August 1997
Volume 61 |
Number 8
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| The Management
of a Pain Practice |
Vivek Mahendru, M.D.
Committee on Pain Management
"HMOs, PPOs, IPAs, EPOS, point of services, global rates,
capitated lives, risk-shared agreements ..." and many other
managed care acronyms and terms have become part of the medical
lingo. What does this mean for the average anesthesia-based, pain
management practitioner?
In today's world of medicine, it often means that the managed
care companies will continue to misunderstand the roles that pain
management practitioners play. As a consequence, pain management
physicians will lag behind the bureaucratic morass of medical
reimbursement by managed care companies. Yet, there is an instinctive
impulse that impels today's practitioners to "go with the
flow" rather than pause and reflect on the sweeping effects
that managed care companies are having on the rendering of quality
medical care. More doctors and organizations of physicians are
joining health maintenance organizations (HMOs) as employers and
employees who have become interested in managed care. Even worker
compensation authorities are looking at preferred provider networks
to provide care for their claims.
These novel health care entities bring with them a general lack
of understanding regarding pain control. In their eyes, pain management
is regarded as a luxury and not a necessity. Even though they
do not understand pain therapy, these companies are acutely aware
of the financial impact of pain disorders, amounting to billions
of dollars due to the loss of worker productivity and loss of
revenues. Yet, managed care organizations claim they have focused
their attention on cost-effective, conservative/preventative care,
resulting in good medical outcomes. Part of the misunderstanding
stems from the fact that managed care medical directors associate
high costs of treatment with patients suffering from chronic conditions.
Yet these same medical directors, who are extremely cost-conscious,
do not understand the concept of an anesthesiologist as a pain
management specialist. They are generally regarded only as interventionists
who have a "block clinic." The notion that pain management
today is relegated to epidural injections needs to be dispelled.
 Conversely,
pain physicians do not understand the mechanics of managed care
operations. In the world of "pre-auths" and "pre-certs,"
pain specialists are easily entangled in this web of pre-approval.
It is frustrating when a patient is in need of medical services
but is precluded from receiving treatment because the pre-authorization
was for the wrong procedure or was not granted because the nurse
case managers at the managed care company did not comprehend the
medical necessity. Staff interaction with these individuals at
managed care companies should always remain professional, but
there are times when managed care company employees should be
properly informed and educated about the diagnosis and procedures.
As these large health care entities increase their presence in
local communities, a concerted effort must be made to work with
them to ensure the adequate delivery of appropriate pain management
services to patients. It is good news that changing the perceptions
about pain management falls entirely in the hands of the practitioners.
A first step would be to visit with your local managed care medical
directors and educate them about the role of anesthesiologists
as natural and sensible practitioners of pain management. Our
knowledge with anatomy, pharmacology, analgesics and pain pathways
makes us most suitable to treat both pharmacologic and interventional
techniques. Talk to them about ways to increase the availability
and quality of pain services in your communities. Develop appropriate
strategies for reducing the costs of delivery for pain management.
An example would be to reduce the number and frequency of emergency
room visits for patients with intractable headaches. Some of the
problems can also be overcome with good clinical documentation
in consultation notes with a systematic and detailed pathway and
plan of recommended care. Medical directors will listen to good
clinical pathways that lead to appropriate outcomes.
Aside from engaging the managed care companies, create public
awareness of pain management within the community. Writing articles
for the health care section of local newspapers is an extremely
effective way to expose many chronic pain patients to remedies
they may have never encountered.
Vivek Mahendru, M.D. is the Medical Director
for the Central Texas Pain Institute, Austin, Texas.
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