It’s too expensive to pay multiple providers, at the same time, they have severely cut back on those programs probably since the early ’80s somewhere. That’s when that trend started. That has come back somewhat but we haven’t seen a revitalization of interdisciplinary chronic pain treatment programs in the United States of America specifically because insurance companies won’t pay for the care.
Lastly, I don’t want to just focus on private health insurance companies in the United States. We have things like Medicare and Medicaid, which are government-sponsored plans. Those two have been cut every year it seems. Some emails go out by organizations, such as the American Physical Therapy Association. It’s called Stop The Cut. That’s where the Medicare fee schedule is reduced.
Each year or every couple of years, the national government tries to reduce payments to outpatient physical therapy services. When payments are reduced, it often has an impact on the number of visits that we can see patients for and the quality of care that we can provide in an outpatient setting. The question is, “How does the health insurance industry perpetuate the chronic pain crisis?”
Joining me is Dr. Michael Schatman. He is a clinical psychologist who spent many years working in multidisciplinary chronic pain management. He is on the teaching faculty of the Department of Public Health and Community Medicine at the Tufts University School of Medicine in Massachusetts and serves as Director of Research and Network Development for Boston PainCare. He has authored more than 100 journal articles and book chapters on chronic pain management and lectures regularly at the international level. He is also the Editor-in-Chief of the Journal of Pain Research.
In this episode, we are going to talk about the health insurance industry and how it impacts the treatment of chronic pain. This is an important episode. Make sure you share this with your friends, families and colleagues all over social media so we can raise awareness on this topic. Let’s begin and meet Dr. Michael Schatman.
Watch the episode here:
How The Health Insurance Industry Perpetuates The Chronic Pain Crisis With Dr. Michael Schatman
Michael, welcome to the show. It’s a pleasure to have you on.
Joe, thank you very much for inviting me. I’m excited about being part of this wonderful show.
I came across your research and I like your research because it’s quite bold around important topics. You are someone I want to reach out to, interview, share your information and perspective. It’s vitally important in the United States of America about pain populations. You are a Licensed Psychologist. You do a lot of research now and you are the editor of a journal. Give us the simple backstory on where you came from and where you are now.
I go back to college where I studied Political Science way back in the late ’70s, early ’80s at Columbia and then ended up going to Psychology and Behavioral Medicine specifically. I was introduced to back pain at the Texas Back Institute in the mid-’80s. I have done nothing but pain work since. However, after spending many years solely as a clinician and someone who developed, and ran an interdisciplinary pain program in Pennsylvania many years, I started seeing that there were a lot of ethical problems in chronic pain management in particular.
I went back into my ethical philosophy in PoliSci days, started writing and put out a book, Ethical Issues in Chronic Pain Management. That was my jumping-off place into academia. I have been a double agent for many years in time in patient care directly but also spending time as a lecturer, policy writer and now, clinical pain researcher. None of them do well but I do a lot of things as my publication record seems to suggest.
It’s a good segue to where we are here, talking about the health insurance industry and how that impacts populations of people with chronic pain, how did that become a focus for you?
It became a focus for me when I saw that ultimately around 2004 or 2005, my last years at the pain clinic in Pennsylvania, that insurers were no longer terribly interested in paying for an interdisciplinary pain clinic of the 6-week, 35-hour week program. That was truly interdisciplinary, including physicians, psychologists, physical therapists, occupational therapists, vocational counselors, biofeedback therapists, nursing, nutrition. We are teaching patients with intractable chronic pain how to self-manage their pain, get back to work, have productive lifestyles and quality of life.
Insurers, even though the data that come from countries that have national health services, show that it’s extremely cost-effective as well as clinically effective. The insurers know that the average American switches insurance carriers about every three years. Rather than putting investment into a labor-intensive program, they will start by saying, “Just prescribed medications,” and that didn’t lead anywhere real good.
This is what year?
In 2005 was when I started to see it. We have gone from over 1,000 interdisciplinary pain programs in this country in 1999 down to about 90 in 2012 when I wrote an article for the International Association for the Study of Pain. In our last count, there are 38 of these programs left and most of them are carve-outs. Meaning that insurance will pay for services and not for others. That shrank, the programs lost. The outcomes are pretty pitiful compared to those that we used to see for years.
From the late ’90s to 2005, let’s say the number of interdisciplinary or multidisciplinary pain programs shrank. My first question is, the data you have, does it include the VA system as well or we are just looking at private insurance programs?
