Improving Access to Care for Patients Taking Opioids for Chronic Pain: Recommendations from a Modified Delphi Panel in Michigan

Adrianne Kehne,1,2 Steven J Bernstein,1– 3 Jennifer Thomas,1 Mark C Bicket,3,4,* Amy SB Bohnert,2– 4,* Erin Fanning Madden,5,* Victoria D Powell,6,7,* Pooja Lagisetty1– 3 1Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA; 2Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; 3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; 4Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; 5Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, MI, USA; 6Palliative Care Program, Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA; 7Geriatrics Research, Education, and Clinical Center, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA*These authors contributed equally to this workCorrespondence: Adrianne Kehne, Division of General Internal Medicine, University of Michigan, 2800 Plymouth Road, Building 16, Floor 4, Ann Arbor, MI, 48109, USA, Tel +1 301 503 3936, Email adkehne@med.umich.eduPurpose: About 5– 8 million US patients take long-term opioid therapy for chronic pain. In the context of policies and guidelines instituted to reduce inappropriate opioid prescribing, abrupt discontinuations in opioid prescriptions have increased and many primary care clinics will not prescribe opioids for new patients, reducing access to care. This may result in uncontrolled pain and other negative outcomes, such as transition to illicit opioids. The objective of this study was to generate policy, intervention, and research recommendations to improve access to care for these patients.Participants and Methods: We conducted a RAND/UCLA Modified Delphi, consisting of workshops, background videos and reading materials, and moderated web-based panel discussions held September 2020–January 2021. The panel consisted of 24 individuals from across Michigan, identified via expert nomination and snowball recruitment, including clinical providers, health science researchers, state-level policymakers and regulators, care coordination experts, patient advocates, payor representatives, and community and public health experts. The panel proposed intervention, policy, and research recommendations, scored the feasibility, impact, and importance of each on a 9-point scale, and ranked all recommendations by implementation priority.Results: The panel produced 11 final recommendations across three themes: reimbursement reform, provider education, and reducing racial inequities in care. The 3 reimbursement-focused recommendations were highest ranked (theme average = 4.2/11), including the two top-ranked recommendations: increasing reimbursement for time needed to treat complex chronic pain (ranked #1/11) and bundling payment for multimodal pain care (#2/11). Four provider education recommendations ranked slightly lower (theme average = 6.2/11) and included clarifying the spectrum of opioid dependence and training providers on multimodal treatments. Four recommendations addressed racial inequities (theme average = 7.2/11), such as standardizing pain management protocols to reduce treatment disparities.Conclusion: Panelists indicated reimbursement should incentivize traditionally lower-paying evidence-based pain care, but multiple strategies may be needed to meaningfully expand access.Keywords: long-term opioid therapy, pain care access, reimbursement models, expert panel