Prioritisation of procedural over behavioural management of chronic pain is warped by public funding signals denying patients better and cheaper care pathways.
About 24 years ago Kathy Hubble received a phone call at her work at a major western Sydney hospital pain clinic that changed her life, and possibly the life of many chronic pain patients moving forward.
The ICU had rung her to let her know that one of her pain patients had been admitted after a very serious incident of self-harm and it didn’t look like they would make it.
The self-harm appeared to be directly related to a particular issue with the patient’s ongoing chronic pain.
The patient had been on the waiting list at the pain clinic for just over three years. Three years turns out to be the average time then for patients on the wait list (apparently it hasn’t improved much since).
The patient didn’t pull through.
For Ms Hubble, it was a story that was all too familiar. She had been working in the field for over a decade and she now felt that things were becoming way too dysfunctional.
System focus warped by the funding model
Ms Hubble’s main beef back then and now is that the system had become hostage to the flow of money, and the way funding was working, then and now, was being warped towards emphasis on procedures and medication.
Although she recognises still that there is a place for procedures, devices and medication in the spectrum of management options for chronic pain patients, she maintains that the singular funding focus on these solutions has incentivised twisted patient outcomes.
She says that within certain organisations the funding paradigm has created an environment of false reporting on the effectiveness of both procedures involving devices and of medication use.
“I’m very ethically driven,” Ms Hubble told Health Services Daily. “The revenue model of this medicine [sector] is now nothing short of appalling. I’ve sat in the room with pain specialists who have blatantly admitted to me what is going on.”
The pain factory
Fast forward to a few weeks ago and a Four Corners expose entitled “The Pain Factory” and the idea of potential corruption and fraud within the sector became a national talking point – but not entirely for the reasons that Ms Hubble has been trying to get aired for the last two decades.
Four Corners used analysis of private health insurer billing data provided by two external providers in an attempt to mount a case that:
- anaesthetists have been systematically rorting Medicare on items charged; and
- that a selection of pain surgeons were pushing certain procedures and devices onto patients, which had a dubious evidence base, a growing track record of failure (along with a requirement for follow up surgery), and some particularly spectacular failures – some of which the program, in typical Four Corners style, duly emphasised.
Like the Four Corners expose claiming that GPs might be rorting up to $8 billion in Medicare payments per annum two years earlier, this episode appeared to miss the mark spectacularly on its Medicare rorting angle.
Immediately after the program the AMA and several key specialists and pain organisations pointed to significant errors and assumptions made by the program in their analysis. The analysis also lacked associated medical records which brought a lot of findings of the program into serious question.
It was unfortunate in many respects for the chronic pain patient community because the questioning on the same program of the evidence base for the use of medical procedures, was, as far as Ms Hubble is concerned, right on point.
The insertion of a spinal cord stimulator can cost up to $60,000, not including any follow up correctional surgery, which the Four Corners program revealed might be occurring at an alarming rate of up to 30% for each initial procedure.
This and the overuse and misuse of medication in the management of pain are precisely what Ms Hubble has been trying to expose as being the product of a funding paradigm that distorts outcomes by largely ignoring the significant opportunity to treat a selected cohort of chronic pain patients via behavioural therapy instead of medication and procedures.
Beyond medication and procedures
Soon after leaving her role as a registered nurse at the major western Sydney pain clinic Ms Hubble established a private clinic in the southern highlands of NSW and, in concert with a local GP practice, piloted a pain management program based in part around an expanding overseas evidence base in managing key behavioural and mental health aspects of a patient’s chronic pain journey.
In early 1998, Ms Hubble, who has completed a masters degree in pain medicine, played a pivotal role in crafting clinical practice guidelines for nurses in pain management and in 2010 chaired the chronic pain clinical practice guidelines for Osteopathy Australia for seven years, then took the unusual path of working in the insurance industry, to understand the problems.
In 2020 Ms Hubble started her own company to pursue the idea of digital health chronic pain management and what she had learnt.
Three years and two seed funding rounds on, Amelio Health is attracting significant interest and business from the local and international health insurance community, and with that a lot more investor interest.
The health insurance community doesn’t have a dog in the public funding fight so, as far as finding a neutral arbiter on the effectiveness of the Amelio product it would be hard to find a more qualified and robust one.
The only interest of the insurers is better outcomes at less cost for its clients and in Amelio Health, it is so far seeing significant potential to change the typically onerous, expensive and often disastrous patient pathway that many of their clients have become used to.
As well, Amelio has an increasing client list of large local insurers such as GIO. Amelio is being picked up in the UK by some key insurance groups and is currently being courted by several major HMOs in the US where vertical integration of services gives insurers much more flexibility to use what is the most cost-efficient means of care in their organisation.
The question now becomes, why does Medicare not recognise what these major insurers are obviously seeing? Why isn’t there a better debate in Australia around developing a funding model that countenances behavioural therapy under certain conditions?
