Abstract
Integrative health services (IHS) are becoming increasingly available within and adjacent to the conventional health delivery system. Over a third of U.S. adults have utilized IHS to improve their health and well-being. 1,2 There is now clear evidence for the effectiveness of these services for multiple conditions, most notably for pain-related conditions. 3 Despite the popularity of these services, many remain unreimbursable by most health insurance plans, requiring individuals to pay out of pocket. Without broader insurance coverage of these services, their use will continue to be limited to those able to afford them.
Health delivery models should be developed whereby individuals can access high-quality integrative health care in a coordinated and cost-effective way. We describe the successful implementation of one such model as evidence of what is possible and to provide encouragement and support to others to think creatively about how to improve access to IHS in other communities.
The Comprehensive Pain Program (CPP) at the University of Vermont Medical Center (UVMMC) was born out of an organizational challenge. An existing specialist-run medical chronic pain program had lost its lead physician. Temporary coverage by fellowship-trained anesthesia pain physicians became unsustainable. The organization hired a family practice physician who understood that chronic pain care had been shifting from primarily medication management to nonpharmacological approaches, including IHS. He had been involved in a burgeoning program of integrative health at both the university and the medical center. With a small team, he offered a different vision and proposed a pilot project.
The development of this project required a series of important steps described below. Each step required an evaluation process that led to practical decisions that shaped the form of the program. Once implemented, program maintenance required continuous quality improvement activities, including ongoing monitoring of outcomes related to initial goals.
Clarification and Organizational Alignment of Goals
Our goal was to create a sustainable and scalable model of IHS for chronic pain patients. We wanted to expand to a larger patient population while continuing to meet the needs of the existing patients. We initially considered including inpatient and pediatric services but soon decided to focus our limited resources on adult outpatients who received their primary care within the medical system.
Developing an Implementation/Business Plan
The development of an implementation/business plan was a necessary step to garner internal support. It required support from administrative and clinical leadership and from business and financial analysts. This took approximately 6 months to finalize.
Garnering Internal Institutional Support
The plan was then presented to all internal stakeholders, including three department chairs and the strategic planning leadership. This required many one-on-one and committee meetings as it moved toward formal approval. One requirement was to establish a relationship with a payer partner who could ultimately assist in creating a path to a sustainable funding model.
Connecting With Appropriate Leaders at Select Payers
Three payers dominate the Vermont insurance system: state-run Medicaid, Medicare, and BlueCross BlueShield of Vermont (BCBSVT). The remaining coverage is provided by a mix of regional and national payers. Since BCBSVT is the insurer for UVMMC, they seemed like a logical payer partner to explore coverage for the pilot. At the time, BCBSVT was exploring ways to provide more cost-effective care for their largest cost driver, musculoskeletal problems (largely pain-related), address the challenges presented by the opioid epidemic, and move toward more value-based care models. The goals of BCBSVT and the CPP were potentially aligned.
Payers vary in size and structure, and it is hard to know which leaders at the payer organization might be interested in innovation. Often, the Director of Provider Contracting and/or of Provider Relations are the primary point of contact for providers and can serve as a conduit to the appropriate internal contact. In our experience, UVMMC was connected to the BCBSVT Chief Medical Officer through the BCBSVT Director of Provider Contracting, with whom there was a preexisting connection.
Ongoing Communication Nurturing of the Partnership Between Payers and Providers
Once a point of contact is identified, it is important to meet to make your case. Understanding payers’ needs and motivations is paramount to a successful first encounter. Leading with only research is unlikely to be successful, as most payer personnel are not clinicians or researchers. Providing a cogent “elevator speech” or a short presentation to describe how your program might benefit the payer from their perspective is an essential first step. We made the argument that our program addressing a high-cost condition could help contain costs both in the short and long terms, improve member retention through support for the integrative care that individuals are already accessing, and is supported by policy and research.
We agreed to codevelop and evaluate the project as partners. It would be a time-limited pilot study, and as a joint “experiment,” we would determine if the effects of this arrangement were mutually beneficial and worthy of ongoing support. Weekly meetings were initiated between the two groups. Initial concerns included payment structure, measurement of outcomes of interest to both payer and provider, mechanics and security of data transfer, and clinical and financial analysis of the program.
Piloting a Financial Model That Was Acceptable to Both Parties
The existing system of paying for specific services via a claim did not allow for services for which there were no Current Procedural Terminology (CPT) codes, including many of the proposed integrative therapies (e.g., massage, Reiki, yoga, health coaching). For many modalities, there is no state oversight/licensure of the profession, and therefore they are not considered eligible for claims reimbursement.
Therefore, we decided to pursue payment as a bundle or episode of care. This is a set rate that covers a service such as a high-volume surgery (e.g., knee replacement) that reimburses all services provided to the patient by the provider over a set time period. Bundled payments are often tied to a small value-based payment and/or risk based on outcomes. For our initial pilot, we agreed to have no additional payment risk as we were unsure of outcomes using this new approach.
Monitoring Outcomes of Interest to Both Stakeholders
The program consists of weekly group health visits with a set curriculum coupled with individual modalities available throughout a 16-week period. During the period, patients scheduled individual visits as they chose (with clinical guidance), which created an environment focused on patient autonomy.
The pilot bundle was based on estimates of average utilization of services for each patient. Because this was an estimate, actual utilization was tracked and compared with the estimate every 4 months. In our pilot, estimates were quite close to actual utilization. The structure allowed for variation in each patient’s utilization of services and care journey with the costs estimated for the “average” patient.
Claims are the currency of payers, and therefore, they are ideally suited to perform utilization and cost analysis. Providers often do not have access to claims data, and the transfer of claims files to the academic medical center is fraught with difficulties related to cybersecurity. Having the payer conduct the claims analysis directly engages them in the analytic work, leading to greater trust in the outcomes of the analysis. We used standardized health survey tools for our clinical analysis. Merging these analyses into one set of outcomes is complex, but if each party owns their area of expertise, it is likely more acceptable.
Transitioning From a Pilot to a Standard Covered Program
Our pilot resulted in outcomes meaningful to patients and to payers. 4 Clinical outcomes in multiple functional domains, including pain-specific measures, showed improvements. Overall costs and adverse utilization, such as emergency room visits, decreased and have had sustained improvement over 2 years. These results motivated the payer to not only transition the pilot to a permanent program but also allowed us to approach other payers, such as our state Medicaid program, with these results. We are now in the midst of a 2-year pilot with Medicaid.
In summary, the development of a sustainable funding mechanism to allow integrative and whole-person care to become part of the larger health system is complex but worth pursuing due to the demand from the public, ongoing research supporting its benefit, and its favorable cost and clinical effectiveness compared to usual care. Initial sustainable funding models may come in the forms of bundled payment models focused on outcomes important to patients, which in our experience translates to improved patient-reported outcomes for chronic pain and effective cost containment in the short term and hopefully also in the long term. When goals are aligned, payers can be important partners in this work.
Footnotes
Authors’ Contributions
A.Q. reported being a shareholder in CHESS Health and consulting for the NIATx Foundation outside the submitted work.
J.P. conceived of the presented commentary and wrote the article with the editorial support of A.Q., D.C., and K.G.
Author Disclosure Statement
J.P., D.C., and K.G. have no conflicts of interest to disclose.
Funding Information
There is no funding to disclose related to the writing of this commentary.