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August 1997
Volume 61 |
Number 8
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Measuring Pain
Management Outcome:
The Political Point of View |
David C. Mackey, M.D.
Committee on Pain Management
There is little doubt that anesthesiologists have historically
provided the principal leadership in the development of the practice
of pain medicine. Our specialty has played a major role in the
clinical care of pain patients, in research and in the development
of pain specialty certification. However, studies continue to
document the persisting prevalence of inadequate pain management,1-3
and prominent physicians note the need for medical regulatory
reforms to address this problem.4-5
In addition, new issues such as practice guidelines and standards,
cost efficacy and outcome analysis are playing increasingly prominent
roles in this era of managed care, medical consumerism, malpractice
liability and accelerating governmental regulation.
If the specialty of anesthesiology wishes to maintain its influence
in the field of pain medicine, it will need to acknowledge these
issues and move aggressively to address them. Such leadership
will be of great value to individual physicians, governmental
regulators, third-party payers and, most importantly, to patients
with acute or chronic pain. If we cannot justify the societal
value of pain management, it will wither as a specialty since
there will be no one willing to pay for it. If we are unwilling
or unable to assume leadership in the further development of this
specialty area, we must be willing to accept the inevitable consequences
of surrendering physician control to nonphysician influences.
The increasing importance of nonphysician influences in medicine
is not necessarily bad. Indeed, one can look to the state of Florida
as an example of the utility of governmental processes in improving
the care of the pain patient. The Florida Agency for Health Care
Administration (AHCA) and the Florida Department of Health have
taken aggressive stances in health care regulation relating to
pain management through enactment of the Florida Intractable Pain
Statute, creation of the Florida Pain Management Commission and
development of a specialized review process for pain management
disciplinary cases referred to the Florida Board of Medicine.
The 1995 enactment of the Florida Intractable Pain Statute improves
patient care by reassuring physicians that they can appropriately
prescribe controlled substances to patients with acute or chronic
intractable pain without fear of unreasonable licensure review
and discipline [Table 1].6
The Florida Pain Management Commission is another mechanism through
which the state is attempting to improve the health care of its
citizens. Organized in 1995, it consists of 20 members with representatives
from AHCA, the Florida Boards of Medicine, Osteopathic Medicine,
Nursing, Pharmacy, and Chiropractic Medicine, and the U.S. Drug
Enforcement Administration. After a series of public forums, it
sent a report to the state legislature including the following
recommendations:
- Continue the funding of the Commission as a voluntary advisory
and educational resource to Florida legislators and regulatory
personnel, health care professionals and the general public.
- Recognize chronic pain as a legitimate condition with appropriate
coding for reimbursement of services.
- Provide greater flexibility to physicians regarding prescriptions
for chronic pain patients.
- Provide centralized statewide registry of pain management
centers, including description of services and basic fee structure.
- Promote pain management educational programs for health care
providers and pain patients.
- Provide a clearinghouse for pain management information, including
patient education materials, professional training programs,
pain management guidelines and researchbased outcome studies.
- Encourage pain management research, development of a statewide
outcomes database, and technology to access national pain managementrelated
resources. The Florida Pain Management Commission is currently
working on legislation to accomplish many of the above goals.
Lastly, the problem of the Florida Board of Medicine's review
of physician disciplinary cases involving pain management has
been specifically addressed. Whereas in the past such cases might
have been reviewed by one or more physicians with little or no
specific experience or expertise in pain management, now all such
cases are reviewed by members of a panel of pain management specialists.
This proactive stance by the Florida Board of Medicine will help
assure practitioners involved in the medical disciplinary process
that cases involving pain management will be reviewed fairly and
accurately.
Recent events in the state of Florida illustrate the potential
and real impact of governmental regulatory, disciplinary and legislative
forces upon the practice of pain management. In addition, patients
(consumers), hospitals, managed care organizations and third-party
payers will increasingly look to government agencies for help
in addressing issues such as cost, quality and professional qualifications.
Pain management specialists must become involved in these
processes in order to prove the value of their work and to guide
its regulation. Such activity is absolutely essential for the
welfare of their patients and for the survival of their profession.
References:
- Von Roenn JH, Cleeland CS, Gonin R, Hatfield
AK, Pandya KJ. Physician attitudes and practice in cancer pain
management. A survey from the Eastern Cooperative Oncology Group.
Ann Intern Med. 1993; 119:121-126.
- Cleeland CS, Gonin R, Hatfield AK, Edmonson JH, et al. Pain
and its treatment in outpatients with metastatic cancer. N
Engl J Med. 1994; 330:592-596.
- Hill CS Jr. Government regulatory influences on opioid prescribing
and their impact on the treatment of pain of nonmalignant origin.
J Pain Symptom Manage. 1996; 11:287-298.
- Hill CS Jr. When will adequate pain treatment
be the norm? JAMA. 1995; 274:1881-1882.
- Foley KM. Pain relief into practice: Rhetoric without reform.
J Clin Oncol. 1995; 13:2149-2151.
- Mackey DC, Grossman AR. Narcotic prescription
for pain management in Florida: The physician and the law. J
Florida Med Assoc. 1996; 83:673-674.
Table 1
Florida Medical Practice Act §458.326
Intractable pain; authorized treatment:
- For the purposes of this section, the term "intractable
pain" means pain for which, in the generally accepted course
of medical practice, the cause cannot be removed and otherwise
treated.
- Intractable pain must be diagnosed by a physician licensed
under this chapter and qualified by experience to render such
diagnosis.
- Notwithstanding any other provision of law, a physician may
prescribe or administer any controlled substance under Schedules
IIV, as provided for in S893.03, to a person for the treatment
of intractable pain, provided the physician does so in accordance
with that level of care, skill and treatment recognized by a
reasonably prudent physician under similar conditions and circumstances.
- Nothing in this section shall be construed to condone, authorize
or approve mercy killing or euthanasia, and no treatment authorized
by this section may be used for such purpose.
David C. Mackey, M.D., is a Consultant
in Anesthesiology and Medicine at the Mayo Clinic Jacksonville,
Jacksonville, Florida. He is a member of the Florida Pain Commission
and the Medical Advisory Committee of the Florida Agency for Health
Care Administration.
E-mail the author.
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