You want me to pay for what??!!

    I hope everyone had a fun Fourth of July. My wife, who happens to have been born on July 4, 1984, is quick to remind me that the firework display every year is in celebration of her birth. In my house, I don’t argue that fact. However, when my neighbors were still shooting fireworks at 10:30 PM and I have a sleeping 1 and 2 year old (well, he woke up), I quickly became the old man on the porch screaming at the neighborhood kids. On top of that, my dog, Charlie, was essentially having a panic attack. As I told Charlie...

    As many of you know, treatment options in MS are changing by the day. I last spoke on the changes to the MS Fee Schedule related to opiates. In an effort to treat without long-term opiate use, physicians, as well as the Commission, are looking for new methods. One of the most modern treatment options, and one being ordered by the Commission routinely, are pain rehabilitation programs. The most popular one in MS is the Pain Rehabilitation Program at Southern Behavioral Medicine Associates. Dr. Geralyn Datz is the Clinical Director of this program, and she was very gracious with her time. She has prepared the article below for my readers which explains the program, success rate and why she feels like it is worth the money long-term. She also tries to dispel any false narratives about programs such as hers. If you have questions or comments after your review, please reach out to myself or Dr. Datz.

    I will now hand the mic over to Dr. Datz. Enjoy!

“The presence of chronic pain in injured workers is very common. The Opioid Epidemic has forced insurers to re-evaluate the way chronic pain is treated both short and long term. As a result, there has been a renewed interest in non-medical based treatments that restore injured workers to health. One such treatment is called functional restoration, or Interdisciplinary Pain Rehabilitation (IDPR). This is an intensive treatment that occurs all day, for 20 consecutive days, with a group of skilled providers (more on this in a minute). However, when presented with a hefty price tag of $16,000.00 and up, often the first reaction to functional restoration is complete and total “sticker shock”.

How could anyone spend that amount of money over a 20-day period??!!

As Director of a functional restoration program in Mississippi, this is a question I am often asked. I can understand the shock and awe. Treatments are all about value and return on investment (ROI). And if there were no perceived value, why on earth would someone pay for something that expensive?

The use of chronic opioid therapy for all patients with pain is a good example of high expense and low return on investment. While opioids can be appropriate in some circumstances, the consensus is that they are currently over-prescribed by physicians and overused by patients, and can be easily obtained by a non-medical user:

http://www.cdc.gov/drugoverdose/data/prescribing.html

In the case of non-specific low back pain, neck pain, or “whole body” (musculoskeletal) pain, for example, opiates are not the recommended first line of treatment, but are nonetheless often used. Extended use of opioids can contribute, ironically, to greater physical pain (in a process called opioid induced hyperalgesia), and reduced activity level, depression and greater disability. Opioids have been under scrutiny for contribution to addiction and overdose risks, as well as death.

These challenges all translate to poorer care of injured workers, increased time off work, and increased costs and difficult claims handling for employers and insurers.

With respect to cost, expenses related to opioid prescriptions per claim continue to grow in the United States.  The National Council on Compensation Insurance (NCCI) indicates that medical costs are now approximately 59 to 60 percent of workers’ compensation claims costs.  Opioid prescriptions account for at least 25 percent of these costs.

If an employer wants to find out how much the opioid epidemic is costing their company each year, look at this calculator: www.nsc.org/drugsatwork

Lost time from work, job turnover and healthcare costs are all itemized by state, industry and workforce size.  

As problematic as medication-only approaches are, at least they are familiar. After all, isn’t the Devil you know better than the Devil you don’t?

When I speak to carriers and employers about functional restoration, this thinking-style and their discomfort with change is often obvious.  Their initial confusion is over wondering how could a treatment last ALL DAY, when we are “simply talking,” (or worse, “watching movies”, or “coloring”, also fears I have heard) for 20 consecutive days in a row. What a rip off!!  If that were what functional restoration was, I would have to agree. As a matter of fact, if a program approaches you, and you sleuth it out, and all it includes is talking, sitting around, and biding time, I strongly suggest you run the other way!

However, true functional restoration could not be more different. True functional restoration is the combination of two highly skilled services. Cognitive behavioral therapy, a kind of specialized psychotherapy, (see a great handout here: http://riskandinsurance.com/wp-content/uploads/2016/03/HES_Psych_030416.pdf)
and intensive physical therapy. Note, I said “intensive”, because regular, 1 hour a day, run-of-the-mill PT isn’t going to pass muster in a functional restoration program. We tell our patients on Day 1 of the program, “You WILL have a flare up in this program. If you don’t, we are doing something wrong.” Our team has folks walking over a mile a day at the end of the 20 days. We have folks increasing strength by 500%. Now that’s PT!

So, here’s some straight talk on what functional restoration is and isn’t.

Characteristics of Functional Restoration

1.    Functional restoration reduces medication intake, in particular opioids. This is perhaps the most important feature of functional restoration. Rule of thumb: If a patient’s medications did not change during a functional restoration program, you definitely just wasted a lot of money.  

