IPRCC Meeting - June 23, 2023

Interagency Pain Research Coordinating Committee

June 23, 2023

Virtual Meeting

On June 23, 2022, at 11 a.m., the Interagency Pain Research Coordinating Committee (IPRCC) convened for a virtual meeting. In accordance with Public Law 92-463, the meeting was open to the public. Helene Langevin, MD, Director of the National Center for Complementary and Integrative Health (NCCIH), presided as chair.

The following IPRCC members were in attendance:

• Federal Members: Helene Langevin, MD (Chair); Walter Koroshetz, MD; Friedhelm Sandbrink, MD; Elisabeth Kato, MD
• Scientific Members: Beth Darnall, PhD; Christine Nai-Mei Sang, MD, MPH
• Public Members: Maggie Buckley; Kate Nicholson; Irma Rodriguez
• Ex-Officio Members: Shannon Zenk, PhD, MPH, RN, FAAN
• Designated Federal Official: Linda L. Porter, PhD

Opening remarks and introduction - Helene Langevin, Director NCCIH, Chair IPRCC

Dr. Langevin welcomed members to the meeting and noted that there are several member nominations still pending approval by the Health and Human Services Department, including for members representing the Centers for Disease Control and Prevention and the Department of Defense, and those representing clinician scientists and pain advocacy organizations.

She then provided an overview of the agenda for the meeting, and noted some recent developments that would be of interest to IPRCC members. President Biden has nominated Dr. Monica Bertagnolli, currently the National Cancer Institute director, to be the next National Institutes of Health director. Dr. Langevin described her as a world-renowned surgical oncologist, cancer researcher, educator and physician leader who has the vision needed to deliver on NIH’s mission and seek fundamental knowledge to promote human health.

She will have to be confirmed by the Senate. Dr. Mandy Cohen was chosen to lead the CDC, and Dr. Langevin noted that during her time as North Carolina’s health secretary, she prioritized whole-person health care and addressing non-medical drivers of health.

Dr. Langevin added that the whole-person health perspective has been gaining traction across other federal agencies, such as the Centers for Medicare and Medicaid Services (CMS), the Veterans Health Administration, DOD, the Agency for Health Research and Quality and the Occupational Safety and Health Administration – and that this focus is very relevant for studying pain and pain management.

Next, IPRCC members approved the minutes from the Nov. 7, 2022 meeting.

Federal updates

CMS coding updates for chronic pain - Ellen Blackwell, Senior Advisor CMS and Maya Peterson, Presidential Management Fellow

Ellen Blackwell and Maya Peterson of CMS provided information about new reimbursement codes for chronic pain management, and the development of the codes.

Nearly 80 percent of Medicare beneficiaries report chronic pain that interferes with their function, and many are disabled due to conditions that cause pain. But there are physician shortages in health care areas that could be serving people with pain. Effective treatment for pain is also one of the goals of CMS’s behavioral health strategy.

In 2022, CMS solicited comments a separate coding and payment system for chronic pain management and treatment. There were around 1900 comments that were overwhelmingly supportive of this plan. Two new codes for chronic pain management were proposed and finalized for the 2023 physician fee schedule: G3002 and G3003, which are billable per calendar month for the first 30 minutes of pain management, and subsequent 15 minute increments, respectively.

The codes encompass comprehensive, patient-centered pain care, requiring an initial screening and evaluation followed by development of a care plan and coordination with other potential pain care providers. Pain assessment requires administration of a validated pain rating scale or questionnaire. The patient-centered care plan must include individualized clinical needs and desired outcomes, emphasizing the fact that no two patients are the same.  Care should cover treatment management, including medication management, and coordination of behavioral health care. It requires pain and health literacy counseling, to make sure that patients have a good understanding of the care plan being developed. The codes also cover related crisis care and ongoing communication and coordination between relevant practitioners.

Those who provide these services must be able to furnish every component, that’s why CMS felt it was important that this code be a “360-degree” bundle around the patient.