That is looking at the VA data as well. Jennifer Murphy, with whom I wrote the most recent chapter on interdisciplinary pain management in the most recent edition of Bonica’s Management of Pain asked her to co-author it with me. I had written the previous one solo but she was running interdisciplinary pain management for the VA system.
Even those are now carve-outs because the VA doesn’t want to spend the necessary money and even though Jen is doing some great work. Three hours, three days a week at most of the programs that do exist, there are about twenty of them around the country is certainly insufficient. If you are not in a certain catchment area, you are not going to get into a program. I reviewed an article, looking at less impressive outcomes.
Why did they shrink so much?
They shrank because they are expensive. When I moved to Seattle in 2005, a couple of years later, they shut down the first interdisciplinary pain program at which was one that John Bonica, Bill Fordyce and a handful of others started at the University of Washington. That program at that point, in 2007, was about $30,000 for a four-week program. It was a spectacular program. There’s no question about it.
I’m not sure if it was not making money or losing money but they decided it was not consistent with the mission of the hospital. Curiously, they took that space and set up a cosmetic plastic surgery that’s very profitable. It comes down to dollars, cents and the bottom line of insurance cost containment and profitability of a business ethic. That collides with medical ethics and certainly with the concept, which I believe, which is pain management as a fundamental human right.
I want to talk about a lot of those topics but I want to balance these two ideas and concepts we are talking about. You had mentioned that interdisciplinary pain management has research around it that says that it’s cost-effective but yet four weeks of treatment and I’m assuming that’s inpatient treatment you are talking about or daycare.
That’s outpatient. That would typically be 35 to 40 hours a week. There’s only a small handful of programs that are inpatient that still exist in one at the Tampa Haley VA that Jen runs but that’s the only one in the VA system that’s an inpatient program. I believe that inpatient programs are still available at Mayo Clinic and Cleveland Clinic.
These programs were particularly important as inpatient entities because part of the goals of these programs was to gradually keep people off their opioids. That made a lot of sense, reducing opioids while giving patients other tools to independently self-manage their pain but they stopped paying for the inpatient. How certain programs can maintain inpatient presences, I’m not exactly sure because that makes it even more effective.
The program that I ran for years in Pennsylvania that I started back in 1989 and I still do some consulting with them, they are still up and running in a lot. When I left, it was a 35-hour week program and we can only treat twelve patients at a time. We had much personnel that is highly skilled. Not kids right out of school but seasoned therapists of various types and they don’t come in extensively. We can only treat that small number of patients. These programs are not particularly profitable, to say the least.
You have this kind of dynamic happening of the program it’s not profitable and it’s expensive for someone to go through a 30-hour program four days a week. What you are saying, when you look at the research, is that it’s more expensive to have someone living with chronic pain, potentially disabled on the greater healthcare system than that $30,000 that’s being spent for the four-week program.
This is why the European Union countries and the UK have been growing their number of programs because they own the patient’s healthcare, including their pain care for life. They are also interested in seeing them get off of say, any kind of disability compensation. If you are an executive with a for-profit health insurance entity and insuring me, and I happened to be on Social Security Disability, that doesn’t affect your thinking in any way, shape or form but in the more civilized countries, there’s a responsibility for the citizenry. We just don’t have that in the United States. It’s capitalism gone rogue.
There’s a disconnect between someone being on disability, Social Security income, not having a job and not being a productive member of society. The insurance company doesn’t necessarily consider that because they are a publicly-traded company. A publicly-traded company, its main objective is profitability.
I have had discussions with the medical directors of these companies. They said, “We have no fiduciary obligation to our enrollees whatsoever. Our sole fiduciary obligation is to our shareholders.” When that individual said that I looked into his eyes and I was like, “You didn’t just say that, did you?” I repeat these years later. If you look at the CEO salaries and bonuses, they have gotten out of hand.
It was in 2016. I may be off by a year, for example, where a UnitedHealthcare CEO made $66.1 million. It has been reported in the mainstream media, yet as a clinician trying to get an 11th and 12th session of physical therapy in a calendar year for a patient that had multiple pain generators was almost impossible, yet the CEO is making $66.1 million.
The fiduciary responsibility is to the shareholders, the people who purchased the stocks, in essence, versus the person who has the insurance card in their back pocket.
People who are insured, the enrollees, have become fungible. They have lost all of their meaning and value to society, and good programs, including the one that I had started in Pennsylvania. We returned 85% of our patient’s year-after-year to work. If you look at the programs now, a lot of them won’t even have a vocational component. The goal is shifted from getting them back to being contributing members of society to just getting them off their opioids.
