Over the past several years, there has been considerable interest in expanding the role of the pain management specialist as an integral member of the health care team. This interest has been stimulated in part by the increased availability of health care professionals with a special interest and advanced training in pain medicine, in part by the increasing societal awareness that undertreated and untreated pain have reached epidemic proportions, and in part by the unprecedented economic pressures of our rapidly evolving health care system. These economic pressures have forced many pain management specialists and hospitals to explore new avenues of revenue generation and to examine new strategies to help improve the efficiency and cost-effectiveness of the care they provide.
The purpose of this chapter is to serve as a guide for pain management specialists who may be considering setting up a pain treatment center or expanding the scope of services currently offered. Although many of the concepts presented are basic, failure to take them into consideration may lead to high levels of professional frustration and dissatisfaction, damage to the professional image of the pain management specialist, economic loss, and increased exposure to malpractice liability.
There is no question that there is a huge demand for quality pain management services. The 2011 Institute of Medicine report titled Relieving Pain in America—A Blueprint for Transforming Prevention, Care, Education and Research found that approximately 100 million American adults are affected by chronic pain.1 This is more than the total number of American adults affected by cancer, heart disease, and diabetes combined.2 The report estimated that the cost of the pain to the United States is more than $635 billion each year and is rising as Baby Boomers age. A recent study of pain patients in America by the National Center for Health Statistics revealed the four most common types of pain complaints are low back pain, headache, neck pain, and facial pain3 (Fig. 101-1).
In recognition of the pain epidemic the 2010 Patient Protection and Affordable Care Act requires that the Department of health and Human Services in partnership with the Institute of Medicine provide a comprehensive assessment of the science surrounding pain, care, research, and education and provide specific recommendations to improve performance in each of these areas.
From these data, it is obvious that there are a huge number of patients who could potentially benefit from quality pain management services.
The first question that must be asked when considering the implementation or addition of new pain management services is how the addition of those new services will interface with existing professional activities. One must take into account the impact of such new services on existing care. The addition or expansion of pain management services requires a high level of commitment from all members of the health care team. Even if additional professional staff is added to provide pain management services, consideration must be given to such issues as call responsibilities, vacation coverage, and so forth.
As with all health care endeavors, there must be sufficient expertise to provide an ongoing level of quality care. One would not implement an open heart surgery program or start a burn unit without adequate expertise or additional training. Pain management requires the same level of training, expertise, and commitment. In addition to the clinical expertise required to provide quality pain management services, there must be administrative expertise if the endeavor is to be economically viable. This is especially important when setting up a pain treatment facility under the managed care paradigm and the new Affordable Care Act.4,5
When setting up a pain treatment facility, it is important that the pain management specialist recognize the high level of commitment in terms of the time and energy essential to providing quality pain management services. For this reason, the pain management specialist must ensure that there are adequate personnel to provide high-quality coverage for any new services that are contemplated or to cover the expansion of existing services.
