Barbara Chasse lies on the massage table, listening to soft music on a CD. Oily aromas waft through the darkened room. A mini waterfall tinkles away in a nearby bowl. Massage therapist Susan Williams slips her hands under Chasse's neck.
"Aaaah, right there,'' Chasse moans with relief. "Yes.''
Such is the face of Florida's tentative new venture into treating poor people for chronic pain.
For 2 years, a few hundred residents of Pinellas, Pasco and Hillsborough counties have been massaged, poked with acupuncture needles, prodded to eat right and bestowed with meditation tapes - all by a Medicaid program usually known for no-frills hospitals and by-the-books doctors.
But with Medicaid gobbling ever-larger chunks of state revenue, the Legislature is experimenting.
Chasse, 42, was disabled for years with herniated discs and bum knees before she enrolled in the "integrated therapies'' project.
Unable to stand very long or even get out of bed without help, she was trying to raise a grandchild and care for her ailing father while fighting through a daily fog of four to six painkillers and muscle relaxers.
When she began Medicaid's massage sessions this spring, "I didn't expect it would work,'' Chasse said. "You don't think of it as traditional medicine. You think of it as something for the rich and famous.''
But with twice-monthly massages, she has dropped to one painkiller a day and taken a full-time job in, of all places, a pill-packing plant.
"This is one of the best things that ever happened to me,'' Chasse said. "I come out of (the massages) and say, 'Thank you, Jesus.' It's like having a morphine button.''
Chasse is not alone. Patients on the program at least six months have reported a 23 percent improvement in their physical condition and 16 percent improvement in their mental condition.
"Primary care doctors don't know how to manage pain. They are just throwing drugs at it,'' said Adrian Langford, regional director for Alternative Medicine Integrated, the Chicago company that runs the pain project.
"We are teaching them to manage their own pain.''
Florida pays AMI roughly $600,000 a year to oversee about 300 Medicaid patients. They all have diagnoses of chronic neck or back pain, fibromyalgia or chronic pain syndrome.
An AMI nurse assesses their physical and mental condition, talks to them about stress and, in most cases, refers them to a massage therapist, acupuncturist or nutrition counselor.
Simple pamphlets offer advice on stretching, exercise and conflict resolution.
Free meditation CDs guide patients through relaxation techniques.
"If someone is having trouble sleeping, it's a lot cheaper to give them CDs for $8 than send them to the pharmacist for sleep medications,'' Langford said.
For years, Florida Medicaid has paid private companies to manage chronic diseases. Patients with diabetes, hypertension, HIV and other conditions receive telephone calls, reminding them to take their medicine and show up for doctor visits.
The chronic pain experiment is new. Though pain affects more Medicaid patients and costs more money than any other chronic condition, the Legislature has been reluctant to pay for special management.
Among other things, pain can't be measured with a lab test, like blood sugar or immune cells can. So when does really bad pain become "chronic''?
Fibromyalgia, generalized muscle pain and fatigue, is recognized as a distinct disease by arthritis doctors and the American College of Rheumatology. But other doctors view the same symptoms as signs of depression.
The mind-body connection is exactly why pain patients should be treated holistically, Langford said. As much as anything, he said, AMI's integrated therapies program is about relationships.
"Chronic pain patients may be medically disenfranchised for years,'' he said. "They may be looked down upon by the physician's staff because they are on Medicaid. They may not be responding to a prescribed drug treatment regimen so they often get tagged as malingerers.''
Massage or acupuncture "is an environment they have never experienced,'' he said.
"They are treated with respect and dignity and clinically appropriate pain relief,'' he said.
During one of Chasse's recent massages, there was plenty of work to be done. At one point, Williams ground her elbow into a wallet-sized knot protruding from Chasse's back.
But the session was also a running conversation.
How's the grandson doing with his heart problems? How is work? Are you trying to lift too much?
Chasse: "I'm a grandma again.''
Williams: "Oh, did your daughter have the baby?''
Legislators aren't accustomed to paying for conversation, but a cost evaluation by the University of South Florida's State Data Center on Aging suggests that AMI's intimate, attentive approach to pain might save money.
Before enrollment, patients in the integrated therapies program cost Medicaid an average of $920 a month for doctors, hospitals and drugs. After enrollment, those traditional costs dropped by $105.
AMI's monthly services cost Medicaid $103 per patient, so the program's savings and costs seem to equal out.
Medicaid's chronic pain patients who are not on AMI's program fared less well, the USF study showed.
Their monthly costs on conventional therapies rose from $845 to $945 during the study period, a 12 percent increase.
Langford claims victory by holding the line on costs while other Medicaid pain patients grew more expensive.
"Everything we do is common sense,'' he said. "Sometimes, just an interaction with a caring nurse makes a difference, when she suggests you use a heating pad instead of going to the emergency room.''
A 2003 study published in the Annuals of Internal Medicine concluded that massage is the cheapest, most effective way to treat persistent back pain, which half of all Americans experience at least once a year.
Massage beat out conventional painkillers, chiropractic and acupuncture.
But the Legislature should be cautious when evaluating costs, said Dr. Ed Wagner, a chronic disease researcher at Group Health in Seattle, which led the 2003 pain study.
Patients who have experienced abnormally painful years may be more willing to experiment with alternative treatments than other patients, Wagner said. Treatment costs may drop for those patients during the experiment, but not necessarily because massage or acupuncture helped them.
Maybe, those patients just returned to a more typical year of pain and complications.
"I can't tell you this program isn't a good idea,'' Wagner said. But the cost comparison of the USF study "just can't answer that question for you.''
Funding for the pilot project expires in January. The Legislature could kill it, renew it, or expand it to more counties.
Florida's Agency for Health Care Administration, which distributes Medicaid money, wants one more cost study before making a recommendation, spokeswoman Krista Moody said.