Abstract

Chronic conditions including chronic pain, mental health, substance misuse, and other chronic illnesses are the top reason people seek care, the top cause of disability, work loss, and the primary driver of healthcare utilization accounting for the majority of healthcare costs. The National Academy of Medicine (NAM 2011) report on Relieving Pain in America states that delayed recovery of pain and other chronic conditions are primarily due to patient-centered risk factors. National Academy recommends that all health professionals’ primary role for pain conditions should be guiding, coaching, and assisting patients with day-to-day self-care to reduce these risk factors and prevent chronic pain and illness. To facilitate prevention, the Prevention Program (PP) with personalized activated coach-supported training was developed to support prevention in routine healthcare by providing risk assessment, patient-centered personalized risk-reduction training lessons, telehealth coaching, remote monitoring, and self-management support to prevent chronic pain and substance misuse. This paper reviews the implementation and billing process for the Prevention Program.

Key Words

Chronic Pain; Prevention; Addiction; Healthcare; Health Coaching; Risk Assessment

Introduction

Chronic conditions including chronic pain, mental health disorders, substance misuse, and other chronic illnesses are the top reason people seek care, the top cause of disability, work loss, addiction, and are the primary driver of healthcare utilization accounting for the majority of healthcare costs [1-10]. When the conditions become chronic, they are associated with intensive use of high-cost, high-risk interventions including opioid analgesics, multiple medications, treatments, and surgeries. These problems exist because over 50% of the people with common chronic conditions continue to have the condition years later, despite treatment, because patient-centered risk factors are not addressed in routine care to prevent chronic conditions [1-10]. To address the lack arising from these problems, the Prevention Program (PP) has been developed to reduce lifestyle risk factors that drive chronic pain and substance misuse, and to be integrated into routine healthcare to support healing and prevent chronic illness and its consequences [11-15]. PPs include screening for conditions, risk assessment, patient on-line training to reduce risk factors, supportive health coaching, and tracking outcomes. This paper describes the background and implementation strategy for preventing chronic illness as part of routine health care.

Delayed Recovery from Pain Conditions and Other Chronic Illnesses: The National Academy of Medicine (NAM 2011) report on Relieving Pain in America states that delayed recovery of pain and other chronic conditions are primarily due to patient-centered risk factors such as poor ergonomics, repetitive strain, lack of exercise, poor diet, sleep disorders, anxiety, depression, stress, and abuse, and many other lifestyle factors.8-9 These risk factors increase peripheral and central pain sensitization, leading to chronic pain and illness with the consequences of substance misuse, work loss, and disability. If usual care fails, clinicians and patients often escalate care to passive higher-risk interventions such as opioids, polypharmacy, surgery, or extensive medical and dental treatment instead of training patients to reduce the risk factors that drive the condition.

Yet, clinical trials have shown that the outcomes of these passive interventions are more short-term outcomes compared to longer-term outcomes that are generated by patient-centered approaches which activate and empower patients with self-management strategies--including cognitive behavioral therapy (CBT), therapeutic exercise, and mindfulness-based stress reduction [16-19]. CBT is a therapeutic approach that helps individuals manage their pain by addressing the thoughts, emotions, and behavioral risk factors that perpetuate their condition by implementing protective actions. For example, CBT strategies focus on how to reduce repetitive strain, enhance coping skills, improve posture, and use meditation for calming, and are delivered through structured sessions via videos, apps, and telehealth coaching.

Thus, the National Academy recommends that all health professionals’ primary role for pain conditions should be guiding, coaching, and assisting patients with day-to-day self-care to reduce these risk factors. However, this is rarely done as health providers lack the time, training, tools, and reimbursement to guide patients in self- care [1, 2]. Thus, an important role of the healthcare system in routine health care should include providing or referring to prevention that include screening, risk assessment, health and wellness coaching, training programs for patients and families on how to change risk factors associated with chronic illness. Progress and outcomes need to be routinely tracked.

