This article was published with permission. www.painphysicianjournal.com
Background: The rapid increase in the prevalence of chronic pain and disability, and the explosion of interventional pain management associated health care costs are a major concern for our community. Further, the increasing utilization of numerous modalities of treatments in managing chronic pain, continue to escalate at a pace which may not be sustainable. There are multiple regulations in place to control the growth of health care expenditures which seem to have been largely ineffective. Among the various modalities utilized in managing chronic pain, interventional techniques have shown a significant increase in their utilization in the face of continued debate with respect to the accuracy of diagnostic interventions and the efficacy of therapeutic interventions.
Objective: To update and assess the utilization of interventional techniques in chronic pain management in fee-for-service Medicare population.
Study Design: An updated analysis of the growth of interventional techniques in managing chronic pain in fee-for-service Medicare beneficiaries from 2000 through 2013.
Methods: The data were derived and analyzed utilizing the Centers for Medicare and Medicaid Services (CMS) Physician Supplier Procedure Summary Master Data from 2000 through 2013.
Results: From 2000 through 2013, in fee-for-service Medicare beneficiaries, the overall utilization of interventional techniques services increased 236% at an annual average growth of 9.8%, whereas the per 100,000 Medicare population utilization increased 156% with an annual average growth of 7.5%. During this period, the US population increased 12% with an annual average increase of 0.9%, whereas those above 65 years of age increased 27% with an annual average increase of 1.9%. Total Medicare beneficiaries increased 31% with an annual average increase of 2.1%, with an overall increase of 64% for those above 65 years of age, an increase of 26%, constituting 17% of the US population in 2013.
The overall increases in epidural and adhesiolysis procedures were 165% compared to 102% per 100,000 fee-for-service population with annual average increases of 7.8% and 5.6%. Facet joint and sacroiliac joint injections increased 417% for services with an annual average increase of 13.5%, whereas the rate per 100,000 fee-for-service Medicare beneficiaries increased 295% with an annual average increase of 11.1%.
Limitations: Limitations of this assessment include the lack of inclusion of participants from Medicare Advantage plans, lack of appropriate available data for state-wide utilization, and potential errors in documentation, coding, and billing.
Conclusion: This update once again shows a significant increase in interventional techniques in fee-for-service Medicare beneficiaries from 2000 through 2013 with an increase of 156% per 100,000 Medicare population with an annual average increase of 7.5%. During this period the Medicare population increased 31% with an annual average increase of 2.1%.
Key words: Chronic pain, chronic spinal pain, interventional pain management, interventional techniques, epidural injections, facet joint interventions, sacroiliac joint injections
Pain Physician 2015; 18:E115-E127
The increasing prevalence in chronic pain and disability, and the economic impact with increases in health care costs continue to be subjects of concern in the United States and across the globe (1-4). Specifically, spinal pain is highly pervasive and has been shown to contribute to disability, with 3 of 5 disorders constituting the cause of most years lived with disability in 2010 in the United States as well as worldwide which includes low back pain, other musculoskeletal disorders, and neck pain (1-10). Thus, not only costs, utilization, and appropriateness, but also complications related to various interventions in managing chronic pain, specifically spinal pain, have been debated extensively (1-4,11-34). Consequently, based on available reports, deaths due to acetaminophen were approximately 1,000 per year; nonsteroidal anti-inflammatory drug deaths, based on 1990 data, were 17,000; opioid deaths in 2012 were 16,235, with deaths secondary to methadone alone of 4,400 in 2011. Deaths have escalated due to heroin and extensive liberalization of marijuana use. Surgical interventions, which have increased 137%for low back pain from 1998 to 2008, resulted in 1,012 deaths in 2008 (15,20,22,27-32). Most of the focus has been on complications of interventional techniques and opioid use with increasing utilization (16-19,23-26,34). The Food and Drug Administration (FDA) has reported 131 deaths, of which 41 were secondary to arachnoiditis (23-26). In addition, there was an unprecedented outbreak of fungal infection due to preservative-free, injectable methylprednisolone acetate in 2012 (33), affecting 76 facilities in 23 states and a total of 751 patients.
