Chapter 82. How to Manage a Pain Practice

A well-managed pain management center is more than an economically successful pain clinic; it provides high-quality multidisciplinary care that meets the changing needs of today’s health care environment.

Pain management centers have had long-standing credibility issues with payers.1–5 Costs of care, narrowly focused specialty specific care, seemingly endless treatment without endpoints, along with unsubstantiated subjective outcomes have resulted in chronic pain management programs being placed under increasing scrutiny. Meanwhile, numerous studies have documented that multidisciplinary pain management centers have better outcomes. These studies have shown that multidisciplinary pain management centers provide improved care, are cost-effective, and have improved long-term outcomes.2–4 Anesthesiology as a specialty is expanding beyond its traditional role in the operating room to provide leadership in the treatment of chronic pain.5 Anesthesiologists have an opportunity to participate in the development of, and provide leadership in, the development of multidisciplinary pain management centers of excellence. To succeed in this role, anesthesiologists must recognize the complexity of chronic pain.6,7

The successful treatment of chronic pain requires the understanding that chronic pain is a multifaceted problem. Chronic pain is not only a sensory complaint but it has profound impacts on a patient’s affect, social circle, vocational pursuits, and cognitive abilities. Pain management centers of excellence understand the unique needs of each of their patients and provide cost-effective care based on those needs. The characteristics of a well-managed pain management that set it apart are:

• The recognition that chronic pain is multifactorial problem that requires specialized care delivered by a team of specialized providers with a full-time commitment to the treatment of chronic pain.
• The organization of the pain management center administration is set up to recognize that different patient groups are affected by chronic pain.
• Specific emphasis on accessibility and customer-focused initiatives that enhance treatment outcomes and facilitate referrals.
• Recognition and planning for outcome measures that understand and trace the specific outcome important to specific payer classes.
• Creation of a network of mutually beneficial relationships that sustain the center’s growth with the center’s various customers including hospital administration and payers.
• Innovative products and services to help patients recover all aspects of their lives, as part of a continuum of care.
• The commitment to increase the visibility and viability of pain management as a discipline within the health care environment.

Single-modality pain management centers that emphasize procedures and short-term relief that these blocks produce do not meet the previously mentioned characteristics. An overemphasis on procedures for short-term relief serves only to enhance the perception of disability and does little for the long-term pain management problems that need to be solved for enhanced patient function. Well-managed pain management centers are organizations that are equipped to manage all aspects of chronic patient disability. A broad focus such as this requires long-term commitments toward multidisciplinary team and program development.

Formulating a strategy is key for successful program development. Separating a multidisciplinary pain management center into smaller elements or key components can facilitate the developmental process. These elements are:

• Organizational structure and administration
• Physical facilities
• The medical treatment continuum
• Service lines
• Practice infrastructure
• Trained interdisciplinary team
• Key patient groups
• Information and outcomes management
• Fiscal management and business planning.

In the following sections each of these elements is examined; strategies are suggested that will lead an organization through the different stages of growth toward a pain management center of excellence.

Organizational Structure and Administration

Chronic pain management centers are under constant pressure to perform, as well as being viewed by many skeptical payer organizations as a large financial burden without appropriate returns. Yet chronic pain remains one of this country’s primary public health problems. Centers of excellence provide the leadership and advocacy necessary to influence the attitudes of the local community about pain management services.

This component recognizes that the organizational foundation of a pain management practice is important to achieve these objectives. These objectives are achieved through the following:

• 1. Mission statement developed by the interdisciplinary team.
• 2. Showing a complete commitment to the discipline of pain management with full-time staff and board certification such as the added qualifications in pain offered by the American Board of Anesthesiology.
• 3. Developing key relationships with affiliated institutions and working toward complete integration of pain management services.
• 4. Development of a governing body that includes members from various interest groups that are representative of patient groups treated by the pain center.
• 5. Formation of a dedicated organization provides the foundation from which a pain management center can build.