In response to comments to the proposed rule, CMS revised and clarified several issues in the final rule. For the purposes of this code, chronic pain is defined as “persistent or recurring pain lasting longer than 3 months.” While many commenters expressed a preference for telehealth services, CMS felt that it was important for the initial visit to be in-person, but subsequent visits can be conducted virtually. Not all of the bundled elements must be provided every month or in every visit. The number or type of providers who can furnish these services are also not limited, but they must be able to furnish all elements required for the code.

Since the code went into effect on Jan. 1, 2023, around 6000 beneficiaries have billed for these CPM codes. It typically takes 2 years for new codes to be more fully adopted and over time CMS will gain insights into which beneficiaries and providers are utilizing the codes.

The final rule also highlights the fact that pain patients do not need an underlying mental/behavioral health conditions in order to receive cognitive behavioral therapy or psychotherapy for their pain treatments.

Questions/comments

• Because the services would be bundled, do the same rules and requirements apply for as if a provider were coding for the respective individual services (such as licensing requirements for behavioral health treatments? Do treatments have to be evidence-based?).
  • The code covers for the coordination of care in addition to the actual care – in addition to the coordination of services, services themselves could also be billed for. A clinician could bill and evaluation and management code at the same visit, such as if they are being treated for a cancer condition, a pain code could be issued separately.
• Given that 30 minutes is a short period of time for a complex case, the final rule includes the 15-minute code that can be applied as many times as necessary (no limit to the number of 15-minute codes that can be used).
• Additionally, since this is a Part B service and not considered preventive care, cost-sharing requirements would apply to the beneficiary.
• Many of the pieces of the bundled pain codes exist in other codes, such as for referral and coordination – but instead of trying to bill for all of these services separately, we are trying to make it easier by allowing them to bill for a single code.

NIH-CMS resource for pain assessment - Linda Porter and Leah Pogorzala, Policy Analyst OPPP

The new Medicare pain code requires an assessment of the beneficiary’s pain using validated screening tools. The Office of Pain Policy and Planning within NIH/National Institute of Neurological Disorders and Stroke developed a list of pain screening tools that clinicians may consider for the purposes of screening Medicare beneficiaries for pain for the use of these codes.

OPPP, working with CMS and others at NIH put together a list of assessment tools that could be useful to providers in different health care settings, including primary care or those more focused on a particular pain condition. All of the tools that are listed are validated, and are available in English and some additional languages.

The screening tools are organized starting with a short list of the most commonly-used pain and pain-related questionnaires, followed by additional health or pain-related areas that are more. specific. All of the questionnaires are provided in accessible, 508-compliant formats. For those that are copyrighted or have licensing requirements, information for how to access them is provided. We are tracking how the resource is being used and are open to suggestions about additional questionnaires and any other feedback to make it the most useful.

We’re already considering other condition-specific screeners to include, such as for arthritis or diabetic nerve pain.

Questions/comments

• Can we envision future funding opportunities to examine the benefit of these codes and patient outcomes?
  • It’s possible that there is implementation research that could incorporate the use of these new codes.
• CMS recognizes that there is not a lot of data on these codes now, and it will take time to assess how they will be used.  
• It seems it will be important to differentiate the type of behavioral health activities as the quality is likely to vary substantially.
• It makes sense that where the use of these codes might make the biggest difference are in places where the providers are the most overworked and don’t have the ability to hire additional personnel to handle things like this. But it will take time – if you have a billing code but don’t have time to do the work required of it, it may not help. You need to be able to grow and make changes to the actual workforce to help deal with the volume of patients. So it could take a while to have an impact but the fact that so many people are using it is great.
• CMS emphasized that it could be billed by a specialist and a different type of provider in the same month – we hope to make it attractive to people by being able to pay them.

