According to a 2010 HealthCare Appraisers survey, pain management is the fifth most desirable specialty for surgery centers, with 76 percent of management companies approving of the choice. VMG Health data also indicates the specialty makes up a considerable percentage of ASC case volume — 14 percent on average.
These statistics indicate that developments in pain management are likely to shake up the surgery center industry — and cause debate among physicians and patients alike. Roberto Saenz, president of VIP Medical Consulting, discusses seven trends affecting the future of the specialty, as well as what pain management physicians can do to improve patient care.
1. Pain management is no longer "the last stop on the line." Mr. Saenz says pain management has evolved over the last five years from a "last resort" treatment option to a more feasible first step for chronic pain. "It used to be that neurosurgeons or back surgeons would refer patients with back or neck pain to pain physicians, and that is evolving," Mr. Saenz says. "At this point, pain management doctors are more of a hub than a last stop." To this end, pain management physicians are forming relationships with primary care providers to create a channel of direct patient referrals.
Mr. Saenz says the referral of patients from primary care physicians to pain management specialists can help in providing more options for treatment. "The patients come directly to the pain management physician, who does an assessment to determine whether they need medication, physical therapy or surgery," he says. "It's a smarter way to do it than to jump right from primary care to a surgical consultation." He says many patients will never need surgery to treat their pain — the issue can simply be "managed" over time with a combination of different non-surgical treatments.
2. Pain treatments are moving past medication and injections. Pain management procedures are becoming more and more advanced, Mr. Saenz says. Gone are the days when all pain was treated with medication or a series of epidural steroid injections for inflammation. Nowadays, pain management physicians are performing more radiofrequency ablations for chronic pain patients who have tried injections. Physicians are also increasingly performing spinal cord simulation trials in their offices, then taking the procedure to the surgery center when appropriate.
Mr. Saenz says these procedures are perfect for surgery centers because the atmosphere decreases patient stress and increases convenience for repeat visits. "You've got a patient suffering from so many issues, and lessening anxiety and stress by avoiding the hospital is critical," he says.
3. Implants are increasingly attractive. Spinal cord implants are increasingly attractive to patients and physicians because of the problems that can arise with pain pumps, Mr. Saenz says. "The problem with pumps is that while they can be very effective in helping a patient control medication flow, refills are necessary and there are complications that go along with the pumps," he says. "These include the possibility of infection and blockage, which could have serious consequences."
Refills for pain pumps are also not reimbursed well by federal or commercial insurers, he says. In many cases, there is no incentive for the physician to perform a refill because the cost of the medication outweighs the reimbursement. Spinal cord implants do not need to be refilled and receive better reimbursement than pumps, he says.
4. Volume no longer reigns for some centers. Pain management has traditionally been viewed as a volume-driven specialty for surgery centers. That may be changing, Mr. Saenz says. "Obviously you still have the traditional volume-driven practices, where they do a lot of injections, but there are more doctors who are looking at working smarter," he says. "They give patients more options than just the routine of coming back for maintenance."
He says instead of injections, physicians may choose to perform minimally invasive surgery to treat pain. Historically, physicians may have treated patients with increased doses of medication and regular injections for years. Now, more progressive physicians may intervene with a more advanced procedure sooner in the process. This is especially important as prescription opioid abuse makes national headlines and highlights troubling prescription practices. "Medication should no longer be the only option, because physicians are getting in trouble and patients are dying," Mr. Saenz says. "It requires physicians to have more tools in their toolbox that are not medication-focused."
5. Younger patients outnumber older ones. While older patients might seem more likely to pursue treatment for pain management, Mr. Saenz says the demographics are more evenly divided that one might expect. "In most practices that I see, there are about 40 percent Medicare patients and 60 percent non-Medicare," he says. "If you look in a pain management lobby, you'll see a lot of patients who were injured in an accident or injured at work." This means while Medicare reimbursement will make up a substantial portion of surgery center payor mix, it's not everything; workers' compensation reimbursement and contracts with commercial payors are essential for pain management-driven ASCs.
Mr. Saenz says the number of younger patients means it is essential for pain management physicians to manage expectations about pain relief. "There's a reason we call it 'pain management' and not 'pain relief,'" he says. "The younger generation has more of an expectation that they will [receive one pill be cured]." Make sure pain patients understand that chronic pain cannot always be cured in one procedure or even several. The key is to help a patient identify and understand his or her level of pain and then make progress from that point.
