ASC Specialty to Watch: Pain Management in 2012

Pain Management

Recent figures estimate more than 116 million American suffer from chronic pain, and a greater awareness of the condition is creating an increase in demand and performance of pain management procedures. In a VMG Health survey of same center data from 2009-2010, pain management case volume increased by an average of 1,235 procedures per center.
Standiford Helm II, MD, medical director of Pacific Coast Pain Management Center in Laguna Hills, Calif., and president of the American Society of Interventional Pain Physicians, and Francis Riegler, MD, co-founder of Universal Pain Management in Victorville, Calif., discuss five points on the future of pain management.

1. Increased demand has led to non-certified physicians treating pain. The demand for pain management procedures is increasing at a natural rate, but other factors, such as non-certified pain management physician performing pain management procedures, are leading to an inflated utilization rate.

"As the baby boomers are getting older, there is — based on demographic trends — a natural tendency for the demand to be rising," says Dr. Riegler. "One of the other things you've got going on is that there are a whole lot more of these procedures being done across the board."

These procedures aren't always done by specialized pain management physicians, he says.

"If you're a physician who's not a trained pain management physician, you can go out and do these procedures and get paid the same amount of money as a legitimate, fellowship-trained pain management physician," he says. "One of the things is that the utilization rate [of pain management procedures] has been rising more than the natural rate of increase."

In an effort to increase awareness and promote interventional pain management as a specialty, ASIPP created the American Board of Interventional Pain Physicians. Dr. Riegler says there are currently 200-300 physicians certified by the board, and the number increases every year. ABIPP hopes to be accepted as a member of the American Board of Medical Specialties, which would add more legitimacy to the specialty and encourage procedures to be done only by pain management specialists.

2. The battle against opioid drug abuse will continue. A recent Center for Disease Control report found more Americans died from overdosing on opioid pain relievers — including hydrocodone, methadone, oxycodone and oxymorphone — than from overdosing on heroin and cocaine combined. Physicians who are prescribing these drugs are being held more accountable. Some physicians have decided to completely stop prescribing opioids while others are being more selective in whom they prescribe opioids to. Part of that selectiveness will be ensuring that opioid therapy is helping the patients.

"In an era where prescription opioid deaths are a major problem, physicians and patients are going to have to show increased function and decreased pain scores," Dr. Helm says. "Colleagues and payors will challenge us on patients who rate their pain eight out of 10 despite opioid use. If the pain is not going down and if function is not going up, what is the point of continuing to prescribe?"

3. Medicare will bundle fluoroscopic guidance into procedure codes. Like most specialties, pain management is seeing reductions in reimbursements for procedures, Dr. Riegler says.

"One of the insidious ways that the Medicare program pulls down the payment for physicians is by changes in the codes," he says.

Medicare can reduce the cost of reimbursements by bundling codes. Next year, Dr. Riegler says the code for fluoroscopic guidance will be bundled into the procedure codes.

"In 2011, we get paid a professional fee for injection and a technical component for the use of a fluoroscope," he says. "In the future, if they bundle the fluoroscope code into the professional code, physicians are going to be getting paid less."

He sees this as a pattern for technology advances. A few years ago, no one questioned the used of fluoroscopic guidance, and reimbursement rates were stable.

"As time went on, fluoroscopic guidance became more commonplace and not particularly new," he says. "We see this tendency to eliminate the separate payment."

4. Increase in ultrasound guidance. One of the newer techniques in pain management is to use ultrasound guidance for injections, such as epidural steroid injections and facet blocks. Currently, the code for ultrasound guidance can be added to the procedure code for things like injections, although Dr. Riegler would not be surprised if that changed in the future, just as it has for fluoroscopic guidance.

"As more and more people start to use ultrasound, the output from Medicare will rise," he says. "The easiest way to dampen the use of a procedure is to decrease the reimbursement. I wouldn't be surprised to see the code be bundled down the road."

5. Procedures will be about providing the best value. As reimbursements decrease and healthcare budgets shrink, Dr. Helm thinks procedures that increase patient function and decrease pain for the best value will be the procedures that take off.

"Pain procedures that are going to thrive are those which add value," he says. "A good example is the MILD procedure, which treats stenosis at a cost far below surgery. In a fixed budget world, that difference will be definitive as to what therapy, if any, is provided. While patients will be interested in increased function, the insurers or ACOs will be more likely to respond to decreased utilization of resources."

The MILD, or minimally invasive lumbar decompression, is a procedure created by Vertos Medical to treat lumbar stenosis. The MILD device used in combination with an epidurogram to remove small pieces of lamina and hypertrophic ligamentum flavum, reducing pain and increasing mobility for LSS patients by restoring space in the spinal canal. Another example of a "good value" procedure is peripheral nerve stimulation for intractable headache. In this procedure, an electrical current is applied to nerves outside the brain and spinal cord.

Dr. Helm also predicts that standard procedures will undergo greater scrutiny.

"Providers will need to show that their usage of our bread and butter procedures, epidural injections and facet procedures, adds value and is not over utilized," he says.

Related Articles on Pain Management:
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