There is a common misconception that pain management can be done at the convenience of the pain management specialist. This is simply not the case. This approach can only lead to high levels of dissatisfaction from both patients and referring physicians. Today’s patient, or what has become affectionately known as today’s “health care consumer,” is unwilling to wait for extended periods in order to receive care. During the implementation of a new pain management facility or an expansion of an existing one, a realistic appraisal of the time required to provide the proposed care must be undertaken to assure the provision of care in a timely manner. Just as there must be an adequate number of health care professionals to provide high-quality pain management services, there must also be a high level of motivation in order for the pain facility to ultimately succeed.6 All members of the health care team must be committed to quality and compassionate provision of pain management services. A lone pain management specialist, no matter how motivated and caring, can do little to make up for the disinterest and lack of support of the remainder of the pain management team. This statement applies not only to the clinical personnel but to the administrative personnel as well. A failure to adequately supervise midlevel providers can also lead to medical misadventures and high levels of patient dissatisfaction.7
In setting up a pain treatment facility, care must be taken to be sure that the practice infrastructure is adequate to support a busy and growing pain management service. If the pain management specialist’s existing billing office is unable to keep up with the volume of work generated from existing activities, the addition of billings from new or expanded pain management service may throw the entire office into disarray and adversely affect cash flow. Obviously, additional help can be added to alleviate this situation, but this should be done in a prophylactic manner.8
Before setting up a new pain treatment facility, the first decision that needs to be made is which specific services (e.g., evaluation, neural blockade, drug management and detoxification) should be offered. To adequately delineate these services, the pain management specialist must take into account his or her existing expertise, experience, and preferences as well as those of other health care professionals providing pain management services within the group practice. The availability of support services such as physical therapy, occupational therapy, psychiatry, and radiology support services (e.g., computed tomography scanning, magnetic resonance imaging, ultrasound, and biplanar fluoroscopy) must also be considered.9 Under the managed care paradigm, some services may not be reimbursed at levels adequate to justify their use from a purely economic viewpoint.
It is important to clearly define to patients as well as referring physicians what a new pain treatment facility can and cannot offer. Too often a pain management specialist with limited experience and training tries to hold him- or herself out as a specialist in all areas of pain management. This not only is academically dishonest but often leads to high levels of patient and referring physician dissatisfaction.5 It may also place the pain management specialist, and those with whom he or she practices, in a potentially serious medicolegal situation. Services should not be advertised that are not available or cannot be provided with sufficient expertise to keep complications to a minimum.
The second decision that needs to be made is delineating the types of patients that the pain management specialist believes are appropriate for the scope of pain management services he or she has chosen to offer at the new facility. The pain management specialist should determine if he or she is comfortable treating cancer pain, headache and facial pain, chemical-dependent problems, acute and postoperative pain, and so forth. As the enthusiasm for the prescribing of opioids for chronic nonmalignant pain wanes, a clear plan as to whether opioids will be prescribed in this clinical setting needs to be clearly defined.10 The pain management specialist must also determine whether he or she will accept patients who are involved in workers’ compensation claims and patients who are involved in litigation. Third, the pain management specialist must decide whether he or she will accept self-referred patients or if he or she will require patients to be evaluated and then referred by another physician (see section on physician referral). Finally, the pain management specialist will also have to decide whether he or she will accept primary responsibility for patients who are admitted to the hospital. This decision has specific implications that must be carefully thought out from a quality-of-care viewpoint because some pain management specialists may be incapable or unwilling to deal with the various medical problems that may occur while a patient is hospitalized under their care. Political issues as to the appropriateness of a pain management specialist providing primary care may also have to be addressed.11,12
The following issues must be handled according to each pain management specialist’s existing financial situation, current policies, and prior contractual agreements with the hospital or third-party carriers, as well as his or her own philosophical and ethical viewpoints on providing indigent care.13,14 To ignore these variables when starting a pain treatment facility is to ensure economic disaster.
For the pain management service to remain on a strong economic footing in this period of ever-decreasing revenues, financial considerations must be carefully considered.8 Some pain management specialists have chosen to provide pain management services on a cash-only basis. Although this may work in some affluent communities, by and large, in view of the high cost of many of the modalities offered, this represents an impractical approach for most pain management specialists.
A decision must be made as to the desirability of accepting Medicare assignment as well as other third-party assignments of insurance benefits. Participation in managed care plans should also be carefully weighed.4 It should be remembered that midlevel providers may be paid at lower levels than physicians, yet these midlevel providers are held to the same standards insofar as fraud and abuse issues are concerned.15 Obviously, local factors have to dictate the variables to be taken into account in making this decision. The pain management specialist must also decide what provisions will be made for the indigent patient who has Medicaid or who is solely responsible for the payment of his or her health care costs. The pain management specialist is likely to be approached by attorneys who want care to be rendered on a contingency basis. The economic impact of these decisions cannot be overstated.