The pain management center must initially make the needed alliances to ensure that the appropriate resources are available. This can be in the form of informal professional contacts, to forming actual contractual links with pertinent organizations such as drug-addiction treatment centers or vocational rehabilitation organizations. Developing an appropriate continuum of care requires not only considerable effort to identify appropriate personnel who have an interest in treating chronic pain but it also requires some ongoing interactions with referral sources and payers to determine the necessary resources needed to fund this treatment continuum. Determining the type of treatment to be included in the treatment continuum requires an understanding of the needs of the referral sources as well as the patients being sent to the pain center. Understanding this requires the tracking of outcomes as well as determining demographics that are seen within a pain management center.

Intensive training in advances in pain management and allied interests, such as enhancing return to work rates, research on adaptive appliances for disability, must be ongoing. This training also lends itself to team building, which is a vital component of a multidisciplinary center. The synergism that occurs during team building will improve outcomes and enhance customer satisfaction. Developing a pain management center of excellence requires a substantial investment in time and personnel to develop the needed resources as previously described to treat chronic pain.

The Physical Facility

Process of care for chronic pain requires team interactions. The physical facility should be developed to enhance interdisciplinary team interaction.8 In addition, as the practice grows, the facility must have enough space that can be allocated to facilitate the integration of medical management services, various psychotherapies, and individual and group as well as rehabilitative therapies in one contiguous building. This integration of services or interdisciplinary treatment approach will have positive impact on patient outcomes. Tight coordination will exist among the disciplines for patient conferences and team interaction. The facility should be designed to enhance patient comfort and confidentiality as well as convenient and accessible for patients with disabilities. The physical facility should have enough space for family conferences, so they can also participate in the rehabilitation process.

The Medical Treatment Continuum

As the pain management center grows, clinical problems tend to increase in complexity. There becomes a need to customize a treatment plan for each patient. Rational customizing of treatment plans requires a framework to classify patients into similar groups and develop an understanding of their unique needs. The emphasis on treatment being both cost-effective and efficient must lead to an understanding of how to optimize the treatment to these groups of patients.9 Treatment of chronic pain requires a triad of therapies: medical management, behavioral, and physical rehabilitation. The assessment of a chronic pain patient must lead to an understanding of the patient’s needs in each of these areas. This assessment could then lead to the classification of the pain syndrome using a combination of various tools available today. The International Association for the Study of Pain (IASP) taxonomy of pain provides both an axis tool and a list of chronic pain diagnoses that can provide a framework for the optimization of treatment plans. Since psychological factors often figure prominently in chronic pain diagnosis, additional understanding of patient subgroups requires a means of stratifying the IASP diagnostic groups.10 The SF-36 (Short Form-36) is a useful evaluation tool that evaluates impact of disease on the patient’s physical and psychological functioning. Using this multidimensional approach allows further subclassificaiton of patients.11 The data collected allow efficient customization of an individual patient plan, as well as the accumulation of data along with outcome data that facilitates quality-improvement activities.

Service Lines

A service line is a list of needed services that are required in the order of occurrence that they are required in order to perform clinical evaluations and treatment. This list becomes a blueprint upon which these clinical processes can be developed. Service lines are useful concepts that can be used to evaluate outcomes and facilitate internal quality-improvement initiatives. Multidisciplinary teams enhance chronic pain management outcomes. But these multidisciplinary teams add greatly to the complexity of determining cost-effectiveness or treatment outcomes as well as determining best practices. Effective treatment requires that the patient be evaluated and treated systematically. This process can become complex to analyze when the many different individualized encounters are considered for the unique needs of each chronic pain patient. Yet, in order to achieve the efficiency and outcomes demanded by today’s health care environment, these processes must be thoroughly understood, documented, and evaluated. Service lines facilitate the identification of the processes and systems that are used to treat patients. This identification process must involve the entire staff. Service lines lend the pain management center a valuable tool to understand the complex processes that must occur for a chronic pain patient to be successfully treated. A service line with a list of processes breaks the treatment continuum into manageable parts and allows analysis to occur that will optimize treatment outcomes. Service lines are used to track all the clinical activities of the pain management center. The processes involved that support the clinical activities, as well as the clinical activities themselves, are listed in flow diagrams that allow the staff to understand the necessary activities to treat a patient. These flow charts are then used to form a framework to measure key outcomes that reflect the needs of referral sources, and the values of the organization as articulated in the mission statement.

