1. Services and patients in interventional pain management are increasing. According to Dr. Manchikanti, the number of patients who are seeking interventional techniques in pain management is increasing. Chronic pain is on the rise at around 11.6 percent annually, based on a recent publication from North Carolina, he notes.
“We see no significant increase in the number of epidural visits per year per patient,” Dr. Manchikanti says, “but the number of patient visits is increasing.”
In addition, more and more patients are looking into interventional techniques to manage their pain. “Retail sales of opioids are increasing,” he says. “Methadone retail sales have gone up 1,177 percent from 1997 to 2006.”
The increase in pharmaceutical treatment in the specialty leads to specialty-wide concerns about potential drug abuse. According to Dr. Manchikanti, there is “an average of nearly nine Floridians dying each day from prescription drugs, according to 2007 data.”
However, interventional pain management physicians are beginning to take strides in order to regulate and cut down on cases where patients are abusing medications.
2. Reimbursement is declining in all areas of interventional pain management. According to Dr. Manchikanti, interventional pain management has been one of the specialties most affected by an overall trend of decreasing reimbursement rates.
Reimbursement rates have seen an 8-36 percent decrease in the ASC setting from 2007 to 2009 for the top nine interventional pain management codes, according to Dr. Manchikanti. Reimbursement rates have also been affected in the office setting but remain relatively unaffected in hospitals.
In addition, expenses are going up in ASCs and in physicians’ offices, which further eats into net revenue for interventional pain management cases. “Actual practice cost inflation has gone up 42 percent from 2001 to 2008,” he says.
3. Numbers of Medicare beneficiaries are increasing. There is an 11.8 percent increase in the U.S. population who are 65 year-old and over, whereas there is a 12.7 percent increase in Medicare beneficiaries. Like in other specialties, the number of patients on Medicare who are seeing intervention pain management physicians is increasing. According to Dr. Manchikanti, physicians have seen a 17 percent overall increase per year from 1997 to 2006.
This increase in Medicare and Medicaid patients could mean lower reimbursement rates for physicians, especially in interventional pain management. “Medicaid reimbursement is 20 percent less in most states,” says Dr. Manchikanti.
Interventional pain management physicians can help their specialty by taking actions to improve Medicare reimbursement. One such action is to change their specialty designation with CMS to “interventional pain management-09,” which is the code used by CMS to determine how many physicians are currently identify as interventional pain physicians, according to Dr. Manchikanti.
In addition, Dr. Manchikanti mentions the importance of the American Medical Association’s practice expense survey. “This is how CMS calculates physician payments,” he says. “If there are enough people who respond, they can accurately measure the rate of increase in practice expenses. We have just completed a survey and hope this will reflect our true expenses for physician services.”
4. Improving the image of interventional pain management is essential for the specialty’s success. Interventional pain management as a specialty is prone to many misconceptions, according to Dr. Manchikanti.
“Many surgeons and internists have had bad experiences when they sent patients to pain specialists,” he says. “In addition, many have varying ideas on what the specialty actually is, and some even claim that there is ‘no scientific basis’ for what we do.”
Part of the reason this misconception over the specialty remains is due to “abuse” and overuse of pain management techniques on their patients by some physicians, specialists and family physicians.
As a result, Dr. Manchikanti says that better documentation of what procedures have been performed on patients is necessary to track this abuse. “A physician should not perform a pain procedure unless it is medically necessary,” he says. “We ask them to follow the ‘yo’ mama test,’ meaning the physician should be willing to perform the procedure on his own mother, realizing that he has two bigger brothers who love her more than he does who are watching out for her.”
Another problem is that some practitioners tend to perform epidurals, facet joint blocks, and sacroiliac joint blocks on the same patients in the same setting without proper diagnosis.
Dr. Manchikanti says that in order to combat this abuse of the system, accreditation of physicians and centers is important. “Patients should only be treated by a well-trained, qualified physician in an accredited setting,” he says.
In addition to worries over unnecessary or unneeded treatments, there is concern over drug abuse in pain management treatment, as mentioned previously. Dr. Manchikanti suggests that one way to control this, and to cut down on abuse in both treatment and medication, is to create a nationwide monitoring system.
For instance, in Florida, based on 2006 utilization data, 47 percent (20 percent nationally) of facet joint interventions were performed by family physicians rather than in a specialist’s office. This allowed a patient to be treated at the family practice and then move to the specialist for another prescription. Because there is no regulation, it is difficult for physicians to tell when a patient has been treated at another location.
Florida is trying to regulate clinics, which is helping to reduce this problem, but according to Dr. Manchikanti, it remains an issue.
Because of these issues, the American Society of Interventional Pain Physicians has proposed the development of the National All Schedules Prescription Electronic Reporting Act (NASPER), a nationwide, physician-friendly system to help provide better monitoring of patients. This will enable physicians to track how a patient had previously been treated when they move to a new area or state. Such a system will help physicians stay aware of what medications their patients are on and if they are seeing other physicians, says Dr. Manchikanti.
Members of ASIPP in Illinois have made advances and created a system for use in that state. Kentucky is one of the first states to create an effective electronic system that includes all patient information. However, Dr. Manchikanti notes that a nationwide system is still the goal for interventional pain management physicians.
One of the biggest hurdles preventing the creation of the system is funding. “Doctors should get involved,” Dr. Manchikanti says.
5. Interventional pain management centers are feeling the effects of the economy. As many centers in the United States face problems during the economic downturn, interventional pain management physicians are among those who have been affected.
“Many centers are going out of business,” says Dr Manchikanti, “because they can’t control expenses.”
He suggests that physicians who are concerned about the effects of the economy on their centers have to be very intelligent when thinking of solutions. One area that he says is most important is to optimize billing in the center.
Most importantly, Dr. Manchikanti emphasizes the importance of quality in keeping a center healthy. “You must provide good care,” he says. “Also, we must all get involved to preserve not just our own practice, but the entire specialty.”
