As part of healthcare reform's initiative to lower the cost of healthcare, the Independent Payment Advisory Board and Patient-Centered Outcomes Research Institute were formed to make decisions about the procedures Medicare will cover. IPAB will develop proposals guiding Medicare as to which treatment methods are necessary and acceptable for coverage while PCORI is charged with conducing evidence-based research for patients and physicians to enhance treatment pathways. Both IPAB and PCORI are led by a small number of people consisting of select medical and non-medical professionals.
For several reasons, physicians from across the board have issues with IPAB and PCORI, both of which stand on the chopping block of healthcare reform. "These two groups are saying they are using science to prove effectiveness, but they are really ways of rationing care by reducing patient access," says Scott Glaser, MD, DABIPP, President of Pain Specialists of Greater Chicago and board member of American Society of Interventional Pain Physicians. He discusses six points on IPAB and PCORI, and how physicians can become part of the advocacy efforts for repeal.
1. Why IPAB and PCORI are troubling for physicians and patients. From the medical professional's perspective, IPAB and PCORI are particularly disconcerting because they take the decision-making process away from physicians and this will be done without oversight or recourse by legislators and legislation. Because neither organization would have legislative oversight as they are part of the executive branch, there wouldn't be any repercussions for mistakes and unintended consequences which may have drastic and direct effects on patient care. Mistakes, at least initially, will be inevitable because the groups are largely led by non-physician professionals, methodologists and very few subspecialists and practicing physicians, says Dr. Glaser.
"These groups are going to be drawing conclusions about what should be compensated and what shouldn't, and this is problematic because they aren't specialists in the field and don't understand the whole continuum of care," he says. "It's possible they will make recommendations that will have huge unintended consequences, especially for new and emerging subspecialties such as interventional pain management."
Interventional pain management has only been around for the last 15-20 years and has developed to fill a void in the treatment of pain between medications and other conservative treatment and the other end of the risk/benefit spectrum, invasive surgery. Many of the minimally invasive techniques these physicians perform were only developed in that time and although these interventions are based on sound scientific principles and there is significant proof of effectiveness, it is not like the kind of proof you have for treating a staph infection with PCN.
"These interventions are based on strong scientific evidence but you can't prove an intervention is effective until you have experience with it, and we are very concerned that elected officials will come up with recommendations that will stop innovation in its tracks," he says. "I tell legislators this: If you implemented IPAB and PCORI 20-30 years ago, you probably would never have had cardiac stents and angioplasties, which are standard for cardiac care now, because they were being developed and weren't proven procedures. These procedures which have dramatically improved quality of life for patients with coronary artery disease were developed because physicians were able to pursue the right thing to do for their patients and understood the shortcomings of the previous treatment paradigm—medications and surgery."
2. What worries physicians about the focus on comparative effectiveness research. A major aspect of healthcare reform has been lowering the cost of care, especially for Medicare patients, and commercial payors have historically linked their payments to Medicare payment rates. However, recently and more audaciously, they are doing their own flawed analysis of the literature and are denying procedures that even Medicare pays for based on it. "Every field that is searching for a better way to do things is going to be harmed by this, which is our greatest fear," says Dr. Glaser. "Blue Cross Blue Shield doesn't approve certain X-ray guided injections for spinal pain because they haven't been proven up to the company's 'standards.' In other words, it's not just Medicare, but everyone that will be affected by these decisions."
This has been extremely concerning to patients and physicians and has led to suffering and reduced access to care. "Insurance companies are driven by one overarching goal—to be profitable companies," he says. "That immediately disqualifies them from doing appropriate quality analysis of the scientific research because they are hopelessly biased. As interventional pain management physicians, we are driven by one overarching goal—to ensure access to care for our patients to scientifically proven procedures."
The grave concern is the knowledge that the insurance companies are waiting for PCORI to come out with proclamations about procedures that they can then use to further deny access to appropriate care. In other words, any potentially mistaken conclusions by this small group of "experts" without legislative oversight or recourse will affect all patients with pain, not just Medicare beneficiaries.