The Prevention Program (PP) is based on the Chronic Care Model (CCM), integrating patient-centered self- management with evidence-based treatment [16-19]. The CCM has documented evidence of its efficacy for many chronic conditions in more than 100 healthcare organizations. The PP uses each of the 12 principles of implementing evidence-based self-management as part of routine patient care including: 1) brief targeted assessment, 2) evidence-based information to guide shared decision-making, 3) use of a non-judgmental approach, (4) collaborative priority and goal setting, 5) collaborative problem solving, (6) self-management support by diverse providers including health coaches, 7) self-management interventions delivered by diverse formats, 8) patient self-efficacy measured and trained, 9) active follow-up, reminders, and reinforcement, 10) guideline-based case management for selected patients, 11) linkages to social support and community programs, and 12) multi-faceted interventions. These practices can be reimbursed by health plans and are part of a teaching curriculum in transformative care for health professionals and health coaches.

Implementing Prevention Program in Routine Healthcare: The PP (www.preventionprogram.com) is an evidence-based therapeutic program to support patients in reducing risk factors for chronic pain, addiction, disability and other chronic illnesses by implementing protective actions in daily life. PP has been evaluated through initial funding from the National Institutes of Health, and subsequent testing in a randomized clinical trial and a longitudinal case series with over 500 patients [14-15].

Table 1: Patient Services in the Pain Prevention Program.