6. Prescription opioid misuse puts pain management in the spotlight. Recent headlines on prescription opioid abuse have shone a negative light on some pain management practices and surgery centers, Mr. Saenz says. "Unfortunately, the image of the pain management doctor is that he's prescribing many meds, but in reality, it's not the pain management doctor who's doing that," he says. In many cases, he says the patient will start with acute pain and visit a primary care physician for treatment. Instead of receiving a low-dose painkiller, the patient receives a high-dose painkiller or narcotic and innocently takes more than he or she should. In other cases, the patient fails to tell the physician that he or she is also taking other medication, such as antidepressants or painkillers from another source. Very quickly, the patient becomes addicted to opioids and contributes to the growing drug abuse problem in the U.S.
While pain management specialists have little control over their patients' actions outside the practice or surgery center, they can help by working with primary care physicians to ensure no medications are prescribed inappropriately. The majority of states use a prescription monitoring website that allows physicians to check whether a patient has been prescribed other medications recently. Unfortunately, these websites are not used as often as they could be; Mr. Saenz says in Oklahoma, only 60 percent of physicians report using the system. "The responsibility [for preventing drug abuse] should be spread amongst all of us — the insurance companies, the primary care physician, the specialists and ultimately the patients, who should ask questions instead of blindly taking everything they're given," he says.
7. Physician shortages affect this specialty too. Like many other physician specialties, pain management is affected by a lack of available physicians. "There's a big problem in that there aren't enough pain management physicians, and there aren't enough fellowship-trained physicians," Mr. Saenz says. "We still have a ways to catch up." He says this shortage of physicians endangers volume-driven surgery centers that rely on a high number of procedures to stay profitable — and places a larger burden on primary care physicians. "These chronic pain patients are being seen by primary care doctors who can only give medication and don't have other services to offer," he says.
Learn more about VIP Medical.
Related Articles on Pain Management:
30 Statistics on Pain Management in Surgery Centers
Important 2012 CPT Coding Changes to ASC Spine & Pain Management Procedures
MGMA Releases Anesthesia and Pain Management Benchmarking Report
These statistics indicate that developments in pain management are likely to shake up the surgery center industry — and cause debate among physicians and patients alike. Roberto Saenz, president of VIP Medical Consulting, discusses seven trends affecting the future of the specialty, as well as what pain management physicians can do to improve patient care.
1. Pain management is no longer "the last stop on the line." Mr. Saenz says pain management has evolved over the last five years from a "last resort" treatment option to a more feasible first step for chronic pain. "It used to be that neurosurgeons or back surgeons would refer patients with back or neck pain to pain physicians, and that is evolving," Mr. Saenz says. "At this point, pain management doctors are more of a hub than a last stop." To this end, pain management physicians are forming relationships with primary care providers to create a channel of direct patient referrals.
Mr. Saenz says the referral of patients from primary care physicians to pain management specialists can help in providing more options for treatment. "The patients come directly to the pain management physician, who does an assessment to determine whether they need medication, physical therapy or surgery," he says. "It's a smarter way to do it than to jump right from primary care to a surgical consultation." He says many patients will never need surgery to treat their pain — the issue can simply be "managed" over time with a combination of different non-surgical treatments.
2. Pain treatments are moving past medication and injections. Pain management procedures are becoming more and more advanced, Mr. Saenz says. Gone are the days when all pain was treated with medication or a series of epidural steroid injections for inflammation. Nowadays, pain management physicians are performing more radiofrequency ablations for chronic pain patients who have tried injections. Physicians are also increasingly performing spinal cord simulation trials in their offices, then taking the procedure to the surgery center when appropriate.
Mr. Saenz says these procedures are perfect for surgery centers because the atmosphere decreases patient stress and increases convenience for repeat visits. "You've got a patient suffering from so many issues, and lessening anxiety and stress by avoiding the hospital is critical," he says.
3. Implants are increasingly attractive. Spinal cord implants are increasingly attractive to patients and physicians because of the problems that can arise with pain pumps, Mr. Saenz says. "The problem with pumps is that while they can be very effective in helping a patient control medication flow, refills are necessary and there are complications that go along with the pumps," he says. "These include the possibility of infection and blockage, which could have serious consequences."
