Chapter 81. Setting Up a Pain Treatment Facility

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 and in part by the unprecedented economic pressures of our rapidly evolving health care system. These economic pressures have forced many pain management specialists to explore new avenues of revenue generation as well as 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 the pain management specialist 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.

Should Pain Management Services Be Offered?

There is no question that there is a huge demand for quality pain management services. The Nuprin Pain Report, which to date is the only comprehensive evaluation of pain in the United States, reveals that there are four billion work days lost due to pain in America alone.1 Seventy-three percent of the patients interviewed reported one or more headaches that interfered with their ability to work; 50% of the people interviewed reported back pain, which limited their ability to work; 46% reported abdominal pain, which limited their ability to work. The Nuprin Pain Report further noted that 43% of Americans saw a physician at least one time in the year preceding the statistical analysis and, surprisingly, 29% of those patients surveyed sought the help of a physician for pain four or more times in the year proceding statistical analysis. Of great interest to our specialty is that of those patients who sought medical attention for more than an occasional pain, 58% saw their family physician; 18% saw a chiropractor; 12% sought help from their pharmacists; and 9% percent sought help from dentists or other health care professionals. Only 3% sought the advice and help of a pain management specialist. From these data, it is obvious that there are a huge number of patients who could potentially benefit from quality pain management services and, equally obvious, is that our specialty has a problem with recognition and identity.

Interfacing Pain Management Services with Existing Services

The first question that must be asked when considering the implementation or addition of new pain management services is how the addition of this new service 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 the 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.2

Are There Adequate Personnel to Provide Quality Care?

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 provide 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 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.3 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 uninterest 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.

Is the Support Staff Adequate?

When 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.4

Services Offered

Prior to setting up a new pain treatment facility, the first decision that needs to be made is the decision as to which specific services (e.g., evaluation, neural blockade, drug management and detoxification, etc.) 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, such as computed tomography (CT) scanning, magnetic resonance imaging, and biplanar fluoroscopy must also be considered. 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 the patient as well as the referring physician what a new pain treatment facility can and cannot offer. Too often a pain management specialist with limited experience and training tries to hold himself or herself out as a specialist in all areas of pain management. This is not only 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 with, 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.

Types of Patients Seen

The second decision that needs to be made is delineating the types of patients that the pain management specialist feels 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. 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 many medical problems that may occur while the 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.6,7

Financial Considerations

The following issues must be handled according to each pain management specialist’s existing financial situation, current policies, prior contractual agreements with the hospital and/or third-party carriers, as well as his or her own philosophical and ethical viewpoints on providing indigent care. 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 specialist’s have chosen to provide pain management services on a cash-only basis. While 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.2 Obviously, local factors have to dictate the variables to be taken into account when 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 desire care to be rendered on a contingency basis. The economic impact of these decisions cannot be overstated.

Availability

It has been said that there are three “As” of a successful practice of pain management: ability, amiability, and availability. Obviously from a patient-care viewpoint, ability is the most important issue. From a practice management viewpoint, however, there is no question that availability is the most important. When starting a pain treatment center, it is imperative that the clinical and administrative staff all agree on the appropriate levels of availability if the facility is to succeed. Most patients expect to see the same physician at each visit, and this fact has specific impact on call schedule issues, for example, days off after call, vacation scheduling, afternoons off. If all members of the pain management care team are not motivated to facilitate the provision of quality pain management services, it is impossible for a single member of the team to make the pain management service successful. This statement also applies to the administrative staff. If the administrative staff refuses to work in additional patients or limits the hours of operation of the pain treatment facility, adverse economic consequences will often result.

Additional issues that need to be determined when setting up a pain treatment facility include the hours of operation for the pain management center. The availability of evening hours has become increasingly important and is increasingly expected by the health care consumer in today’s competitive market. Weekend coverage and holiday coverage must be also clearly defined for both the patient and referring physician. Expectations of the pain management specialist who is covering these periods should also be delineated to avoid friction between members of a group pain management practice and to assure appropriate availability from all members of the pain management care team. A clear protocol for how emergency referrals will be handled is mandatory in order to assure quality, compassionate care with a high level of satisfaction for both patient and referring physician.