The reason that that’s happened is that the insurers understand that with chronic opioid therapy, there are a lot of comorbidities and that these comorbidities are expensive to treat. They have shifted their thinking and messaging from, “Give them medications to don’t give them medications because the research has shown great expenses associated dealing with the comorbidities and certainly the development of dependence in opioid use disorder. That’s only the tip of the iceberg because there are other comorbidities associated with clinical opioid therapy.”
I’m not anti-opioid. I’m not one of the pro-opiate people, either. I’m pro-patient. I believe that opioids need to remain a part of the chronic pain management armamentarium with certain patients, for whom there are no other options. As insurance pays for less and Coordinated Care has gone by the wayside, opioids will continue to be important if we didn’t have state legislation and such that turns doctors into criminals for prescribing.
If a patient wanted to piece together their own interdisciplinary pain team, could they successfully do that within the constraints of the insurance system now?
Most patients will look at your discipline of physical therapy. If I can divulge that, a lot of physical therapists like seeing young, athletic, in-shape individuals with acute injuries, they come to see them twice a week for a month to give them their exercises. If they are better, they go home. The amount of physical therapy generally needed for someone with severe chronic pain coming from multiple generators are a lot more than would be needed for someone with a typical post-injury acute pain on physical therapy. Every five years, I dig myself up skiing, running or doing whatever I’m doing. I’m in and out. I’m old. It’s a different paradigm. It would be very hard for the patient to piece it together.
The other thing that’s important in regards to your question is the distinction between interdisciplinary and multidisciplinary. We have a multidisciplinary system. Meaning they see a lot of different disciplines but not in a coordinated fashion. Rather, we do sequential care. If you are my primary care physician, I come in with chronic pain. You will start me on some kind of medication.
I may come back a month later saying, “It’s not helping.” You may say, “I don’t know if I want to go to opioids or increase the opioids you are already on. Let’s send you to physical therapy.” In physical therapy, I’m not doing well because I’m not totally adherent. I’ve got a lot of emotional sequelae to my chronic pain condition. I’m not necessarily trusting.
You kicked me back to the PCP, the Primary Care Physician and say, “That didn’t work. Let’s get some injections and send you to a pain specialist. It’s 1, 2 and 3 epidural steroid injections and you are out.” The American society is fixated with the number three. In baseball, with three strikes you are out with the whole trinity. I have not quite figured this all out.
A big complaint of primary care physicians that I trained in pain management is when I sent it to a specialist, they never touch the medications. I know physicians that I have worked with who when I call them up and say, “This patient needs this and that. We need an antidepressant on board. We need consideration of a therapeutic level of a gabapentinoid,” they go, “Call the primary care. We don’t do medications at our practice.”
They do the things that are grave in many cases. They don’t get into the holistic overall treatment of the patient with pain. After the injections don’t work, the physician may say, “This person needs to go see a shrink.” They send them to a psychologist. There’s a shortage of pain psychologists in this country. When I left Seattle in 2017, my partner in my practice and I were the only trained pain psychologists in private practice. There are plenty over on the other side of the U, who are academicians and great researchers. They are some of the best but because they were doing a lot of grant writing, bringing in tens of millions of dollars, a lot of them are not even allowed to see patients, much less want to see patients.
This is why I’m engaged in the project with North Carolina State University. We started with the first pain clinical social work program in the history of the country because we need to provide good mental health pain treatment and behavioral treatment to chronic pain, which is very hard to find. Even a lot of university pain treatment centers are unable to find that. I’m talking about some well-known universities.
When you are talking about stepped care in that whole story, you mentioned that there are steps of different care in there. A lot of times now, a couple of steps are just traversed in one shot. Try physical therapy, “That doesn’t work our right to injections.” There are pieces in there. In your research in working with insurance companies and these interdisciplinary treatment centers, how do we start to free ourselves from where we are?
That’s going to be difficult. One of the problems as I see it is that we are the only industrialized nation in the world without a national health service. Even though we spend twice as much per capita as any country in the world in healthcare, including pain care, we ranked number 37 in the world between Cuba and then a country whose name I can’t even pronounce. A big part of that is access to care. We have a system where not only is the insurance industry but the hospital corporation industry, which is rich and powerful, are sucking up the resources that should be available for healthcare and certainly for pain care. This is a problem that we are having.
