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Should Pain
Management Services Be Offered?
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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.
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Interfacing
Pain Management Services with Existing Services
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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.
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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
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Are There Adequate
Personnel to Provide Quality Care?
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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.
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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.
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Is the Support
Staff Adequate?
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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
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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.
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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.
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Types of Patients
Seen
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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
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Financial Considerations
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Support Staff
Availability
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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.
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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.
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Physician-Referred
versus Self-Referred Patients
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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.
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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.
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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.
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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.
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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.
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Hospital-Based
versus Free-Standing Facilities
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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.
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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
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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.
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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
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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.
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