For example, a service line such as Evaluation and Assessment could be used to measure the speed that a new referral patient is seen. Managed care places a premium on customer service and the importance of rapid response to patient concerns. Pain management centers working with managed care organizations could use the service line Evaluation and Assessment to understand the barriers to timely intervention and improve performance. Other service line examples are:

• 1. Limited Service Line is used to describe patients who need treatment plans with a smaller focus.
• 2. Comprehensive Pain Management Program used to describe treatment plans that require comprehensive treatment such as returning a long-standing disabled worker to work.
• 3. Research Service Line can be used to track the research activities of a pain management center. Integration of a clinical trial’s center can be a useful tool to enhance expertise in the clinical staff, improve the image of expertise of the pain management center, and develop important referral sources.
• 4. Follow-up and Referral service line is used to track long-term outcomes of patients after they have left the active treatment program.

Service lines can be used to formulate outcomes as well as treatment costs that will allow the pain center to engage in creative managed care contracting, which gives the pain center a potentially competitive edge. Data using performance measures of these processes are used for quality-improvement activities directed toward meeting specific needs of the pain management center’s patients, referral sources, and payers. The data that are collected allow the pain center to become a strong advocate for its patients and their unique needs.12

Practice Infrastructure

The multidisciplinary nature of chronic pain management treatment requires extensive interaction and team building on an ongoing basis to achieve optimal outcomes. This at times can make team building difficult, but this must occur nonetheless. In addition, the rapidly changing health care market demands that an organization be versatile, communicate effectively, and be able to innovate quickly and effectively. Regular meetings within the pain management center personnel to identify issues as they occur and create solutions are a vital component of the success or failure of any pain management center. Meetings such as those devoted to performance improvement or customer service are just two examples of important skills that pain management centers must have. Other subcommittees may be formed within a pain management center to keep the organization vital; these can include a managed care committee, quality assurance, and various ad hoc committees to address new program development as the opportunities become apparent. By having these meetings on a regular basis, all personnel within the pain management center begin to understand the intricacies and nuances of the varied professional backgrounds of the multidisciplinary team. This helps to strengthen the team and also understand the broad range of services that the pain management center can offer. The need to move away from modality-based services such as repeated epidural steroid injections in the case report described earlier to more comprehensive outcome functionally orientated treatment plans should be apparent. Functionally oriented treatment plans are increasingly being demanded by managed care. The continuing case report in this section illustrates this.

An interdisciplinary team forms the foundation of treatment of any chronic pain management center.3,4,9 The primary goal of any treatment plan is to provide for the unique needs of each individual. Patient satisfaction has been used to provide insight to treatment effectiveness.13 Patients who report high satisfaction with their treatment are less likely to miss appointments,14 show better treatment compliance,15 and adopt a more active role in the treatment plan.16 These are all important success criteria for chronic pain management treatment plans. In addition, high patient satisfaction correlates with successful treatment outcomes.17 Payers are also increasingly looking for providers with consistently high patient satisfaction results to form relationships with.

The foundation of successful outcomes begins when a patient makes an appointment. The professional interaction of the interdisciplinary team conveys trust and facilitates the transference that will lead to patient trust to change behavior. Chronic pain management treatment plans often require multiple visits and intensive treatment regimens. Patient satisfaction and the resulting transference will provide the needed motivation for patients to radically depart from the norms they have come to rely on. Ingrained behaviors such as long-term disability are difficult to change.

High customer satisfaction means performing pain management center services in a manner that patient’s view as highly valid and appropriate. Pain at times can be overwhelming for a patient; accessibility and convenience are important elements of a customer-service-driven organization. In today’s health care market, price for service seems to be the only criterion upon which one is evaluated. Customer satisfaction can be a key positioning point when negotiating for new referral sources. To achieve uniform high customer satisfaction ratings, the entire organization must be dedicated to that goal with a passion that is equaled only by the passion for high-quality care. It is important to understand that what a health care professional may determine is important for customer satisfaction is not necessarily the same for varied groups of patients that receive their treatment in a pain management center. Customer satisfaction means much more than timeliness of office appointments. Customer satisfaction may mean having services in a convenient location, where a person may not need to miss work, and varied services that will support patient needs such as letter writing to employers, disability evaluations, and general efficacy for a patient who has chronic pain.