I spend time every year in Europe, at least on one occasion, lecturing my Italian, British, Belgian and Spanish colleagues. They pointed out that we are barbaric in that we just don’t care about people. We care about, “Capitalism is good. Anything else that’s socialized stuff that Bernie Sanders wants is very bad.” I’m not a communist, mind you. I like being able to live in a nice condo in Boston, send my son to college at NYU and drive a nice car but certain things are commodities, healthcare and pain care.
As doctors Brennan, Carr and Cousins wrote in 2007, “These are not commodities. These are fundamental rights.” Unless we get the extraneous resource-sucking players out of the game as has every other civilized country in the world, I see very little hope for healthcare generally, including pain care. Our system is clever in that we have discovered that it’s much more profitable to treat a disease than to prevent it.
The first step should be a promotion of pain care. That’s the first step in the entire stepped system that you are talking about. Health promotion continues through every step. There’s a little room in our current system the way it’s set up. Are there other models in the United States of conditions that were problematic at one point and have changed? Have we found solutions to changing them that we could follow in pain care to help improve it?
None of which I’m aware of. Some conditions are treated much more effectively than chronic pain but chronic pain is such a complex condition. It’s not something that attacks you just physically but something that often attacks you vocationally, legally, recreationally, socially, sexually, spiritually and emotionally.
There are so many different dimensions and one is being that are affected by chronic pain, which I consider disease of the person. To throw simple solutions to complex problems is clearly a sign of simple minds. It is simple minds that look at just the profitability of an approach and that’s what’s happened. I don’t want to sound like Che Guevara of pain medicine but it’s necessary. This is why pain care in our country is so woefully poor.
If we take it out of the healthcare spectrum, stop looking at it as a disease and start to look at it as a human rights issue, it puts it into a completely different context in a way. Are there human rights movements that we could potentially lean toward and lean on about chronic pain?
For example, the Americans with Disabilities Act attorneys and the ACLU seem to be not particularly interested in the plight of chronic pain patients. We have spoken to these groups about that since the opioid pendulum has swung from the indiscriminate prescribing years ago to prank opiophobia and oligoanalgesia and the fact that so many Americans with chronic pain are killing themselves daily. Within the VA system, 21 veterans commit suicide a day.
The VA has acknowledged that the majority of them suffer from chronic pain. If we extrapolate out from there into the non-VA, we are potentially talking about many hundreds of suicides being committed by undertreated chronic pain patients every day. Whereby the oligoanalgesia was at least a part of the reason for the suicide but how do insurers respond to that? “That’s one less expensive patient.”
I wrote an article with Lynn Webster, the past President of the American Academy of Pain Medicine. We published it in 2015 on insurances’ refusal to pay for abuse-deterrent formulations of opioids, which continues to this day. We went as far and we’ve got a little bit of heat for this. The article has to state, “Insurers would rather see a patient who is expensive to maintain expire as opposed to having to pay for their very expensive treatment on a long-term ongoing basis.” It’s perverse in many of our eyes.
I hope that this current administration that we can get to them once COVID is brought under a modicum of control and help elucidate the problem of the chronic pain crisis that we are in, whereby we have 50 million chronic pain patients in this country. By conservative estimate, twenty million of them have high-impact chronic pain but a progressively lower percentage of these patients can access opioids and analgesia. They are likely too far gone to benefit from some other treatments. What do we do with them? By doing nothing with them, we are essentially killing them. Patients are angry with social media. It’s crazy.
We know that well here because our community talks about those things, both the practitioners and people with pain who follow this show. We know the challenges here. I always take a curious stance toward things. I try to see all sides of the picture because when you can keep a flexible perspective on different things, there might be some answers. Not the complete answer but there might be some inroads to things. What about technology? Could technology help with reaching people and be a less expensive alternative?
There’s encouraging evidence from COVID that Telehealth works largely. Telemental health has been wildly successful. Those of us in the fields of mental health are anxious that the plug is going to be pulled on remote therapy. I still treat about half a dozen patients remotely. Insurers are happy to pay for it. In most states, there’s a government that will have to pay for it but if that goes away, then where are people who are in underserved areas going to get their care? The answer is they are not going to get care.
This country is still heavily rural. People are living in rural areas who are more susceptible to chronic pain and doing the type of work that they have done but no one seems to care. The technology is good and important but it’s not going to be quite the game-changer. If you can access a pain psychologist, you can get good quality care via Zoom or whatever other medium but how do you get diagnostic imaging and therapeutic injections? Injections are necessary. Are you going to be the physician saying, “Michael, now take the syringe and put it right above?” It’s not going to work.
