With the growing prevalence of chronic pain, depression, anxiety, and other symptoms, doctors and the healthcare system for which they work are increasingly considering how to augment the care they provide within the limited time allotted for patient appointments. Collaborative care can help by providing patients with needed support between physician visits, amplifying medical practice via telephone or another telecare modality that is easy for patients to fit into their schedules.
DocWire News spoke with Regenstrief Institute Research Scientist Dr. Kurt Kroenke, a pioneer and internationally respected leader in the field of medical symptomology, to discuss collaborative care.
DocWire News: Can you start off by providing some background on yourself and your specialty?
Dr. Kurt Kroenke: So I’m a general internist, which would be considered a primary care physician. My research has been in primary care and specialty care, but particularly with an interest in symptoms, things like pain, fatigue, dizziness, as well as psychologic symptoms like depression or anxiety. These kinds of symptoms cross all medical and psychological conditions. They’re really quite prevalent in all practices. That’s where my niche is.
What exactly is collaborative care and how does it benefit patients?
Well, one way of thinking of it, it’s extra help for the primary team. Now, it’s been best studied in primary care, but it’s also been studied in a variety of specialty care settings like cancer and neurology and places like that, cardiology. It’s been particularly used for conditions like depression. It’s been studied a lot for depression. That’s where there’s been the most research. More recently, pain and anxiety. We’ve also been involved in studies that have targeted all of these symptoms. But it’s the kind of stuff that benefits a lot from maybe more regular contact early on. Much of it can be done by telephone, educating the patient, monitoring how they’re doing, adjusting treatment. The patient still sits in their primary care or their specialty team, but this is another team that provides extra help for what I’d call, particularly, these kinds of symptoms.
Why is there a growing prevalence of chronic pain, depression, and anxiety, among other symptoms, in today’s society?
I think they’ve always been prevalent. I think they’re often associated with a variety of medical diseases and sometimes they’re the primary problem. Somebody comes in and says, “I’m having back pain.” That’s a common one. I’m having headaches. I’m feeling tired. I’m not sleeping. I’m dizzy. I’m having stomach trouble. These are examples of symptoms. Sometimes it’s easy. We do some tests and we find a specific medical diagnosis. And half the times, these kinds of symptoms are the primary reason the patient comes in and even after testing, we’re left with treating the headache, the back pain, the fatigue, trouble sleeping. I think these have always been around. They’ve gotten somewhat less attention probably, because our training of doctors is very disease-based. Once we find a disease, we’re pretty good at treating it. But these kinds of common symptoms, I think both in training as well as our knowledge, it’s less perfect.
I think these symptoms may take a backseat sometimes in practice. But there are evidence-based treatments for it. Interesting, they can be medications. They could be behavioral treatments, like exercise, CBD, educating patients about it, monitoring them, seeing if they’re getting better, if not, changing the treatment. Often there’s not time in a few visits in a system to deal with that. So for these kinds of conditions, having some team, collaborative care, augment the care that the primary doctor does, much through telephone based. Has there been an increase in the last year since the pandemic? Yes, particularly mental health conditions. There has been an uptick. But they’ve always been among the more common conditions seen. And even after the pandemic goes away, there’ll be a role for virtual care by telephone. And collaborative care lends itself to that.
You recently wrote a viewpoint in the Journal of General Internal Medicine (JGIM). What was the basis of this article?
Collaborative care trials have been around a couple of decades. Again, they first started in depression. There’s probably been 70 trials of collaborative care and depression. In the last decade, there’s been more trials on things like pain and anxiety and even some on substance disorders. But one of the barriers to uptake in the healthcare system, frankly, has been reimbursement. It’s been unclear to what degree payers will pay for this extra collaborative care, even though it’s been shown to be cost effective. I think that’s been accelerated a little bit, because there’s been more virtual telecare done in the last year. When it comes back, I don’t think it’s going to go back to where it was.
What prompted me to write this piece is because we’ve been doing collaborative care trials probably 10 or 15 years. We’re not the only one. There’s other groups that have done it. This particular piece was to put together practical suggestions for actually implementing this in real world practice. That doesn’t come through in the research studies all the time. So you might look at it as a guide for how to use this in the real world.
What do you see as the future of collaborative care?
I see growth for it. I think where it’s had bigger uptake is in what we call, integrated healthcare systems. Let me give you an example. I spent about a decade working in the VA hospitals. VA hospitals is you have a population of patients to care for. Other integrated healthcare systems, Kaiser is a good example of that, there’s other integrated healthcare systems. So where you’re taking care of a population of patients, there’s an incentive to take care of their problems, which you can do by phone if it reduces healthcare costs, if it improves satisfaction and outcomes. In a standard fee-for-service model, I think there what’s going to get more uptake is by reimbursement mechanisms for it.
Medicare has taken steps about five years ago. There is now an extra code if you’re delivering collaborative care that you can bill for. So I see growth. There’s been growth in the integrated healthcare systems like federal integrative systems, VA and military, and private integrated systems that you have mentioned. But I think in the fee-for-service, I think the extra reimbursement that will persist after the pandemic wears down for tele-care, I think that’s where the growth or an uptake will be.
Any closing thoughts?
I think the other message for this is, how do the patients receive it? Generally, we’ve done satisfactions. They like the extra attention, because between visits, this is, what you might say, a between-doctor-visit service, where they get some extra calls, especially when you’re initiating treatments to make sure it’s going well. I think physicians find this service useful because the mechanism for frequent follow-ups in the first couple of months is not there. So I do think that that’s, with patient provider satisfaction, will seem to be good with this.