The PP is a 6-month therapeutic program that guides patients in patient-centered strategies to reduce risk factors, implement health protective actions and relieve pain conditions to prevent chronic pain, delayed recovery, substance misuse and the opioid crisis. The program includes physician evaluations, preventive medicine counseling, assessments, learning modules, telehealth coach support, progress dashboard, and resource handouts to help patients heal and recover from pain conditions. Patient services include the following services over 6 months.
Physician Telehealth Evaluation. If needed, PP physician will conduct an evaluation and review the patient signs and symptoms, past history and diagnoses, current treatment, confirm the diagnoses, review red flag criteria and make a referral to the PP if appropriate. CPT code 99204	Physician Preventive Medicine Counseling. The physician will provide initial preventive medicine counseling to help the patient begin self-care and healing the pain condition. Red flag conditions such as depression, abuse, and mental health problems for referral. CPT code 99402
PP Assessments and Training Modules Assessments are completed and reviewed by the health coach and physician to understand and personalize the training and support. Progress on learning modules are self-directed by the patient.	PP Telehealth Coaching Sessions Health Coach supports patients in achieving their goals of recovery from pain and achieving health and well-being. Each session is directed by the patient and their goals
1. Evaluation and Introduction to PP Module: Email to patient with link and log-in review of the importance of the PP Program and telehealth coaching for recovery. Patient completes assessments including current pain, severity, previous care, goals, coping strategies, risk factors, and protective factors. No patient fee.	Orientation: Discuss the PP program with learning and health coaching. Discuss background, rationale, timetable, and goals of program to reduce factor in each realm of their life. Assess readiness for change and interest in engaging in a self- management program. CPT 99409
2. Understand Pain: Learn about causes of chronic pain and how treatment with self-care can heal pain long-term. Personalized Pain Assessment is reviewed to understand risk and protective factors to relieve pain in realm of your life. CPT 99408	Big Picture Goals: Review Pain and Risk Assessment with patient. Explore overall vision and goals for the patient including preventing chronic pain and addiction while encouraging a healthy life within all 7 realms including mind, body, emotions, lifestyle, spirit, social life, and environment. CPT 99409
3. Immediate Self Care: Learn how and why self-care HEALS actions can begin to heal and relieve pain. Self-Care Assessment reviewed with current self-care strategies used to better cope with pain. CPT 99408	Pain Cycles: Review Assessments with patient. Coach reviews how pain, risk factors and pain cycles drive pain, and protective self-care actions and treatments to heal pain. CPT 99409
4. Mind Assessment and Modules: Learn how positive mindset, thoughts and attitudes can improve pain. Mind Assessment reviewed to identify thoughts and attitudes that PP pain. CPT 99408	Mind Realm: Review Mind Assessment with patient. Provide coaching support for goals and how optimism, having self- efficacy, realistic expectations, and resilience help recovery from pain. CPT 99409
5. Body Assessment and Modules: Learn how use of body with exercise, posture, and reduced strain to improve pain. Body Assessment reviewed for how body use imPPs pain and recovery. CPT 99408	Body Realm. Review Body Assessment with patient. Provide coaching support for goals and for implementing optimal posture, stretching, exercise, and reduce straining to PP pain. CPT 99409
6. Lifestyle Assessment and Modules: Learn how to improve daily behaviors of diet, sleep, substance use, and pacing to improve pain. Lifestyle Assessment reviewed including diet, sleep, substance use, & pacing PP pain & recovery, CPT 99408	Lifestyle Realm: Review Lifestyle Assessment with patient. Provide coaching support for goals and implementing an anti- inflammatory diet, restful sleep, balanced pacing, and limiting substance use can PP pain. CPT 99409
Physician followup—evaluation. The physician will conduct an followup evaluation and review the patient’s progress in the PP and their treatment program and reinforce the importance of maintaining self-care with treatment. CPT code 99214	Physician Preventive Medicine Counseling. The physician will review the self-care HEAL strategies with continued preventive medicine counseling to help the patient be successful with self- care and healing the pain condition. CPT code 99401
7. Emotions Assessment and Modules: Learn how emotional coping and processing pain and recovery. Emotion Assessment reviewed including positive and negative emotions that PP pain & recovery, CPT 99408	Emotions Realm. Review Emotions Assessment with patient. Provide coaching support for goals and understand emotions, coping with negative emotions and shift to positive emotions to PP pain. CPT 99409
8. Spirit Assessment and Modules: Learn how motivation, purpose, meaning can PP pain and recovery. Spirit Assessment reviewed including motivation, hopes, determination PP pain and recovery. CPT 99408	Spirit Realm. Review Spirit Assessment with patient. Provide coaching support for goals and understanding the role of purpose, self-compassion, hopes and dreams, and determination in recovery from pain. CPT 99409
9. Social Life Assessment and Modules: Learn how social connections and support can PP pain and recovery. Social Assessment reviewed and how relationships PP pain & recovery. CPT 99408	Social Realm. Review Social Assessment with patient. Provide coaching support for goals and to understand how social belonging, positive support, and relationships PP pain. CPT 99409
10. Environment Assessment and Modules: Learn how living safely within the world around PPs pain & recovery. Environmental Assessment reviewed with safety factors PPing pain and recovery. CPT 99408	Environmental Realm. Review Environment Assessment with patient. Provide support for goals and safety in the environment that you live, work, and receive care in and how to prevent re-injury. CPT 99409
11. Living in the 7 Realms: Integrating a whole health plan to prevent future pain. Follow-up Assessment completed. CPT 99408	Follow-up Session. Review next Assessment with patient. Provide support with takeaways, progress, resources and goals beyond the PP program. CPT 99409
12. Pain-free living over a lifetime. How to continue to maintain sustained changes in healthy daily actions. Follow-up Assessment completed. CPT 99408	Follow-up Session. Review follow-up Assessment with patient. Provide support with takeaways, progress, resources and goals beyond the PP program. CPT 99409
Physician re-evaluation. The physician will conduct an final evaluation and review the patient’s progress in the PP and their treatment program and reinforce the importance of maintaining self-care long-term. CPT code 99214	Physician Preventive Medicine Counseling. The physician will review the self-care HEAL strategies with continued preventive medicine counseling to help the patient be successful with self- care and healing the pain condition. CPT code 99401

Table 1 illustrates the semi-structured patient care services supported by the health coach during each bi-weekly visit. By integrating a PP into routine health care, a more transformative model of care to improve both short-term and long-term clinical outcomes is created. This comprehensive whole person model of healthcare seamlessly integrates prevention strategies with treatments to improve clinical outcomes and prevent the development of chronic pain and other chronic conditions. PPs provide patient-centered personalized risk assessments and risk-reduction training lessons, telehealth coaching, remote monitoring of progress and outcomes, and self-management support (Fig. 1). PP includes the following:

• Evidence-based Patient Engagement Platform. PP provides HIPAA compliant, evidence-based self-care interventions that are implemented with digital platform accessible by both computers and mobile phone app.
• Requires minimal clinic time. PP can be easily integrated into a treatment plan or order set with a simple patient explanation- “I’m happy to treat your pain, but is more effective if we also train you to reduce the causes of pain. Are you willing to learn self-care changes?”
• High Patient Engagement and Long-Term Outcomes. Patients who participate in the PP have 95% engagement, long-term pain reduction and improved functional outcomes, reduced opioid use, and increased patient satisfaction.
• Reimbursed by Health Plans. Patients participating in the Prevention Program may be able to be reimbursed by health plans for either in-network or out of network providers.
• Remote monitoring system tracks patient engagement and patient-centered progress, and makes recommendations and steps to the patient to change lifestyle factors and overcome barriers to healing.
• Predictive data analytics facilitates personalized care by predicting outcomes through the use of data about patient-centered risk factors, protective factors, and associated outcomes among both patient and provider groups.

Examples of Patient comments

• “PP was the most valuable part of my treatment plan and taught me many self-management strategies that I do regularly to relieve and prevent my pain” –Kathy, age 38.
•  “PP has provided me confidence to self-manage my pain with simple strategies and avoid the ongoing treatments and medications for pain that I have used for years. Monica, age 24 year.
• “PP is incredibly helpful. I expect that in 10 years every doctor in the country will be using PP as part of their treatment for pain.” –Zoe, age 62.
• “I am off opioids for the first time in years because I learned how to manage the pain myself. The health coaching has been great. I practice calming and stretching every day. It works to reduce my pain.” –Steve, age 71 with 20 years of chronic pain and daily opioid use.

Telehealth Coaching to Support Prevention Program

Health and Wellness Coaches are trained and nationally board certified by the National Board of Health and Wellness Coaching.

Figure 1: Components of the Prevention Program (PP)

There are currently over 12,500 such board-certified health coaches to support patients in improving their health and wellness. Health coaching is a relationship-centered, client-driven process designed to facilitate and empower a client to achieve self-determined goals related to health and overall well-being. While client goals may be informed by or suggested by others, such as an individual’s physician or other health providers, the selection of the goal and exploration of where one is in relationship to the goal is up to the client. Telehealth Coaches are an integral part of the PP and collaborate directly with the referring provider as part of the interdisciplinary team for pain management, similar to health psychologists and physical therapists. Telehealth Coaches are trained to review risk assessments, provide self-management training, and support patients with pain conditions through facilitating their knowledge and skills necessary for self-management. The process incorporates the needs, goals and life experiences of the patients and is guided by evidence-based interventions for the targeted pain condition. Health coaching is provided in a safe and confidential space to support positive change in a client’s holistic well-being. Clients can explore their thoughts, emotions, and actions, in a way that allows them to recognize the power of their own choices to impact their health and wellness and prevent chronic pain and illness.

Health Coaching differs from health education, counseling or therapy, though it can work well in combination with those other practices. Health Coaches assume that people have strong intrinsic resources and strengths, can access the self-motivation needed to function autonomously and competently, and are able to realize positive change within a safe and confidential alliance, where they are inspired, respected, and supported. By applying clearly defined knowledge and skills, they support individuals or groups in mobilizing their internal strengths and external resources to achieve sustainable changes in beliefs or behaviors. Health Coaching has the potential to help individuals and their families, through individual and group coaching practices, to achieve improved health and well-being by;