How patient phone calls are handled will also have an impact on the ultimate success of the pain management specialist. Calls from referring physicians, the pharmacy, and patients, as well as support services including laboratory, radiology, physical therapy, and occupational therapy are the rule rather than the exception. Again, it must be clearly defined as to how these call will be handled by all members of the pain management care team in order to provide consistent, quality care and avoid lost revenues through missed consults or unavailability. The use of answering machines and voice mail as a way to avoid dealing with patients and referring physicians is to be avoided, and may require careful monitoring by the pain treatment facility management team.

Coupled with the need for the prompt returning of phone calls is the timeliness in which outpatient appointments and inpatient consultations are handled. Although specific times may vary from community to community, seeing inpatient consults (other than emergencies) within 24 hours of being called works well in most situations. Any consult requested on an emergency basis should be seen as soon as possible. Seeing all routine consults that are received before 4:00 pm on that same day (this includes Saturdays, Sundays, and holidays) projects a strong message that the pain patient will not suffer needlessly while waiting for pain management service to be implemented. The same reasoning applies to the availability of outpatient consultation. When setting up a pain treatment facility, immediate appointments should be available on a same-day basis for patients with acute pain problems and pain emergencies. Such appointments should allow appropriate screening and triage for such patients without disrupting the flow of previously scheduled patients.

This approach also makes good sense from a time management viewpoint. As the pain treatment facility grows busier, if inpatient and outpatient consultations are put off, a large backlog of patients waiting to be seen may result. Given the competitive nature of pain management services in most geographic areas, such delays will result in significant lost revenues and high levels of patient and referring physician dissatifaction.

Support Staff Availability

Tandem to the issue of physician availability is the issue of support staff availability. How consultations and phone messages for the pain management service are to be handled is of paramount importance to the ultimate success of the pain practitioner. In many hospital-based pain treatment facilities, all scheduling activities have been made the responsibility of the hospital secretarial staff. Oftentimes this simply does not work, both in terms of efficiency as well as motivation, when applied to the pain management service. The hospital employee may not be willing or able to provide prompt and courteous handling of phone calls from referring physicians as well as patients. Messages may get misplaced or lost. Generally the 7:00 am to 3:30 pm staffing patterns of the hospital do not meet the needs of the referring physician who is often in his or her office until 5:00 or 5:30 at night. For this reason it is desirable as well as cost-effective to hire a high-quality secretary whose prime responsibilities are the administrative aspects of the pain management service. This will ensure that the phone is answered courteously and promptly, that phone messages are handled appropriately, that patient records are readily available, and that there is an appropriate level of motivation to work in add-on and emergency patients.

The pain management support staff must be available during regular clinic hours. The overuse of an answering machine and voice mail is strongly discouraged because most busy referring physicians are unwilling to make several calls trying to reach the pain management physician to discuss or schedule a patient. Provisions for phone coverage during lunch and break periods by the pain management support staff is mandatory.

Physician-Referred versus Self-Referred Patients

Pain management specialists have traditionally felt that physician-referred patients are desirable. In fact, many practitioners will not accept self-referred patients. There are distinct advantages and disadvantages to this philosophical viewpoint as outlined in Tables 81-1 and 81-2.

The physician-referred patient may be appropriately worked up and carry a correct diagnosis. Conversely, the pain specialist has limited control over the appropriateness and quality of the evaluation and treatment of the physician-referred patient. The patient may be inadequately or inappropriately evaluated, which puts tremendous medicolegal responsibilities on the pain management physician to complete the evaluation. These problems can be magnified under the managed care paradigm since the managed care plan may want to save money by limiting diagnostic testing. Furthermore, the patient referral may not be appropriate for the services and expertise available at the pain treatment facility chosen by the referring physician or managed care plan.