Key Patient Groups

A pain management center’s influence should extend beyond the walls of the clinic. The roots of relationships that link the pain management center to the community are critical for survival. Focused efforts to enhance these relationships will result in an ongoing positive image in these areas. External relationships are necessary to track patients and to cultivate local, regional, and national referral sources. In addition, these interactions can help to improve reimbursement and generate community support and good will. Identification of key patient groups is very important in determining needs, patient treatment satisfaction, and successful outcomes.18

High-quality pain management services are recognized as a right in today’s health care environment. However, providing these services effectively demands an appropriate referrals and reimbursement. Relationships to address these concerns are vital. Positive internal relationships are imperative to keep the team, administration, and referral sources abreast of all new program development in the pain management center. External key customer relationships between a pain management center should include payers, referral sources, vendors of medical equipment, pain management center users (such as patients and case managers), and other health care institutions within the community with which the pain management center must interact. These entities can support the patient referrals, medical education, latest technology, reimbursement, and their external consultations that a pain management center needs in order to survive. Strong relationships with these entities are essential to development and success of a pain management center.

Marketing is also another activity that is placed in this key component. Marketing not only involves activities to increase the visibility of the pain management center but it is also used to identify specific patient needs, which may lead to restructuring of the pain management center described in earlier key components. For example, marketing for workers’ compensation programs requires an understanding of what services are highly valued and will enhance the care for patients from these referral sources. For example, this may involve developing a seamless continuum of care, which brings a patient through a pain management center that engages in specific rehabilitative needs and is able to refer immediately to a vocational training program so that back-to-work rates are optimized. Regular round table discussions with referral sources will be helpful to focus the pain management centers efforts and provide the necessary understanding to customize programs.

Information and Outcomes Management

Ensuring the delivery of consistent high-quality medical care along with patient satisfaction has to become part of the culture of the pain management center. Activities have to be focused on achieving these goals. Concurrent program evaluation and identification of areas needing improvement leading to the design of new systems and processes are the key to reaching and maintaining consistent high-quality care. This evaluation, leading to innovation followed by implementation, is a constant cycle in any organization that is focused on becoming a center of excellence. All activities included in the pain center have to be understood by the team in the minutest detail, and evaluation systems put into place by the people who are responsible for these tasks. Appointing an “overseer” to run these activities can quickly destroy effective teamwork and lead to deterioration in morale, decreased staff effectiveness, and decreased customer satisfaction. Performance goals that are set by the team are much more meaningful and lead to more rapid improvement in quality of care. Continuous quality improvement is part of everyone’s job. Appropriate outcomes for chronic pain management are often discussed. Examples such as back-to-work rates, perceived helpfulness, and physical activity scores are all used to define value of chronic pain management programs. Increasingly pain management programs are being called upon to justify expenditures and to control costs.1 Determining program costs, cost-effectiveness, and cost-benefits of a program requires a thorough and complete understanding of the pain management center processes used to deliver care. Payers will require appropriate financial analysis (give examples) of pain management center treatment.22 Evidence-based algorithms are the foundation for determining cost of care and calculating cost-effectiveness of treatment.23 Algorithms should be diagnosis-specific, evidenced-based, and inclusive enough to achieve pain center physician consensus. Algorithms are then used to standardize treatment for each specific diagnosis, thus permitting financial analysis and disease-specific outcome analysis. Using this structure, a center of excellence will be able to accumulate data to permit informed analysis of the entire treatment continuum for chronic pain management.

Fiscal Management and Business Planning

In general all managers must have the appropriate information to manage, and pain management centers should have access to theirs as well. Knowing the monetary impact a pain center can have on an institution’s bottom line is vital. This is extremely important for success in negotiations with the institution. These financial reports should provide the pain management center with the necessary information to develop reimbursement strategies, and search for new business opportunities that are ever developing in this rapidly changing health care environment. Meetings with payers to discuss their needs and develop new services along with them can provide valuable new insights and ensure successful program development. Appropriately structured pain management centers can provide services in a fiscally responsible manner and still achieve excellent patient outcomes. This perspective not only comes from the hospital itself but also from payers and referral sources. Chronic pain has a devastating impact on a significant number of people in the United States.