Federal Pain Research Strategy

Background and next steps - Dave Williams, Professor, University of Michigan; Associate Director, Chronic Pain and Fatigue Research Center; retired IPRCC member

During the November 2022 IPRCC meeting we presented information about contributions from the NIH HEAL Initiative toward fulfilling the recommendations of the Federal Pain Research Strategy. Former IPRCC member Dave Williams volunteered to help expand on this effort along with Dr. Porter and Anthony Domenichiello.

The FPRS had its origins in the 2011 Institute of Medicine report on pain, which identified a public health crisis associated with pain that had a huge cost in terms of lost productivity and health care costs – costs which exceeded the investments being made in pain research. It called for a cultural transformation in pain prevention, care education and research, and the development of a population health strategy.

That led to the development of the 2016 National Pain Strategy, a broad plan with discrete steps for changing how the nation perceived and managed pain, with two elements meant to relieve the burden of pain: expanding and sustaining investment in basic and clinical research in biopsychosocial mechanisms of pain; and the development of safe and effective pain treatments.

The NPS led to the development of the FPRS by the OPPP and IPRCC, and a diverse group of pain experts, patient advocates and federal representatives. The FPRS was meant to provide a long-term plan for NIH and other agencies that supported pain research, and its priorities spanned from clinical pain research to implementation studies and dissemination of results.

To create the FPRS, the task force developed working groups based on NPS themes, including: prevention of acute and chronic pain, acute pain, the transition from acute to chronic pain, chronic pain and chronic pain management, and disparities in pain and pain care.

Each of those working groups undertook an analysis of the research landscape and identified and prioritized a number of research topics by these themes. Each task force was also asked to rank and identify the merit of various gaps and needs for research. Then all of the working groups rated all of the priorities, and the highest ranked across working groups were deemed the highest priority topics.

Each task force was allowed to vote for one priority that was considered the most impactful within that theme – one priority that had the greatest near-term value There were two opportunities for public comment during planning phase and prior to finalizing document.

Cross-cutting themes that were identified included the development of novel drugs and non-pharmacological treatments; screening tools; national registries and data research networks; models of care; and precision medicine approaches.

The most impactful and near-term value priorities identified included: prevention; optimizing public health strategies; educating patients to manage pain; understanding cellular mechanisms of acute pain; understanding plasticity associated with causing pain and the resolution of pain; determining safe and effective chronic pain management and approaches; and investigating biopsychosocial factors that contribute to group differences/disparities that that we see in chronic pain.

The intention of the FPRS was to take 10 years to achieve these priorities and develop a coordinated effort in pain research across federal agencies, help optimize resources and identify a duplication of effort.

Today, we know that the NIH HEAL Initiative has supported many of the priorities identified by the FPRS, but while cataloging advancements and remaining gaps has been possible at NIH, we have less of an idea of the progress in other government agencies and we need to better track what is happening.

With some priorities being addressed, it is likely that new gaps are emerging as science progresses. We need a method of remaining current on the pain research being conducted across all federal agencies, not just NIH.

Approach for FPRS portfolio update

 Linda Porter and Anthony Domenichiello, Policy Analyst OPPP

Our updated effort to track pain research and see where it corresponds to the FPRS will build off the data collected for the Nov. 2022 IPRCC presentation. At the time, we focused on HEAL programs and how they would fit into the FPRS recommendations, but now we would like to look closer at the details, such as the specific number of awards, which priority areas they fit into, and reach across the NIH more broadly and to other federal agencies.

Anthony Domenichiello of OPPP has developed a data collection form that we hope to send out to NIH program staff and officials at other agencies this summer, hoping to have the information returned by early 2024. We will prioritize collecting information about active grants, but since the FPRS came out in 2017 we think we will have good coverage of the recommendations.

The data collection form will be organized by the research priority, and staff will be asked for information such as the number of grants addressing a priority detail, how much is being spent, accomplishments, and what aspects of the priority details the programs are addressing. We would welcome input on any other information that we should be collecting.