Advantages of the self-referred patient include pain management specialist control over the evaluation and treatment and the choice of consultants needed to help him make the diagnosis, these consultants may be of a higher quality than those utilized by some referring physicians. The pain management specialist has control over treatment and the use of prescription medication (especially controlled substances) when providing care for the self-referred patients. Furthermore, the pain management specialist may exercise a choice in diagnostic imaging facilities or for hospitals should admission for further evaluation be necessary. As an increasing number of patients under managed care have out-of-network or point-of-service benefits as part of their managed care contract, such patients can choose the pain management physician and/or pain treatment facility in spite of the dictates of the managed care plan.9,10 Such patients can represent a significant source of revenue for a pain treatment facility, and care should be taken to identify patients with such benefits before assuming they cannot be seen at a pain treatment facility.

Disadvantages of self-referred patients include the fact that the pain management specialist and pain treatment facility has sole responsibility for the evaluation and treatment, essentially assuming the role of primary care physician. Once the patient is under the care of the pain management specialist and facility, transfer of the patient to a more appropriate specialist or facility may be difficult should a problem arise.

The pain management specialist and the pain treatment facility must weigh these variables to determine the best course to follow. Should a pain management specialist decide to accept self-referred patients, he or she must recognize that in essence one is assuming the role of primary care physician. Incumbent to this role is an increase in responsibility with its attendant nighttime phone calls, emergencies, talking with family members, and so forth. Regardless of the pain management specialist’s ultimate decision, it is the author’s strong belief that the physician-referred patient requires the same level of vigilance and quality of evaluation that a self-referred patient does, especially under the managed care paradigm.

Hospital-Based versus Free-Standing Facilities

As hospital administrators, government, managed care plans, and third-party payers seek to exert greater control over hospital-based physicians, pain management specialists have sought to limit their vulnerability to this situation, for example, the opening of surgical centers, affiliating with rehabilitation centers, and so forth.11 An additional option is the development of a freestanding pain treatment facility. By developing such a facility, the pain management specialist may avoid the “label” associated with a given hospital. This can be good or bad depending on the public perception of a specific hospital. It should be remembered that these perceptions can change over time and what may be a desirable hospital to practice in at one point may represent a negative practice location at another.

An additional advantage of starting a freestanding pain treatment facility is that the pain management specialist may choose its geographic location. This is advantageous if the pain management specialist’s primary hospital practice is located at a less desirable geographic area of the city.12 A freestanding pain treatment facility can use advertising to great advantage when seeking to increase market penetration at a new geographic location.13

In some localities, it is possible for the pain management specialist to bill not only for his or her professional fees but also for the drugs, trays, radiology services, laboratory services, and block room and recovery room charges. Some third-party carriers in specific geographic locations in the United States (e.g., the East Coast) allow the pain management specialist to charge 150% of his or her professional fee to cover the cost of drugs, trays, and room charges. In other areas, local or state law as well as policies of the third-party carriers may require that the facility be licensed and accredited as an ambulatory surgery center in order for a facility fee to be paid. At the time of this writing, Medicare is considering paying the pain management physician a higher professional fee if he or she provides care in an office setting rather than an ambulatory surgical center or hospital-based pain treatment facility. This may lead to a shift in where pain management services are provided in the future.

In the freestanding pain treatment facility, the pain management specialist will have greater control of the space, staffing, hours of operation, capital expenditures, and utilization review–quality assurance activities. Obviously with this added control and flexibility, there comes an added measure of responsibility and risk.14

The major disadvantage of the freestanding pain treatment facility is cost. The pain management specialist can anticipate a large capital expenditure to provide adequate space, equipment, and personnel to implement pain management services at a freestanding location. In addition, the pain management specialist assumes the added liability and cost of malpractice insurance of the facility as well as the liability for professional services offered. The pain management specialist also inherits the liability for the actions of his or her staff. The advantages and disadvantages of the hospital-based pain management practice versus the freestanding pain center are summarized in Tables 81-3 and 81-4.

Starting a pain treatment facility is a significant undertaking both in terms of time as well as tangible expense. While the risks are great, so can be the rewards if done properly. By addressing the previously mentioned issues as an integral part of the planning process, the pain management specialist will be better able to determine if setting up a pain treatment facility is the right decision.