Scott Glaser, MD, President and co-founder of Pain Specialists of Greater Chicago, discusses the biggest threats to pain management today and where the field is headed.
1. Physician employment. An increasing number of physicians have signed employment contracts over the past five years due to declining reimbursements, decreased referrals, and burdensome regulations on the private practice of medicine. Coupled with the uncertainty surrounding healthcare reform implementation, both primary care physicians and specialists are gravitating toward secure employment.
"That's a sea change across medicine and interventional pain management is not immune," says Dr. Glaser. "We are seeing the one- and two-person groups struggle because their referral sources are drying up as a result of the consolidation in the industry. Their major referrals sources, primary care physicians and orthopedic surgeons, are joining larger groups and forced to refer within those groups."
Independent pain management specialists are at a crossroads. Do they join larger groups, forfeiting independence and unconstrained decision making to obtain security from market forces? Many are finding unique and creative ways to keep their practice open and thriving. In many communities, the independent physicians are aligning to form larger groups or joining provider networks for contract negotiation power. They are harnessing the powers of social media to increase their word of mouth referrals. They are working with lawyers doing personal injury work.
Dr. Glaser says, "We are reviewing all of our options from working with national groups to form networks driving patient volume to consolidating local providers into a cohesive group which can provide care throughout Chicagoland."
"Healthcare is reforming; to paraphrase a quote I heard at the last Becker conference, you can resist it and die, accept it and survive; or lead it and prosper," says Dr. Glaser. "I want to lead it and prosper. Pain management's role and goals fulfill all of the goals of accountable care organizations and other efforts to reduce the big ticket items in patient care- ER visits, hospitalizations, and surgery. This is done through strategic outpatient management of common painful syndromes and improving the patient’s quality of life through minimally invasive treatment."
2. Pain patient triaging. Pain physicians are currently viewed as the last line in treatment for patients in pain; however patients would benefit from seeing an interventional pain management specialists much earlier. Interventional pain physicians are the physicians most familiar with both conservative and interventional treatment and they can guide patient care in the most beneficial direction. Surgeons, who are often viewed as the quarterback, have little training in conservative care or interventional treatment and must refer to others for those treatments.
"We are most effective when we embrace the roles and responsibilities as the quarterbacks of musculoskeletal pain," says Dr. Glaser. "We should be the physician assessing the patient initially, monitoring them, treating their symptoms and performing minimally invasive interventions when required to reduce pain and improve quality of life. For injured workers, we must always be motivating them and providing care that allows them to return to work and continues treatment while they are working. This would be a paradigm shift from patients starting out seeing their primary care physicians and then being sent to the orthopedic surgeon before seeing us."
Patients are also being mismanaged by physicians with opioids without being made aware of the short and long term risks and the treatment alternatives. They are becoming more tolerant to pain medication prescribed by non-pain specialists who do not appropriately monitor their use. There are multitudes of people who have become addicted to pain medication or misused controlled substances with sometimes fatal consequences.
"Our goal as interventional pain management physicians is to reduce the rate of addiction and effectively and safely manage patients on narcotics," says Dr. Glaser. "We also want to raise awareness of these risks. Choosing to treat pain with opioids is as fraught with the risk of adverse long term consequences as deciding to have surgery."
3. Limited access to care. Another change in pain management is the continual downward pressure on access to the appropriate treatment as insurance company policies become stricter on which procedures they approve. "They are creating or revising more restrictive policies based on their interpretation, or in my mind, willful misinterpretation of the literature," says Dr. Glaser. At the same time, more patients have insurance today than ever before because of health insurance exchange programs and expanded Medicaid coverage in some states.
"As these insurers are having to accept all these new patients, many whom are ill and therefore more expensive, the coverage will have to come from somewhere and it is obviously coming from higher copays and deductibles," says Dr. Glaser. "Access to effective pain management procedures then becomes limited. Patients are unable to afford X-ray guided procedures that they had performed for pain in the past because their deductible is now $5,000 instead of $500. If you are middle income, these deductibles and copays in essence change your insurance to catastrophic insurance only."
The Independent Payment Advisory Board could also limit access to care in the future. IPAB was created to review Medicare coverage and make recommendations, but there is no legislative recourse to their decisions as it is under the executive branch. IPAB came into existence as part of the Affordable Care Act, but the new nominee for the Secretary of the Department of Health and Human Services Sylvia Burwell recently said if appointed, she does not expect to realize the board during her tenure.
"IPAB goes too far," says Dr. Glaser. "I think Americans have decided something needed to be done by the government to control healthcare spending, but I do not think they would ever get behind any efforts by the government to control healthcare decisions."
4. Coverage hurdles. There are several examples of insurance companies limiting access to procedures they once covered, and interventional pain procedures are no exception. Additionally, newer, better procedures have little chance of coverage as insurance companies tighten the belt to maintain profitability. Physicians are spending more time today fighting for coverage, and many are sent to peer-to-peer reviews with the insurance company's medical directors — often not spine specialists — to defend their treatment decisions.
"I did a peer-to-peer with two head physicians at a major insurance company recently and one was a general surgeon; the other was a primary care physician, not exactly peers in my book" says Dr. Glaser. "And yet, based on their interpretation of the literature, which is certainly biased by their employment, they were making decisions on whether I could implant a peripheral nerve stimulator for a patient that met all the criteria for the procedure and had already undergone a wildly successful trial. The situation is becoming bizarre."
5. Low reimbursement. The Centers for Medicare and Medicaid Services 2014 Final Payment Rule included a significant cut to reimbursement for several specialties, including pain management:
• 33 percent cut for cervical epidural payments
• 56 percent cut for cervical epidural when performed in an office setting
• 19 percent cut for lumbar epidural injection payments
• 49 percent cut for lumbar epidural when performed in an office setting
Dr. Glaser and his colleagues at the American Society of Interventional Pain Physicians met with U.S. Representative and House Majority Leader Eric Cantor in April and discussed the impact these cuts were making on access to care. "I'm certain action will be taken," says Dr. Glaser. "These cuts are draconian and difficult to comprehend based on the knowledge of the risks of the procedure and the possible complications including quadriplegia, paraplegia, and death."
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