Unfortunately, one of the most successful treatments for chronic pain out there, which are hip and knee replacements, went by the wayside for quite a long time because they were considered non-essential surgeries. Rehabilitation had its problems because physiatrists or pain management specialists were pulled from pain management into the rehabilitation of enfeebled, deconditioned individuals who have been dented and survived COVID but needed a great amount of attention. I don’t think another pandemic is the answer to our problem.
What about cross-training licensed health professionals? Do you see a major trend in physical therapy for psychologically informed physical therapy that’s combining some of the Principles of Cognitive Approaches with the already established Principles of Physical Approaches as a way to save money and add professionals to the community who can help people?
It’s good to see that in Doctorate Physical Therapy programs that so many of them are focusing on behavioral patient management within the curriculum. I can tell you that the physical therapist who took over my program in Pennsylvania is a DPT and a much better psychologist than I ever was. Interdisciplinary care is a good training ground for cross-disciplinary training in pain medicine.
It’s a good point that you make. I’m just not sure what the future is going to hold. You can be trained in behavioral management but can you bill for it? As long as the insurance carrier is saying what you can and cannot bill for, then you are not going to be likely to provide the service that may be in the best interest of the patient. You are going to provide what you get paid for and what puts food on your family’s table. It’s the norm.
There are restrictions to insurance companies. Some of them have restrictions to billing. What you are saying is the coding is what dictates the care at times, not what the patient needs?
Certainly, not the clinical evidence basis. A lot of physical therapists, particularly in other countries, provide behavioral healthcare routinely because their national health service says, “You are trained. You can do it.” They get some incredible results but that’s not the way it is in this country as long as profitability and cost containment are the mantras.
I do know many physical therapists who have found ways around that and are creative about their evaluation and treatment planning, which is what we need, more creativity. Sometimes if we wait for the system to change, it might not change. We may have to find creative ways to negotiate around the system at the same time we begin to change the system. If you had a magic wand and you could wave it, what would you do to repair our healthcare system for people living with pain?
I try to educate state legislatures that are passing Draconian Laws and State Medical Boards, which never include any pain specialists so that physicians and other clinicians who are willing to take on the challenge of patients with chronic pain are not punished for doing so. We have a very unhealthy climate and that’s being pushed by states. Everyone wants to blame the 2016 CDC Guidelines for primary care physicians but it’s not the guideline itself but the weaponization of the guidelines that was so problematic.
This was already beginning to happen before the guideline was published. I was on the 2015 Washington State opioid guideline writing committee. I was the one dissenting vote and certainly the only psychologist and non-physician on the guideline writing committee. Unfortunately, that same group from PROP, the Physicians for Responsible Opioid Prescribing, which is centered in Seattle, went to the Federal level and put out the state to the CDC guidelines, which have been so badly weaponized. That was the intention of many of the members of PROP. My research will show I’m a huge fan of opioid-sparing but to some of these people, just the most severe members, the answer is opioid eradication, not opioid-sparing and it’s ugly.
If I had a magic wand, I will tap society on the head and say, “Let’s stop the lying. The lying is bad.” Insurers do not talk about concerns about patients. They have policies that belie that. The anti-opioid zealots don’t throw out rhetoric and hyperbole, which kills patients and makes doctors fearful of prescribing.
The pro-opioid zealots including physicians and it’s always physicians who have lost their licenses to practice sit there on Twitter and say, “Opioids are the only real answer for chronic pain.” If I publish spinal cord stimulation research, which I do in the United States and to my Italian team, they all of a sudden become methodology experts and say, “That’s garbage research.”
I’m like, “We are publishing it in the Journal of Pain Research, Neuromodulation, and High-Impact Back Journals that don’t accept many articles. What makes it garbage?” They come up with, “It’s garbage.” I will ask, “Why? Where did you do your research methodology training?” Everyone knows that and then patients will chime in, “I read on Google that.” We have to stop garbage and the misinformation out there. It’s killing patients. I’m working on an article and editorial with a primary care physician who was leaving primary care as soon as she finishes up law school.
In fact, both sides of the opioid argument lie blatantly and feel very comfortable in doing so. They pull it down with Trump and create data that doesn’t exist. They find a small 1989 study that was done by polling right with selection bias and response bias that couldn’t be published anywhere these days. As I see, this is proof. I want to shoot them and shoot myself. I all of a sudden, become a firearm advocate when I see this stuff.