Any successful enterprise requires the development of a clearly written business plan. Although this will not guarantee that your practice will be a success, most successful businesses are based on well-developed business plans that are revised as required for changing conditions. The purpose of a business plan is to document in writing a brief description of the business, the market niche served by that business, as well as the infrastructure that is required to become a successful practice. Financial resources required to start, sustain, and staff the clinic as well as an outline of a marketing plan are also vital components of a business planning process. Developing a comprehensive outline and understanding of the reimbursement climates under which the pain center exists, including governmental managed care insurance companies, and patients is vital. This can only occur in an accurate fashion when a pain management center develops the solid internal and external relationships as described in an earlier key component.

Managed care has become the most important force driving the health care market in the United States. Different areas of the country are in various stages of managed care penetration. For ease of description, managed care penetration has been placed in four stages. Each stage of change requires adaptations in the delivery of health care services to meet this challenge. These are known as the evolving stages of value.24 Pain management centers are part of this evolving health care market and therefore must identify the stage of the local area in which they are operating. The evolving stages of value in the health care market describe four levels:

• Stage 1, or the unstructured stage, describes a market with independent hospitals and physicians, few unsophisticated purchasers, and >10% penetration of managed care. The organizational source of value comes from its hard assets, and quality is defined internally while reimbursement is fee-for-service. Examples of chronic pain management care in this environment would be the intensive 6- to 8-week inpatient programs, with very little program customization for individual patient needs.
• Stage 2, or the loose framework stage, is characterized by a growing presence of managed care, decreasing profit margins, and eroding hospital bottom lines. With the emphasis on outpatient care, hospitals have excess inpatient capacity. Joint ventures are beginning to form between the medical staff and health care facilities. Quality increasingly is defined by the near-term cost of care. Chronic pain management treatment plans in this environment require customization of treatment plans specific to each patients needs, with an increasing emphasis on outpatient care and day programs.
• Stage 3, or the consolidation stage, is defined by the development of large health care systems and increasing emphasis on developing a complete integrated health system. Quality is defined by customer satisfaction, along with cost of care. Managed care is an important part of the market, with penetration now up to 50%. This stage is found in most major population centers in the United States. Pain management centers existing in this environment must also reengineer themselves to reflect these changes. Internally, the pain center must focus on outcomes, understand the needs of their referral sources, and design programs that address these needs. Pain management centers that work toward becoming part of an integrated delivery system will find many opportunities in this environment.
• Stage 4, or managed competition, is characterized by employer coalitions, which drive the market toward the formation of strategic alliances and the shifting of risk to the health care provider. The focus of these organizations on health status and quality is now defined by the health status of populations or covered lives. Health care systems are driven to provide the highest customer value, and the most important source of value comes from capability of the organization and its image. Capitation is an important reimbursement mechanism in this stage. Specific disease-state-management initiatives are developed for high cost or high volume diagnoses. Chronic pain in this stage has now become a real cost that must be effectively and appropriately treated.

Using the components and health care stages described in the preceding sections, five stages can be described that allow pain management centers to set goals and respond to the changes of the health care market. Table 82-1 presents a matrix of the key components as well as characteristics of each of these five stages.

Health care is changing from a product-focused practice (fee-for-service reimbursement) where reimbursement encourages utilization, to much more sophisticated reimbursement schemes that emphasize outcomes. Capitation is an example of the focus being shifted to outcomes rather than reimbursement plans based purely on volume of services.

It is important to note that as a pain management center begins to work itself through the stages of change, as outlined earlier, all nine key components must be coordinated to achieve progress. Planning time frames of years can be needed to achieve desired results. Only with total and complete commitment of the pain management staff can the pain center evolve into a center of excellence. The stages described are fluid, and changes in personnel and health care reimbursement strategies may cause the pain center to regress. A commitment for ongoing process improvement as described earlier will allow a pain management center to achieve and maintain leadership in the community. The key to achieving a center of excellence reputation is the full-time commitment of the medical staff. Pain management should not viewed as opportunity to earn supplementary income by providing procedure-orientated services. Reviewing Table 82-1, along with the previously described stages, will give a comprehensive understanding of the planning process that must take place for success to occur. Understanding these stages of change25 and using them as a framework for a methodical planning process and breaking the planning process into the key components described earlier will lead to a strong and dedicated organization with a passion to succeed and an ability to achieve the goal of becoming a well-managed pain management center known as a pain management center of excellence.