Amelio and Ms Hubble do not push their solution as the alternative to procedures and/or medication management. But the evidence base the group is building suggests there exists a certain and not insignificant cohort of patients where a well-designed behavioural program with good monitoring and ongoing patient engagement and feedback provides a significantly better alternative for a certain class of chronic pain patients.
Based on the data obtained from Amelio, patients reported experiencing a clinically significant improvement in their overall health. On average, they reported a 50% reduction in depression, anxiety, fatigue, sleep disturbance, and pain. What’s even more remarkable is that 60% of patients stopped using opioids to manage their pain.
The Amelio program involves a comprehensive initial screening assessment, which is getting more and more sophisticated through incorporating AI elements into the software, and then the use of live data via wearable devices (they have an exclusive deal with Fitbit and Google Health), ongoing feedback driven education, and a live and, partly AI-driven health coaching, and adaptive behavioural program, over eight weeks.
While the software behind the program is based on IP developed over 20 years by Ms Hubble, her collaborators and on an increasing spread of peer-reviewed and evidence-based scientific literature, Ms Hubble sums up what she thinks is the secret to their product and program in very simple terms.
“I found that if you actually listen to the person and you say, what do you need? And how can I help, a lot will go back to work. And so I figured out how I could actually build that process so that it’s digital, and people can access it from anywhere and everywhere.”
Ms Hubble’s main assumption was that the cohort of patients that Amelio could assist were those who had been lost in the healthcare system and felt that they were being unfairly treated, leading them to resist the system. According to Ms Hubble, the number of patients who end up taking this path is surprisingly high.
“When we dug deeper into the data the main communication from the claimants was feelings of injustice from the workplace, and family/friends,” Ms Hubble says.
“The feelings of injustice were also coming from the insurers who were judging them, and even from frustrated health professionals who were saying ‘you’re making it up’, you just want to take opioids … you don’t want to get back to work’.”
Health professionals are the keepers of knowledge, and only provide it to individuals for a fee, the knowledge may be distorted to suit the providers best interests, this is injustice. The Amelio program empowers people with knowledge so they can make informed choices about their care and live their best lives through self-management.
To enable this within the limits of reasonable scale is what Amelio is doing, says Ms Hubble.
Helping GPs manage chronic pain patients better
While much of the initial interest in Amelio is coming from the insurance sector, some GPs are starting to refer their patients to the program, despite it not attracting any Medicare rebate.
The cost of the eight-week program is $4000. That sounds a lot but Ms Hubble explains that once a patient is set on a course of seeing a specialist ($380 per visit), a program of pain medicines ($1000s per year), and inevitably some sort of procedure ($10,000s), the cost to the patient will often end up being significally more. And that’s not counting time, opportunity and emotional cost.
At prices of more than $60,000 for some procedures involving devices, before any follow-up surgery, the cost is obviously significantly more for the taxpayer and the health insurer than it has to be in these situations. The cost of suffering for the rest of their life is insurmountable.
Some GPs are getting their patients across the line on the benefits of the program in spite of the cost. Some are also seeing the benefits of managing the patients themselves via the Amelio program.
According to Dr Ati Jhajj, the program offers GPs with certain categories of chronic pain patients an alternative a lot better than simply trying to manage them on medication within their own remit or refer them onto a pain specialist, which is typically what happens.
She cites a few problems GPs tend to face with chronic pain patients:
- As generalists, typically GPs knowledge around chronic pain management is medically oriented and this tends to pass over other key aspects facing their chronic pain patients, including social and psychological aspects in a typical patient’s experience
- Referral to a pain specialist typically ends up in a patient not even having their first consult for at least 6 to 12 months, meaning a GP has to manage them anyway for a long time, usually by medication in the intervening period. This is often a time consuming and emotionally draining process
- Typically you might get that patient back after another 6-8 weeks from the specialist with a letter recommending a medication management pathway, which you already suspect is not working well.
Dr Jhajj suggests that in some circumstances, getting a patient on the Amelio program, can end up being better for both the GP and their patient, despite the commitment that a GP then has to make to follow the program with their patient.
According to Dr Jhajj the program was a key learning experience for both herself and the patient and was made very easy by regular online updates and reporting back to her on her patient’s progress.
“I found the ease of the referral great. I could simply go to the website and instantly refer my patients with them. They’re in the clinic with me. If I didn’t have approval from an insurer, it was alerted in the referral system and then Amelio would follow it up straightaway.
“Once Amelio had the approval, they notified me instantly and the person started the programme right away. My first report from Amelio came back after a week of them being in the programme, and it provided a baseline for all the behavioural and functional measures impacting the patient’s life and a clear strategy for recovery.
“The next report came out week four, and provided a diagrammatic update on all the measurements taken in the programme and how the patient was progressing. It also provided a plan of action for medication reduction that the patient had decided on while in the program.
“I was provided with a final report with ongoing strategies to maintain the progress of the patient, and the patient then joined the alumni, where they can keep in touch with the health coaches.”