Questions/comments

• It will be important to see how well this can be exported to agencies other than NIH and translate into the kind of data that they can provide.
• Will you be looking for IPRCC members to populate any of the granular information?
  • This is being asked of the officials who oversee the grants, but if there are IPRCC members who want to help out with an area or recommendation and take a deep dive into the research, we would be happy to have that help. We don’t want to create a large burden for IPRCC members, as this will likely take a long time to achieve.
• What are you envisioning for a final product? How will it effect how we go about our work?
  • When the data is collected we would like to publish a summary online, and as a larger objective we would like to help the agencies understand where we might be duplicating effort or how we can leverage current research programs. It could help inform decisions over programs that are being reconsidered or renewed, and affect our strategic planning. We may be able to identify gap areas that are now obsolete, or we could reconsider because of advances in technology.
• One potential long-term outcome that would be nice would be a lay summary for the public addressing which gaps have been filled and how we have addressed the FPRS over time.
• It would be good to use this to communicate to the research community, clinical care providers and patients how much we’re doing in pain research and help people see the big picture.
• We may identify new things that are important that were not considered in the FPRS, and while we may not want to redo the whole strategy, need to be able to amend it or add to it.
• Once we’ve collected the data, we can run the information by the IPRCC and get some initial feedback.

HEAL PURPOSE for Pain Research Work Force Enhancement - Laura Wandner, Program Officer OPPP

In October 2022, the HEAL Initiative funded a pain research coordinating center known as PURPOSE – “Positively Uniting Researchers of Pain to Opine, Synthesize and Engage”.

The goal is to connect pain researchers across the continuum of pain research, all disciplines and career stages using a digital platform and an annual meeting.

The network provides webinars and training and weekly news digests, aggregates funding announcements and job opportunities, and enables multidisciplinary collaborations when developing grant applications.

As of June 22, there were 1022 people who had joined the network. We are encouraging all NIH funded pain researchers to join, as well as anyone who is interested in applying for grants and PWLE who are involved in research, and other federal colleagues.

The network’s web platform allows you to search for profiles of other members and reach out to potential collaborators; upload information about your current studies; post and search for funding opportunities and job announcements; post upcoming events and meetings; identify potential mentors and establish formal mentoring relationships.

The inaugural meeting of the PURPOSE network was held May 11-13. It provided educational content for graduate students, post-docs and early-stage investigators. Sessions were recorded and will be posed on the PURPOSE platform in the summer. The 2^nd annual meeting will be held in 2024, which will include more content for researchers across the pain research spectrum as well as mid-career and later-career investigators.

This summer PURPOSE is planning more webinars, offices hours for NIH program officers, reviews of aims pages and research concepts, and hope the community groups will become more active with announcements of events and jobs.

Please consider joining the network by signing up at painresearchers.com.

The network is led by Jacob Coverstone, the managing director of Neurovations Education, Inc. – jacob@neurovations.com. The two NIH leads are Dr. Laura Wandner (laura.wandner@nih.gov) and Dr. Delany Torres (delany.torressalazar@nih.gov), both from NINDS.  

Please send feedback about content, whether it meets research needs, ideas for next year’s meeting – please consider including your own posts.

Questions/comments

• With the limited amount of funds available for travel and additional pain conferences, could there be plans to link the PURPOSE Network to other meetings so there aren’t as many travel obligations in a single year?
  • That would be a question/suggestion for Jacob Coverstone – the date and location of the next meeting are still to-be-determined.

Meeting adjourned

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We certify that, to the best of our knowledge, the foregoing minutes are accurate and complete.

Linda Porter, PhD
Designated Federal Official
Interagency Pain Research Coordinating Committee
Director, Office of Pain Policy, National Institute of Neurological Disorders and Stroke
 
Helene Langevin, MD
Chair Interagency Pain Research Coordinating Committee
Director, National Center for Complementary and Integrative Health
 
These minutes have been formally approved by the committee

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This meeting summary has not been formally approved by the committee. This meeting summary was prepared by Andrew Siddons in the Office of Pain Policy and Planning at the National Institute of Neurological Disorders and Stroke.