Published reports show that utilization of interventional techniques in managing chronic pain has been increasing substantially over the years. Manchikanti et al (16,19), in an assessment of the population in the fee-for-service sector of Medicare, showed an overall increase of 228% and 177% per 100,000 Medicare beneficiaries from 2000 to 2011. In addition, they (17) also reported utilization and costs from 2000 to 2008. They found a 240% increase in costs and a 229% increase in procedures. They estimated the costs of spinal interventional techniques to be over $362 million in 2000, increasing to over $1.2 billion in 2008. Overall, per patient expenditures increased 19% and per visit expenditures increased 6% (17). Manchikanti et al (16), in describing accountable interventional pain management, a collaboration among practitioners, patients, payers, and government, discussed various issues related to escalating utilization, costs, and measures to reduce utilization and costs without affecting access to care. There have been multiple investigations from the Office of Inspector General in reference to the utilization of facet joint injections and transforaminal epidural injections (35,36).
An emerging specialty, interventional pain management (IPM) and its techniques have their own definitions (37,38). IPM is represented on Carrier Advisory Committees (39) in the United States. The specialty has a specific responsibility to provide medically necessary services while at the same time improving quality and curbing costs (12,16,40); however, it is extremely difficult because of counter-acting forces with ever-changing coverage policies, regulations, an increasing population that has pain and disability, and finally health care reform and excessive utilization (16-19,40-43). In addition, there also has been extensive debate on IPM’s efficacy and effectiveness, including medical necessity, indications, and appropriateness of interventional techniques for managing chronic pain (44-53) with a case being made for and against these techniques by appropriately performed systematic reviews (12,44-48), and others with inappropriate evidence synthesis and lack of appropriate methodology (39,50-52).
With the institution of national health care systems across the globe and affordable health care in the United States and an increasing aged population and Medicaid expansion in the United States secondary to the Affordable Care Act, interventional techniques have become the focus of attention in the United States. Further, Medicare has become a standard due to the organization being larger than any other insurance provider. Medicare continues to expand rapidly and all other payers, specifically Medicaid with its explosive expansion, seem to base their decisions on the policies of Medicare. As expected, multiple measures are applied by insurers and various governmental agencies across the globe to get a handle on exploding health care costs, specifically costs of chronic pain management with a focus on interventional techniques. However, the basic understanding of chronic pain itself and the proper and safe application of interventional techniques compared to various other clinical modalities available for managing chronic pain seems to be misunderstood. Further, utilization patterns, costs, and policies continue to emerge.
This study was undertaken to update previous assessments (19) about the utilization of interventional techniques in chronic pain from 2000 through 2013.
METHODS
The study was performed utilizing the Centers for Medicare and Medicaid Services (CMS) Physician Supplier Procedure Summary Master Data from 2000 through 2013 (54). The data were purchased from CMS by the American Society of Interventional Pain Physicians. This study was conducted with the internal resources of the primary author’s practice without any external funding, either from industry or elsewhere. CMS’s 100% data set is therefore expected to be unbiased and unpredictable in terms of any patient characteristics. Even though previous studies (55,56) used only patients aged 65 or older, in this study we have used all patients enrolled in fee-for-service Medicare. A significant proportion of patients below the age of 65 receive interventional pain management services (17). Medicare represents the single largest health care payer in the United States, with over 51.9 million beneficiaries in 2013 (57). Thus, the procedures performed on Medicare beneficiaries represent a large proportion of the procedures for chronic pain being performed in the United States. Rates were calculated based on Medicare beneficiaries for the corresponding year and are reported as procedures per 100,000 Medicare beneficiaries.