• Setting goals. While a person’s goals may be informed by the condition (such as to reducing the pain) or may be suggested by others like a health professional or the on-line training (such as to do exercise), the health coach will help with selection of the goal and exploration of where one is in relationship to the client- selected goal.
• Practice grounding and calming. The first step in coaching is to help a person be grounded in the moment to practice calming.
• Facilitating change. Individuals may be just beginning to consider a change, may be exploring aspects of preparing for a change, or may be ready to implement actual actions. In a safe, consistent, non- judgmental, and supportive space, clients can explore their thoughts, emotions, and action plans, in a way that allows them to recognize the power of their own choices to impact their well-being.
• Empowering people. Health coaches assume that people have strong intrinsic resources and strengths and can access the self-motivation and energy needed to accomplish their goals.
• Engaging responsibly. Health coaches assume that people will function autonomously and competently and are able to realize positive change within a safe and confidential alliance with the health coach. The coaching relationship is one of inspiration, respect, and non-judgmental support.
• Achieving goals. By applying clearly defined knowledge and skills, the health coach can support individuals or groups in mobilizing their internal strengths and external resources to achieve sustainable changes in thoughts, emotions, and behaviors to achieve their goal of improved health and wellbeing.
• Figure 2 illustrates the PP work flow with scheduling of the patient with the physician and health coach, the engagement of the patient in the PP and follow-up with the health coaches and as needed the physician.

Figure 2: Implementation of the Prevention Program (PP)

Prevention Program Collaboration

The success of the PPs is based upon referral from health professionals, employers, health plans, and health care organizations who want their clients to prevent chronic conditions and improve long-term outcome with patient-centered, preventive care. The following individuals, healthcare professionals or organizations current support the Prevention Program.

• Patients with Pain Conditions or other Illness. The National Health Interview Survey (NHIS) found that 126 million adults (55.7%) experienced a pain condition in the past year with 20.1% having daily pain and 31.8% experiencing severe pain.
• Physicians and Dentists: Medical and dental clinics across the country are implementing prevention programs within their clinic to improve screening, outcome and care for their patients.
• Physical Therapists and Chiropractors These health professionals provide treatment for pain and dysfunction from musculoskeletal disorders. They also provide self-management preventive strategies to complement treatment such as exercise and posture.
• Provider Organizations. National organizations and conferences such as American Academy of Family Medicine, American Academy of Pain Medicine, International Association for the Study of Pain, Pain Week, and others have implemented provider awareness training programs to focus more on prevention.
• Health Plans: Health plans are currently implementing on-line consumer training programs to support their members in managing their own health and improve their health and pain through self-management.
• Employers/Employees: Health care coalitions of employers and employee groups such as the Buyers Health Care Action Group (BHCAG) and the Labor/Management Health Care Coalition of the Upper Midwest (LMHCC) are focusing more effort on preventing health conditions before they become chronic, particularly chronic pain.
• Workers Compensation Insurers: Employer coalitions and workers compensation insurers have expanded their prevention efforts when employees are first injured to improve recovery, healing, and return to work.
• Implementation of the Prevention Program: The PP can either be set up as an independent telehealth PP or integrated into an existing health care clinic. The process for integrating the PP into routine health care includes pre-implementation, implementation, and a financial model.

Pre-implementation of the PP

1. Health coaches can collaborate with the Prevention Program by enrolling at www.preventionprogram.com.
2. The health coach completes an on-line PP training program available at https://www.centerwithin.com/ courses-with-michele/#CEapproved. An additional course is available at https://www.coursera.org/learn/ chronic-pain
3. The nationally board-certified (NBC-HWC) health coaches use the PP-contracted physicians to complete evaluations and follow-up evaluations. They will ensure the patients diagnosis is clear, treatment as needed is provided, client appropriateness for the PP, and facilitate billing through the physician.
4. Electronic health records (EHR) are set up for health coaches to document services and allow for billing to health plans through the physician. This includes order sets for the doctor, and documentation for the doctor and health coach, coding and billing to health plans.
5. The PP digital patient engagement platform (PEP) includes an interactive website, pain and risk assessments, personalized risk reduction training lessons, outcomes tracking, progress and engagement reports, and integration into electronic health records.
6. Marketing materials are provided to health professionals and consumers in a region to make them aware of the prevention program. This includes brochures for patients and referring doctors, mailing cards, and social media to make both patients and health professionals aware. Additional marketing can be implemented by the specific PP and health coach.
7. Initial set-up of a PP includes health coaches and provider groups enrolling in the PP platform (preventionprogram.com) to make referrals and scheduling of patients.

Implementation of the PP

Patients enroll at the website, www.preventionprogram.com to schedule their first visit with the health coach and physician, if needed. This can occur with patient self-referral through the website or through referral from health professionals, employers, or insurer. The patient can also call the PP help-line to schedule.