Functional restoration is about reducing reliance on medication and teaching patients to self-manage pain. We treat patients prior to the program enrollment when needed to get their medications down. We have reduced patients from 400mcg or mg of opiates a day or more to zero or PRN opiates at the end of the program. We do this through counseling, coordination with prescribers, and lots of coaching and education. We also use medically assisted detox (a few days in-patient admission either using old fashioned taper or suboxone) if needed.

It may come as a surprise, but most patients don’t want to be on the medications they are on. They feel they have no choice and no alternatives. When given an alternative for a fuller, restored, healthier and more active life, many of them jump at that chance.

2.    Functional restoration is very focused on Return to Work. If return to work or former job is not feasible, then it’s about Return to Life. As the name implies, these programs are about restoring function. On Day 1 of our program we also tell our patients, “Our goal is to get you back to work, life and things you have given up.”

Effective programs spend time teaching patients about return to work. The literature shows that functional restoration has 75 to 88% RTW rates. This is because the program is designed to help patients overcome the mental and physical obstacles that prevent their recovery. If the employer is willing to work with the client, there is more success in returning the client to their original position, or some modified version of it.

3.    Functional restoration is alternative to surgery, particularly when a patient doesn’t want, or doesn’t qualify for surgery.  Many studies have shown that functional restoration is an effective alternative to spine surgery and other surgical procedures, and can produce greater benefits.

Spine surgery is far more costly than functional restoration, and while it is often touted as an effective means to return to work, the data does not support this. Several well-performed studies have demonstrated that RTW rates after spinal fusion are relatively poor. In a 2011 Ohio Work Comp cohort, only 26% of those who had surgery RTW, compared to 67% of patients who did not have surgery. Of the lumbar fusion subjects, 36% had complications, 27% required another operation. Even more troubling, the researchers determined there was a 41% increase in the use of painkillers, with 76% of surgery patients continuing opioid use after surgery.

One very interesting study allowed injured workers to enter a functional restoration program for 10 days, even despite being elective spine surgery candidates. After 10 days in the program, they could either continue the program, or quit it and have surgery. After 10 days, a whopping 74% of the enrollees voluntarily decided to stay with functional restoration and declined surgery.

What this and other studies keenly show is that when people are given other alternatives, more often than not, they will take them. Injured workers have no idea how to rehabilitate themselves; however, when shown, this is when true recovery is possible.

4.    Typical functional restoration programs have a team of highly qualified providers. These providers deliver up to 3 hours of physical therapy a day, in addition to 3 hours of cognitive behavioral therapy a day, plus another 1 to 2 hours of other adjunctive treatments like yoga, meditation, mindfulness and self massage. The team has group meetings and should be available for consult. This is the format our program follows. We utilize a Physical Medicine Physician (DO), a clinical pain psychologist (PhD), a Doctor of Physical Therapy, a Physical Therapy Assistant (PTA), 2 Licensed Clinical Social Workers (LCSWs), a certified yoga therapist, licensed massage Therapist (LMT), and a nutritionist. (That’s a lot of people and there’s definitely no time for coloring!) The guidelines for enrollment and staff of Interdisciplinary Pain Programs can be found in the Physical Medicine Section of the MS Workers’ Compensation Guidelines issued by the MSWCC.


5.    Functional restoration facilitates claim closure.

In the past, functional restoration has been primarily used on tail claims, as a last resort. However, functional restoration can be used at any time (early, middle or late) in the claim cycle, but is most beneficial for RTW within the first 8 months of injury. One study showed that the average cost savings of using functional restoration early in the claim cycle, total economic cost savings was $170,000. This translated to cost savings of 64% and productivity loss savings/disability savings of 80%!  

While enrolled in our program, patients are taught to refocus their mind on recovery, return to life and return to work. Work gives us purpose, resources, and makes us feel worthwhile. Psychotherapy techniques used in these programs help empower patients to reclaim their lives from pain.


Incidentally, beware of functional restoration programs that at discharge frequently refer for other medical treatments, like spinal cord stimulators, spine surgery, or medication, and report that the program “didn’t work.” While there are some exceptions, these should be rare, and functional restoration is not designed to become a referral program for surgeries or other interventions.  The goal of functional restoration is to stabilize the patient, improve their mental and physical functioning, and make them LESS reliant on the medical system and more reliant on themselves!”

Geralyn Datz, PhD, is a licensed clinical health psychologist in Mississippi and Louisiana, and immediate past president of the Southern Pain Society. She is the Clinical Director of the Pain Rehabilitation Program as well as the President of Southern Behavioral Medicine Associates, PLLC, in Hattiesburg, MS.
Dr. Datz has authored scientific articles and book chapters on the topics of health psychology, pain treatment, the mind-body connection, and treatment of injured workers. She frequently presents at industry and scientific conferences. Dr. Datz provides independent medical opinions and case review. She can be reached at drdatz@southernmed.com @drdatz (on twitter) and www.southernbmed.com