Saturday, February 5, 2011

Trying to manage finances while treating chronic pain

From The NY Times:

Maybe the question is not who suffers from some type of chronic pain, but who doesn’t?

“If you tally up everybody who has chronic, recurring back, headache and musculoskeletal problems, it includes almost everybody by the time people get into their 30s,” said Dr. Perry Fine, a professor of anesthesiology at the Pain Research Center and the University of Utah and incoming chairman of the American Academy of Pain Medicine.

Given the prevalence of chronic pain — often defined as recurrent pain that lasts more than three to six months — you might expect that by now medical science would have figured out how to alleviate it and that health insurers would routinely cover its treatment.

If only it were that simple. Pain is a sneaky opponent. Invisible, it cannot be detected with a blood test or a scan; sometimes it has no identifiable cause. Pain is perception, and what one person considers intolerable may be only moderately uncomfortable to another.

This makes treatment challenging. And insurers often do not make it any easier.

For the last 15 years, Ernie Merritt III, 46, (pictured) has been coping with the aftermath of a back injury he suffered working as a pipefitter in southeastern Maine. At the time, he thought he had just pulled a muscle. But after an M.R.I. revealed a herniated disc pressing on his sciatic nerve, he underwent the first of four operations.

Surgery has not been enough. Mr. Merritt’s back still hurts, and now he must wear a brace full time to stabilize it. He has developed carpal tunnel syndrome and shoulder problems. The nerves in his legs are damaged, and doctors cannot figure out why.

Because Mr. Merritt is disabled, he qualifies for Medicare, but he says he had to drop the Part B outpatient portion of the coverage. With all of his doctor visits — neurologists, orthopedists and physical therapists, not to mention his regular primary care physician — the 20 percent co-insurance charges were more than he and his wife could afford.

Now he pays $3,000 a year for coverage with his wife’s health plan through her job at the county courthouse. Specialist co-payments are a flat $15 per visit, and he can see his primary care doctor free.

Given his medical needs, it was the right decision, he said: “I have so many things going on that they can’t explain.”

If you have chronic pain, chances are you have discovered that getting the care you need at a price you can afford can be, well, excruciating. These suggestions may help.

The most common causes of chronic pain are musculoskeletal conditions — including arthritis, lower back problems and fibromyalgia — and recurrent headaches. Chronic pain also afflicts many patients with such serious illnesses as cancer, AIDS and irritable bowel syndrome.

Pain management almost always involves medication, and physical or occupational therapy is common. But there is no one-size-fits-all approach, and patients often see several doctors on a regular basis.

It is important to find a primary care provider who will serve as your “medical home” and will work with you to coordinate care. You will avoid duplicative tests and procedures, and you are more likely to find the care you need.

In addition, many primary care doctors provide therapies like nerve blocks, said Dr. Roland A. Goertz, president of the American Academy of Family Physicians. A savvy primary care physician can help keep expenses in check.

People with chronic pain are twice as likely to suffer from depression and anxiety as the general population, but insurance coverage for mental health problems often is inadequate for these patients. Fortunately, the recently passed mental health parity law should help make those services more available.

Until then, consider some alternate community resources. Stanford University, for instance, has developed a chronic disease self-management program that is available in nearly every state through local area agencies on aging. The six-week program teaches participants relaxation and cognitive behavioral therapy techniques, among other things, and is free in many areas.

For a quicker fix, check out the American Chronic Pain Association’s free five-minute relaxation guide.

“People in pain don’t exercise,” said Penney Cowan, founder and executive director of the American Chronic Pain Association. Big mistake. Exercise is one of the most effective and most affordable ways to manage chronic pain. Gentle stretching and exercises to increase range of motion and strength training are all helpful. (Get the go-ahead from your doctor before starting, though.)

Although physical and occupational therapy are often recommended for people with chronic pain, insurance plans typically cover only a limited number of sessions. Make the most of your visits by asking the therapist to teach you what you can do on your own, said Dennis Turk, a professor of anesthesiology and pain research at the University of Washington.

“Eight to 15 sessions of physical therapy may be more than enough if the patient is learning what to do on their own,” he said.

Insurance coverage for many types of pain management treatment is often inadequate, say advocates and physicians who treat it. Medication and interventional therapies like nerve blocks are more likely to be routinely covered than physical or behavioral therapy.

Part of the problem is that pain management is complex, and people respond to therapies differently. “When people keep coming back and saying something’s not working, insurers begin to doubt that reality,” Ms. Cowan said.

If your plan turns down your request for physical or behavioral therapy, or any other treatment, get a copy of the policy and read the fine print, said Jennifer C. Jaff, executive director of Advocacy for Patients With Chronic Illness.

If the policy says therapies are covered only if they are medically necessary, for example, you may be able to challenge the denial in an appeal. Sometimes insurers say they are denying coverage because you have not shown improvement, a standard that someone with chronic pain may find impossible to meet. Appeal those decisions, too. Ms. Jaff’s organization files free insurance appeals for patients.

Medication is a mainstay for people with chronic pain, and drug therapy is one of the few chronic pain treatments that insurance plans reliably cover, said Mr. Turk.

Even if you have coverage, however, it can be tough to figure out which drugs will effectively manage your pain. People with severe chronic pain may take prescription opioids like codeine and oxycodone, as well as antidepressants and muscle relaxants.

Some insurers require that patients do “step” therapy: trying to relieve symptoms with aspirin for a few months, for example, before going on to a more powerful painkiller. In addition, some doctors are reluctant to prescribe some analgesics because they fear serious side effects and worry that patients may become dependent on them.

It is important to find a doctor who will work with you to find a drug regimen that manages your pain and who will advocate on your behalf with an insurer. As with any drug, it pays to ask your doctor if an older, generic drug might be a reasonable substitute for a brand-name prescription.

If you do not have insurance or if a drug you need is not on your plan’s list of covered drugs, check out, a clearinghouse for programs that provide free or discounted drugs to people, generally based on income.