Prior to the first visit with the physician and health coach, the patient will complete a brief history of their problem via the EHR link to allow the physician and health coach to understand the patient’s history, past records, referral and diagnoses.

At the physician evaluation, the physician will review the patient signs and symptoms, past history and diagnoses and treatment, confirm the diagnoses, review criteria for referral to the PP, and provide initial preventive medicine counseling to help the patient begin self-care and healing the pain condition. The physician will then schedule a 2 to 3-month follow-up to monitor patient’s engagement and success in the PP.

At the health coach initial meeting, the health coach will review the patient signs and symptoms, past history and diagnoses, ask the patient what their goals are, and introduce them to the PP. Health coaches do no diagnose or treat. The health coach will review an overview of the full program to help the patient focus on achieving their goals by reducing risk factors through protective actions in each of the seven realms of the person life including the mind, body, emotions, lifestyle, spirit motivation, social life, and environment.

The health coach will schedule more visits, per client’s preference, at an estimated 1 to 2 weeks intervals over the next several months, to complete and implement the whole PP. The health coach communicates to the referring physician with regular documentation. The visit times are typically scheduled each week at the same time and day of the week. Reminders are sent from both the PP platform, as well as from her, to encourage the patient to engage in the program.

Patient are sent monthly progress assessments to review engagement and progress in achieving the self- directed goals throughout the program. The health coach also reviews the progress assessments to determine patient engagement in self-care, change in risk factors, improvement in the condition, and identifying and overcome barriers to success.

Table 2: Characteristics and scientific efficacy of each component of the Prevention Program (references are available at www.preventionprogram.com or reference 14.

PP Intervention	Scientific Basis	Implementation
PP self- management	Systematic reviews of chronic care model self-management	Training to reduce risk factors and strengthen protective factors
Tele-health coaching	Systematic reviews of health coaching and social support	Support from health coach, friends and family, reminders, and alerts
Healthy HABITS	Systematic reviews of cognitive- behavioral therapy	Healthy Actions that Bring Improvement & Transformation Daily habits of exercise, posture, diet, sleep, safety and injury prevention, and others
Daily PAUSES	Systematic reviews of mindfulness-based stress reduction	Pause to Assess Understand Start new, & Enjoy moment. Mindful pauses to check in daily on body, lifestyle, thoughts, emotions, purpose, social harmony, and environment
CALMING practice	Systematic reviews of meditation, relaxation, and guided imagery	Calming Actions that Lift the Mind & Mood. Calming relaxation training to relax the body, mind, and mood and gain insight, understanding, motivation, and compliance
Online delivery platform	Systematic reviews of computer- based and Internet interventions	Computer and smart phone apps that are accessible, personalized, engaging interactive, confidential, and secure

Financial Model

The PP financial model includes revenue from both health plan reimbursement and ‘fee for service’ reimbursement as defined and documented in the above clinical services. These services include health coaching visits, risk assessments, physician evaluations, physician telehealth visit, and preventive medicine counseling.

At each of the physician and health coach visits, the EHR will be documented with the care provided and the relevant CPT codes. The PP billing team completes submission of the claim for services to the patient’s health plan after each visit on a fee for service basis under the supervising physician.

The PP is reimbursed by health plans for the clinical services through the physician including assessments, health coach and physician visits. There are several CPT codes that can be used as reviewed in Table 3.

Table 3: CPT codes that can currently by used by physicians and other licensed health professionals to reimburse Prevention Progras.