Refills for pain pumps are also not reimbursed well by federal or commercial insurers, he says. In many cases, there is no incentive for the physician to perform a refill because the cost of the medication outweighs the reimbursement. Spinal cord implants do not need to be refilled and receive better reimbursement than pumps, he says.
4. Volume no longer reigns for some centers. Pain management has traditionally been viewed as a volume-driven specialty for surgery centers. That may be changing, Mr. Saenz says. "Obviously you still have the traditional volume-driven practices, where they do a lot of injections, but there are more doctors who are looking at working smarter," he says. "They give patients more options than just the routine of coming back for maintenance."
He says instead of injections, physicians may choose to perform minimally invasive surgery to treat pain. Historically, physicians may have treated patients with increased doses of medication and regular injections for years. Now, more progressive physicians may intervene with a more advanced procedure sooner in the process. This is especially important as prescription opioid abuse makes national headlines and highlights troubling prescription practices. "Medication should no longer be the only option, because physicians are getting in trouble and patients are dying," Mr. Saenz says. "It requires physicians to have more tools in their toolbox that are not medication-focused."
5. Younger patients outnumber older ones. While older patients might seem more likely to pursue treatment for pain management, Mr. Saenz says the demographics are more evenly divided that one might expect. "In most practices that I see, there are about 40 percent Medicare patients and 60 percent non-Medicare," he says. "If you look in a pain management lobby, you'll see a lot of patients who were injured in an accident or injured at work." This means while Medicare reimbursement will make up a substantial portion of surgery center payor mix, it's not everything; workers' compensation reimbursement and contracts with commercial payors are essential for pain management-driven ASCs.
Mr. Saenz says the number of younger patients means it is essential for pain management physicians to manage expectations about pain relief. "There's a reason we call it 'pain management' and not 'pain relief,'" he says. "The younger generation has more of an expectation that they will [receive one pill be cured]." Make sure pain patients understand that chronic pain cannot always be cured in one procedure or even several. The key is to help a patient identify and understand his or her level of pain and then make progress from that point.
6. Prescription opioid misuse puts pain management in the spotlight. Recent headlines on prescription opioid abuse have shone a negative light on some pain management practices and surgery centers, Mr. Saenz says. "Unfortunately, the image of the pain management doctor is that he's prescribing many meds, but in reality, it's not the pain management doctor who's doing that," he says. In many cases, he says the patient will start with acute pain and visit a primary care physician for treatment. Instead of receiving a low-dose painkiller, the patient receives a high-dose painkiller or narcotic and innocently takes more than he or she should. In other cases, the patient fails to tell the physician that he or she is also taking other medication, such as antidepressants or painkillers from another source. Very quickly, the patient becomes addicted to opioids and contributes to the growing drug abuse problem in the U.S.
While pain management specialists have little control over their patients' actions outside the practice or surgery center, they can help by working with primary care physicians to ensure no medications are prescribed inappropriately. The majority of states use a prescription monitoring website that allows physicians to check whether a patient has been prescribed other medications recently. Unfortunately, these websites are not used as often as they could be; Mr. Saenz says in Oklahoma, only 60 percent of physicians report using the system. "The responsibility [for preventing drug abuse] should be spread amongst all of us — the insurance companies, the primary care physician, the specialists and ultimately the patients, who should ask questions instead of blindly taking everything they're given," he says.
7. Physician shortages affect this specialty too. Like many other physician specialties, pain management is affected by a lack of available physicians. "There's a big problem in that there aren't enough pain management physicians, and there aren't enough fellowship-trained physicians," Mr. Saenz says. "We still have a ways to catch up." He says this shortage of physicians endangers volume-driven surgery centers that rely on a high number of procedures to stay profitable — and places a larger burden on primary care physicians. "These chronic pain patients are being seen by primary care doctors who can only give medication and don't have other services to offer," he says.
Learn more about VIP Medical.
Related Articles on Pain Management:
30 Statistics on Pain Management in Surgery Centers
Important 2012 CPT Coding Changes to ASC Spine & Pain Management Procedures
MGMA Releases Anesthesia and Pain Management Benchmarking Report