In the United Kingdom, PCORI's counterpart, the National Institute for Health and Clinical Excellence, came out with treatment guidelines for lower back pain in 2009, and those guidelines didn't include interventional pain management. Unsurprisingly, says Dr. Glaser, the group was led by expert surgeons, chiropractors, physical therapists and one pain management physician who didn't practice interventional pain management. Patients became unable to receive the treatments that had been helping them, and the government is now holding hearings to potentially change the recommendations.
"At the 2011 American Society of Interventional Pain Physicians meeting we had a speaker from the UK and the effect of these treatment guidelines has been dramatic and has significantly reduced access to procedures which help patients control their pain and reduce their need for narcotics and surgery,” says to Dr. Glaser.
3. How interventional pain management leaders are protecting the field. Prior to the emergence of interventional pain management, the only options for patients were conservative physical therapy, pain medication and surgery. Interventional pain management was developed as a minimally invasive middle step between conservative treatment and surgery. "Our field has opened up through research, innovativeness and the use of technology," says Dr. Glaser. "This has completely revolutionized the treatment of spinal pain."
With some what interventional pain management physicians do under fire, the American Society of Interventional Pain Physicians has been able to defend the procedures by conducing high quality studies for evidence and systematic reviews. Led by Laxmaiah Manchikanti, MD, an interventional pain management physician in Paducah, Ky., ASIPP has released treatment guidelines based on these studies that describe whether there is scientific benefit for a procedure or not. These guidelines can be found on the National Guideline Clearinghouse website which is hosted by the Agency for Healthcare Research and Quality under the US Department of Health and Human Services.
4. Why guidelines should focus on the algorithm of spine care instead of isolated treatments. Dr. Glaser says one of the biggest hurdles physicians are facing right now is steering the guidelines away from focusing on isolated scientific studies to incorporating different treatment methods into an algorithm of care. This may be the greatest concern about the makeup of the committees doing the research for PCORI and IPAB.
"If you are not an expert in the field you are evaluating and you don't have a perspective on the risks and benefits of all alternative treatments, then you may come to inaccurate conclusions about a particular treatment that falls outside your realm of expertise," he says. "In the human spine there are a certain number of specific places where the pain comes from. You try the first treatments in an algorithm, and if they don't work you go on through to the next pathway until you are able to relieve the patient of their pain." Although relief may not be complete and procedures may need to be repeated, this pathway of treatment is often a safer and more effective long term treatment than narcotic painkillers or invasive surgery, the most utilized alternatives. These algorithms or treatment pathways are found on the National Guideline Clearinghouse website.
5. How to work your way around Washington. Dr. Glaser was recently a member of a large group that traveled to Washington, D.C., to advocate for the repeal of IPAB and PCORI. "When you are visiting Washington, D.C., you don't have much time but the legislators do pay attention," he says. "Our group was featured in the newspapers because we went out there to speak with legislators about these and other big issues such as fighting prescription drug abuse."
All Republicans and some Democrats are making an effort to repeal IPAB and PCORI, but there is still opposition on Capitol Hill, which means more effort could be made to influence these decisions. Physicians and others involved in the care of patients in pain who can't travel to meet with the legislators can still become involved by calling their representatives' offices or sending messages to them about the importance of repeal.
"Tell them you don't want IPAB and PCORI to go through because it will affect your ability to care for patients," says Dr. Glaser. "Don't focus on how it might impact the physician, but how it could hurt the patients and limit their access to care. These representatives don't know what people think about these issues unless we call and talk to them, because they aren't going to come to us and ask."
A further way to become more involved in politics is by financially supporting candidates with similar values. Compared with other professionals, such as lawyers, physicians give much less liberally to the candidates they are backing and are less involved in the campaigning efforts. "It's hard to become involved because we are all so busy, but we have to make the time," he says.
6. What you can do with your patients to get them involved. One of the best tools physicians have for supporting advocacy efforts is the patients themselves. If a particular patient has experienced success with an interventional pain management procedure that may not be covered in the future, that patient has a vested interest in advocating for continued coverage.
"We are talking with patients about the possibility of losing access to care, such as the injections they receive for their spinal stenosis, and they get really nervous about it," says Dr. Glaser. "Patients are very upset once they understand what could happen." These patients can send messages to their representatives advocating the repeal of IPAB and PCORI.
Learn more about Pain Specialists of Greater Chicago.