Preventing Chronic Pain and Substance Misuse. Many lifestyle risk factors can lead to chronic pain, illness, addiction, and other conditions. Health coaching can support patients in self-care strategies to relieve pain and prevent chronic pain, impairments, substance misuse, and subsequent conditions. CPT codes used for health coaching include SBIRT (screening brief intervention, referral for treatment/coaching) codes: 99408 Risk Assessment for Preventing Chronic Pain and Substance Misuse (<30min) 99409 Preventing Chronic Pain and Substance Misuse (>30 min) 99401-99402 Preventive Medicine Counseling Codes CPT G0397 (Medicare)

Behavioral Health Management Support. Mental health conditions can interfere with health and well-being and lead to chronic pain, illness, addiction, and many other conditions. Health coaching can support patients in self-care strategies to relieve these conditions and the subsequent illnesses. CPT codes used for health coaching; 90792 biopsychosocial and medical risk assessment 90834 behavioral therapy 38-52 min 90837 behavioral therapy 53 min or more

Chronic care management (CCM). CCM can promote better patient health and reduce health care costs. Revised rules for 2020 brought new payment opportunities for CCM. Services based on CCM can include behavioral health integration and principal care management. The following new CPT codes in 2022 can be used by health coaches who are either licensed as a physician, social workers, nurse practitioner, or other providers or supervised by a licensed healthcare provider in the state. CPT codes used for chronic care management services for patients with two or more non-complex chronic conditions include; G0506: Comprehensive assessment and care planning for patients with two or more chronic conditions 99487: 60 minutes of time spent by clinical staff under the direction of a physician or QHP G2065: principal care management by a clinical staff time under the direction of the physician/QHP 99358: Evaluation and Management codes for prolonged E/M services for the first hour

With health plan reimbursement, PP provides a therapeutic solution using 2 models

Health Coach PP Model. A doctor refers to PP with order set. The PP provides all clinical services including doctor consult, health coaching, and risk assessment. PP bills to directly for these services to health plans using the EHR through the PP physician supervision.

PP Platform Model. A clinic, employer, or health group hires their own health coach, schedules coach visits through the scheduling coordinator, and licenses the PP platform to support the coaches, patients, and providers.

Additional pain management services are available including data analytics to determine what patient- centered factors drive success versus failure in value-based health plan reimbursement models.

Case Series Study of Preventive Care

To introduce PPs with self-care training of patients to prevent chronic pain and illness into their routine care, the solution must be easy to implement, add minimal time to daily schedules, improve patient outcomes and satisfaction, and be reimbursed by health plans. In this case series, we have implemented PP in 604 patients in 2 clinics, with 2 health coaches and 6 medical providers. The study demonstrated that health professionals were able to integrate PP smoothly into their routine care without adding any time to their schedules. The PP has been initially reimbursed by health plans as preventive services to prevent chronic pain and substance. The estimated fees billed out for the 6-month pain management program with estimated 20 visits generates revenue for the clinics. Table 4 presents the data from 1,684 claims submitted for PP reimbursement and the in-network reimbursement rate. However, health plans change the CPT codes and different ones can be used depending on the state.

Table 4: In-network reimbursement Rate of CPT codes by health plans for preventing chronic pain and substance misuse.

Description of procedure	cpt code	# claims processed	% of claims paid	Fee submitted	mean fee paid	In-network collection rate
Preventive medicine counseling by provider at follow-up visit (<15 min)	99401	690	93%	$75	$47	63%
Preventive medicine counseling by provider at initial visit (15-30min)	99402	352	89%	$110	$99	89%
PP services for Health Coaching (30 to 60 min).	99409	403	90%	$165	$100	61%
PP services for Risk Assessment/ and Training	99409	403	90%	$165	$100	61%
Total		1,805	90%	NA	NA	71%

Conclusion

Chronic pain and addiction are the big elephants in the room of health care. They are the top reasons people seek care, the #1 cause of disability and addiction, and the primary driver of healthcare utilization, costing more than cancer, heart disease, and diabetes. The National Academy of Medicine (2011) report on Relieving Pain in America recommends that health professionals’ primary role for pain conditions should be guiding, coaching, and assisting patients with day-to-day self-care to reduce these risk factors using transformative care model. The Prevention Program (PP) with personalized, coach-supported training was developed to support transformative care by providing patient-centered digital risk-reduction training, telehealth coaching, remote monitoring, and self-management support to prevent chronic pain and substance misuse. The PP model for health and wellness coaching has been developed to encourage the health care system to expand their efforts to support patients in preventing chronic pain conditions. The PP implementation process would provide support for all services including billing for the health coach and collaborative physician and reimbursement as seamlessly as possible.

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