For analysis, the Current Procedural Terminology procedure codes for interventional techniques [Epidural and Adhesiolysis procedures (62310, 62311, 64479, 64480, 64483, 64484, 62280, 62281, 62282, 62263, 62264); Facet Joint interventions and SI joint blocks (64470, 64472, 64475, 64476, 64490, 64491-new, 64492-new, 64493-new, 64494-new, 64495-new, 64622, 64623, 64626, 64627, 64633-new, 64634-new, 64635-new, 64636-new, 27096); Discography and Disc decompression (62290, 62291, 62287) other type of nerve blocks (64400, 64402, 64405, 64408, 64410, 64412, 64413, 64417, 64420, 64421, 64425, 64430, 64445, 64505, 64510, 64520, 64530, 64600, 64605, 64610, 64613, 64620, 64630, 64640, 64680)] were identified for 2000 through 2013. The data were then tabulated based on the place of service – facility (ambulatory surgery center, hospital outpatient department) or nonfacility (office). The calculated data included the number of interventional pain management services and the rate of services per 100,000 Medicare beneficiaries.
Various specialties were described as providers: interventional pain management -09, pain medicine -72, anesthesiology -05, physical medicine and rehabilitation -25, neurology -13, psychiatry -26, all constituting interventional pain management; orthopedic surgery -20, general surgery-17 and neurosurgery -14 as a surgical group; radiology specialties as a separate group (-30 diagnostic radiology, -94 interventional radiology); all other physicians as another group; and all other providers were considered as other providers.
Statistical Analysis
The data were analyzed using SPSS 9.0 statistical software (SPSS, Inc., Chicago, IL) Microsoft Access 2003, and Microsoft Excel 2003 (Microsoft, Redmond, WA). The procedure rates were calculated per 100,000 Medicare beneficiaries.
RESULTS
Population Characteristics
As illustrated in Table 1, the number of Medicare beneficiaries increased from 39.632 million in 2000 to 51.900 million in 2013, an increase of 31% compared to an increase of 12% in the US population.
Utilization Characteristics
Table 2 illustrates a summary of the frequency of utilization in various categories of interventional techniques in Medicare beneficiaries from 2000 to 2013.
Overall, the increase in interventional pain management procedures from 2000 to 2013 was 236%, with a 156% increase per 100,000 Medicare beneficiaries. The increases were highest for facet joint interventions and sacroiliac joint blocks, with 417% total and 295% per 100,000 Medicare beneficiaries, followed by 165% and 102% for epidural and adhesiolysis procedures, 161% and 99% for other types of nerve blocks and finally, a 3% increase and 22% decrease for disc procedures. The geometric average of annual increases was 9.8% overall with 13.5% for facet joint interventions and sacroiliac joint blocks and 7.8% for epidural and adhesiolysis procedures.
Fig. 1 illustrates the distribution of procedural characteristics from 2000 to 2013.
Specialty Characteristics
Tables 3 and 4 illustrate procedural characteristics based on specialty. Overall increases were 236% with a 156% increase per 100,000 Medicare beneficiaries. For interventional pain management, these increases were 268% and 181%; for surgical specialties, including neurosurgery, orthopedic surgery and general surgery, increases were 101% and 54%; for radiology, they were 194% and 125%; for other physicians, they were 60% and 22%; and for other providers, they were 323% and 223% increase overall and per 100,000 Medicare beneficiaries. Fig. 2 illustrates the distribution of specialty characteristics.
DISCUSSION
Interventional techniques for chronic pain have increased dramatically from 2000 to 2013. The increases were present in all settings and by all types of specialists. Over this period from 2000 to 2013, beneficiaries increased 31%, whereas overall interventional pain management services increased 236%, whereas rate per 100,000 Medicare beneficiaries increased 156%. The study also showed an exponential increase in facet joint interventions with a rate of 295% increase per 100,000 beneficiaries and annual average growth of 11.1%, more than any other modality. Overall, average annual increases were 7.5 % per 100,000 Medicare beneficiaries.
The results of this evaluation of growth patterns are similar to previous evaluations (17,19,55,56,58-60) although they differ in select aspects. Friedly et al (55,56) focused on the escalating use of injection therapies coupled with a lack of evidence for managing chronic low back pain and geographic variation in epidural steroid injections, reaching inaccurate conclusions (61). These results no longer represent the present day atmosphere. Abbott et al (18) basically utilized an inappropriate concept and hypothesis.