More Expertise From Dr. Scott Glaser:
How Interventional Pain Management Will Contribute to ACOs: Q&A With Dr. Scott Glaser
Interventional Pain Management: New Concepts to Reduce ER Visits, Hospitalizations and Re-Admissions
6 Questions on Whether ACOs Will Assist Pain Management
For several reasons, physicians from across the board have issues with IPAB and PCORI, both of which stand on the chopping block of healthcare reform. "These two groups are saying they are using science to prove effectiveness, but they are really ways of rationing care by reducing patient access," says Scott Glaser, MD, DABIPP, President of Pain Specialists of Greater Chicago and board member of American Society of Interventional Pain Physicians. He discusses six points on IPAB and PCORI, and how physicians can become part of the advocacy efforts for repeal.
1. Why IPAB and PCORI are troubling for physicians and patients. From the medical professional's perspective, IPAB and PCORI are particularly disconcerting because they take the decision-making process away from physicians and this will be done without oversight or recourse by legislators and legislation. Because neither organization would have legislative oversight as they are part of the executive branch, there wouldn't be any repercussions for mistakes and unintended consequences which may have drastic and direct effects on patient care. Mistakes, at least initially, will be inevitable because the groups are largely led by non-physician professionals, methodologists and very few subspecialists and practicing physicians, says Dr. Glaser.
"These groups are going to be drawing conclusions about what should be compensated and what shouldn't, and this is problematic because they aren't specialists in the field and don't understand the whole continuum of care," he says. "It's possible they will make recommendations that will have huge unintended consequences, especially for new and emerging subspecialties such as interventional pain management."
Interventional pain management has only been around for the last 15-20 years and has developed to fill a void in the treatment of pain between medications and other conservative treatment and the other end of the risk/benefit spectrum, invasive surgery. Many of the minimally invasive techniques these physicians perform were only developed in that time and although these interventions are based on sound scientific principles and there is significant proof of effectiveness, it is not like the kind of proof you have for treating a staph infection with PCN.
"These interventions are based on strong scientific evidence but you can't prove an intervention is effective until you have experience with it, and we are very concerned that elected officials will come up with recommendations that will stop innovation in its tracks," he says. "I tell legislators this: If you implemented IPAB and PCORI 20-30 years ago, you probably would never have had cardiac stents and angioplasties, which are standard for cardiac care now, because they were being developed and weren't proven procedures. These procedures which have dramatically improved quality of life for patients with coronary artery disease were developed because physicians were able to pursue the right thing to do for their patients and understood the shortcomings of the previous treatment paradigm—medications and surgery."
2. What worries physicians about the focus on comparative effectiveness research. A major aspect of healthcare reform has been lowering the cost of care, especially for Medicare patients, and commercial payors have historically linked their payments to Medicare payment rates. However, recently and more audaciously, they are doing their own flawed analysis of the literature and are denying procedures that even Medicare pays for based on it. "Every field that is searching for a better way to do things is going to be harmed by this, which is our greatest fear," says Dr. Glaser. "Blue Cross Blue Shield doesn't approve certain X-ray guided injections for spinal pain because they haven't been proven up to the company's 'standards.' In other words, it's not just Medicare, but everyone that will be affected by these decisions."
This has been extremely concerning to patients and physicians and has led to suffering and reduced access to care. "Insurance companies are driven by one overarching goal—to be profitable companies," he says. "That immediately disqualifies them from doing appropriate quality analysis of the scientific research because they are hopelessly biased. As interventional pain management physicians, we are driven by one overarching goal—to ensure access to care for our patients to scientifically proven procedures."
The grave concern is the knowledge that the insurance companies are waiting for PCORI to come out with proclamations about procedures that they can then use to further deny access to appropriate care. In other words, any potentially mistaken conclusions by this small group of "experts" without legislative oversight or recourse will affect all patients with pain, not just Medicare beneficiaries.
In the United Kingdom, PCORI's counterpart, the National Institute for Health and Clinical Excellence, came out with treatment guidelines for lower back pain in 2009, and those guidelines didn't include interventional pain management. Unsurprisingly, says Dr. Glaser, the group was led by expert surgeons, chiropractors, physical therapists and one pain management physician who didn't practice interventional pain management. Patients became unable to receive the treatments that had been helping them, and the government is now holding hearings to potentially change the recommendations.