If I had a magic wand, it would be the truth-telling wand. I would spend time on Twitter. What you found @HeadDock is very controversially calling out people on either side that lies, does not follow an evidence basis, are agenda-based and is killing patients because patients don’t want to get any injections that are all bad. They are not all bad. “I don’t want to get spinal cord stimulators because they kill you.”
When they look at research in the 1980s and you had these spinal cord stimulators that were tonic, not high frequency and not burst stimulation, they were not effective. They were also about the size of my head that would be implanted in people. These caused a lot of problems but I have seen great technological advances in spinal cord stimulation, great outcomes and yet, the people are saying, “Opioids alone will help you.” That sounds like something President Trump said, “I and I alone can help you.” They are his words but it’s disingenuous. It’s persuading patients from rejecting good quality care.
A very good example would be ERAS protocols, Enhanced Recovery After Surgery. The guru of this is Ed Mariano at Stanford. I wrote an article late in 2019 pointing out ethical ERAS protocols exist and they should be opioid-sparing. That’s a good thing but opioids cannot be taken off the table post-operatively because some patients will not respond well to ERAS protocols and they will hurt. It’s inhumane to deprive them of post-op analgesia but as a result of some medical centers doing this, patients are afraid to go in for elective surgeries, including a routine hip or knee, which may solve their problem, to begin with.
One of the ways that we see we can confront this challenge and as it’s multi-level is health promotion. A lot of what we do here is a public service announcement, which begins to educate people. We are educating people with pain, practitioners and maybe even someone reading from an insurance company or a business who is self-funding their insurance for employees who have an interest in this.
The health promotion aspect that we can tweeze that through that step, from basic education and primary pain medicine, which includes primary care providers, PTs, chiropractors up through specialist care and then finally into interdisciplinary care, then we would be in a better place than we are. We need a lot of advocacy for patients. I don’t think we advocate enough for patients. I know the average clinician probably would say, “I do this every day by going to work.” I don’t think that’s enough for the type of problem we have. The advocate has to spill over outside the clinic into other areas to improve this.
There are a lot of patient advocacy groups out there. The best of them by far is founded by Penney Cowan, who is in the original first class of the Cleveland Clinic’s Interdisciplinary Pain Program under Ed Covington. She is in 1979 founded the American Chronic Pain Association. That’s a great educational organization for advocacy.
If you go on Twitter, you see these groups that are fleecing patients of their money. You see these people who run them, living high on the hog at major conferences on the nickels and dimes that patients can send in. They don’t advocate for pain care. They advocate for unfettered access to opioids. That’s not the answer, either.
Michael, it has been a pleasure chatting with you. Everyone can go on to PubMed and find Michael Schatman’s information. You can reach out to him on Twitter. His Twitter handle is @HeadDock, which is pretty easy. I want to thank Michael for being on the show as we keep talking about the challenging topic of the intersection between quality pain management and cost containment from publicly traded insurance companies. Make sure to share this information out with your friends, colleagues, practitioners and anyone who struggles with chronic pain. Make sure you go over to the Integrative Pain Science Institute and hop on our mailing list so we can send you the latest information each and every week. It’s a pleasure being with you.
- Tufts University School of Medicine
- Boston PainCare
- Ethical Issues in Chronic Pain Management
- Bonica’s Management of Pain
- Article – The health insurance industry: Perpetuating the opioid crisis through policies of cost-containment and profitability
- Physicians for Responsible Opioid Prescribing
- @HeadDock – Twitter
- Enhanced Recovery After Surgery
- Article – Enhanced Recovery After Surgery: Current Controversies and Concerns
- Penney Cowan – LinkedIn
About Dr. Michael Schatman
Dr. Schatman is a clinical psychologist who has spent the past 35 years working in multidisciplinary chronic pain management. He is currently on the faculties of Tufts University School of Medicine and Tufts University School of Dental Medicine in Boston, as well as the School of Social Work at North Carolina State University.
Dr. Schatman is the author of over 140 journal articles and book chapters on various aspects of chronic pain management, and lectures regularly on pain management on local, national and international bases. He is also the editor of Ethical Issues in Chronic Pain Management and Chronic Pain Management: Guidelines for Multidisciplinary Program Development, both of which were released by Informa Healthcare in 2007.
Dr. Schatman is a member of the Editorial Boards of numerous journals. For the past 7 years, he has served as the Editor-in-Chief of the Journal of Pain Research. He is on the Board of Directors of the American Society of Pain Educators – which named him 2011 Clinical Pain Educator of the Year.
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