Some critics of increasing utilization continue to claim interventional techniques lack evidence, and question if back pain is increasing (15,62-64). However, disability secondary to spinal pain, health, and economic impact are increasing at an explosive rate, along with evidence of the increase in the prevalence of spinal pain (1-10,13,65-73). In fact, Freburger et al (5) showed an increase in low back pain in North Carolina of 162%, from 3.9% to 10.2% over a period of 14 years from 1992 to 2006. Our understanding of the impact of chronic pain has changed over the years, specifically with its comorbid disorders and functional limitations. The impact of chronic pain has been described by various organizations as it fits their needs. The Institute of Medicine (1), based on data from Gaskin and Richard (2), estimated chronic pain in 100 million patients to have a cost of $650 billion; however, these estimations are inaccurate in that moderate and severe persistent pain contributed to 44.9 million persons, costing approximately $100 billion a year in the United States (74). Further, the FDA commissioner also used these numbers to justify the approval of Zohydro ER (Zogenix Inc., San Diego, CA) which faced stiff opposition from multiple organizations, Congress, and governors (74).
There are several limitations to our study; for example the lack of inclusion of participants in Medicare Advantage plans and potential coding errors. In contrast to previous studies (55,56), we employed all patients receiving Medicare either below the age of 65 or over the age of 65. This inclusion is extremely important because patients below the age of 65 represent a significant proportion of patients receiving interventional techniques with higher frequency (4.50 vs. 3.35 services per patient) in 2006 (60). Further, by limiting to the Medicare database, this study has not evaluated other insurance providers including Medicaid, workmen’s compensation and other carriers. However, the data from the FDA (26), shows utilization of epidural injections in Medicare and non-Medicare population. This data showed that over a period of approximately 5 years, 6.6 million epidural injections were administered to 1.4 million patients over the age of 65 years. Thus, even this data has missed those of less than 65 years of age and Medicare Advantage plans. The FDA data also showed among other payers, in those who were aged 0 to 59 years, with 150,572 patients receiving 262,301 epidural injections in 2012. Thus, the present data correlates with the data provided by the FDA.
Overall interventional techniques are escalating and are associated with complications; and complications should never be minimized. Consequently, application of principles of accountable and value-based interventional pain management are crucial. Other developments include reducing over-regulation and applying appropriate regulations without shifting services from one sector to the other with evidence-based approaches.
CONCLUSION
Interventional techniques increased significantly in Medicare beneficiaries from 2000 to 2013. There was an increase of 156% in utilizing interventional pain management services per 100,000 fee-for-service Medicare beneficiaries, with an annual average increase of 7.5%. The study also showed an exponential increase in facet joint interventions and sacroiliac joint blocks.
ACKNOWLEDGMENTS
The authors wish to thank Tom Prigge, MA, and Laurie Swick, BS, for manuscript review, and Tonie M. Hatton and Diane E. Neihoff, transcriptionists, for their assistance in preparation of this manuscript. We would like to thank the editorial board of Pain Physician for review and criticism in improving the manuscript.
Author affiliations:
Dr. Manchikanti is Medical Director of the Pain Management Center of Paducah, Paducah, KY, and Clinical Professor, Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY.
Vidyasagar Pampati is a Statistician at the Pain Management Center of Paducah, Paducah, KY.
Dr. Falco is Medical Director of Mid Atlantic Spine & Pain Physicians, Newark, DE; Director, Pain Medicine Fellowship Program, Temple University Hospital, Philadelphia, PA; and Adjunct Associate Professor, Department of PM&R, Temple University Medical School, Philadelphia, PA.
Dr. Hirsch is Vice Chief of Interventional Care, Chief of Minimally Invasive Spine Surgery, Service Line Chief of Interventional Radiology, Director of NeuroInterventional Services and Neuroendovascular Program, Massachusetts General Hospital; and Associate Professor, Harvard Medical School, Boston, MA.
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