"At the 2011 American Society of Interventional Pain Physicians meeting we had a speaker from the UK and the effect of these treatment guidelines has been dramatic and has significantly reduced access to procedures which help patients control their pain and reduce their need for narcotics and surgery,” says to Dr. Glaser.
3. How interventional pain management leaders are protecting the field. Prior to the emergence of interventional pain management, the only options for patients were conservative physical therapy, pain medication and surgery. Interventional pain management was developed as a minimally invasive middle step between conservative treatment and surgery. "Our field has opened up through research, innovativeness and the use of technology," says Dr. Glaser. "This has completely revolutionized the treatment of spinal pain."
With some what interventional pain management physicians do under fire, the American Society of Interventional Pain Physicians has been able to defend the procedures by conducing high quality studies for evidence and systematic reviews. Led by Laxmaiah Manchikanti, MD, an interventional pain management physician in Paducah, Ky., ASIPP has released treatment guidelines based on these studies that describe whether there is scientific benefit for a procedure or not. These guidelines can be found on the National Guideline Clearinghouse website which is hosted by the Agency for Healthcare Research and Quality under the US Department of Health and Human Services.
4. Why guidelines should focus on the algorithm of spine care instead of isolated treatments. Dr. Glaser says one of the biggest hurdles physicians are facing right now is steering the guidelines away from focusing on isolated scientific studies to incorporating different treatment methods into an algorithm of care. This may be the greatest concern about the makeup of the committees doing the research for PCORI and IPAB.
"If you are not an expert in the field you are evaluating and you don't have a perspective on the risks and benefits of all alternative treatments, then you may come to inaccurate conclusions about a particular treatment that falls outside your realm of expertise," he says. "In the human spine there are a certain number of specific places where the pain comes from. You try the first treatments in an algorithm, and if they don't work you go on through to the next pathway until you are able to relieve the patient of their pain." Although relief may not be complete and procedures may need to be repeated, this pathway of treatment is often a safer and more effective long term treatment than narcotic painkillers or invasive surgery, the most utilized alternatives. These algorithms or treatment pathways are found on the National Guideline Clearinghouse website.
5. How to work your way around Washington. Dr. Glaser was recently a member of a large group that traveled to Washington, D.C., to advocate for the repeal of IPAB and PCORI. "When you are visiting Washington, D.C., you don't have much time but the legislators do pay attention," he says. "Our group was featured in the newspapers because we went out there to speak with legislators about these and other big issues such as fighting prescription drug abuse."
All Republicans and some Democrats are making an effort to repeal IPAB and PCORI, but there is still opposition on Capitol Hill, which means more effort could be made to influence these decisions. Physicians and others involved in the care of patients in pain who can't travel to meet with the legislators can still become involved by calling their representatives' offices or sending messages to them about the importance of repeal.
"Tell them you don't want IPAB and PCORI to go through because it will affect your ability to care for patients," says Dr. Glaser. "Don't focus on how it might impact the physician, but how it could hurt the patients and limit their access to care. These representatives don't know what people think about these issues unless we call and talk to them, because they aren't going to come to us and ask."
A further way to become more involved in politics is by financially supporting candidates with similar values. Compared with other professionals, such as lawyers, physicians give much less liberally to the candidates they are backing and are less involved in the campaigning efforts. "It's hard to become involved because we are all so busy, but we have to make the time," he says.
6. What you can do with your patients to get them involved. One of the best tools physicians have for supporting advocacy efforts is the patients themselves. If a particular patient has experienced success with an interventional pain management procedure that may not be covered in the future, that patient has a vested interest in advocating for continued coverage.
"We are talking with patients about the possibility of losing access to care, such as the injections they receive for their spinal stenosis, and they get really nervous about it," says Dr. Glaser. "Patients are very upset once they understand what could happen." These patients can send messages to their representatives advocating the repeal of IPAB and PCORI.
Learn more about Pain Specialists of Greater Chicago.
More Expertise From Dr. Scott Glaser:
How Interventional Pain Management Will Contribute to ACOs: Q&A With Dr. Scott Glaser
Interventional Pain Management: New Concepts to Reduce ER Visits, Hospitalizations and Re-Admissions
6 Questions on Whether ACOs Will Assist Pain Management