May 1998
Volume 62 |
Number 5
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| Biting the Bullet:
One State's Plan to Ease the Pain |
Lawrence S. Gorfine, M.D.
Committee on Pain Management
At the request of the governor of Florida, the 1994 Florida Legislature
created a Pain Management Commission, which was administered by
the Agency for Health Care Administration (AHCA). The commission
was to study pain management activities in the state and prepare
a full report to the legislature.
The report and recommendations were intended to help the
legislature formulate policy. At the same time, an intractable
pain provision was created. This allowed a licensed and qualified
physician to diagnose intractable pain and, in a prudent manner,
prescribe controlled substances (DEA Schedules II-V). It further
reported that the state did not condone mercy killing or euthanasia.
The Pain Management Commission held three public forums
in the spring of 1995. The dates and locations of these forums
were widely publicized by press releases and flyers sent to health
care providers and advocacy groups. The forums were held in Tallahassee,
Orlando and Miami. Members of the press were invited and attended
at least two of the sessions. Before the Miami forum, the Miami
Herald wrote a special article about pain management.
Public testimony included experiences of pain sufferers
as well as health care providers. Medical doctors, osteopaths,
chiropractors, dentists, massage therapists, psychologists, nurses,
hospice caregivers and health education experts were among the
many health care providers represented. A survey was also created
by the commission to determine issues and attitudes relating to
pain management.
The survey overwhelmingly determined for the commission
that all patients have a right to adequate pain management. It
further suggested that there is a need for specialized pain treatment
centers and pain specialists. The respondents indicated that the
government should not be involved in prescribing pain medications.
The survey also found that the most common reason for termination
of pain treatment was refusal or cancellation of payment by third-party
payers (33.3 percent).
The forums were conducted with a panel of commission members
and assisted by staff members of AHCA and local health councils.
Input from all represented groups was received by oral and written
testimony. The final report suggested the need for more study
in several controversial areas. These included the area of guidelines
for pain management, reimbursement issues, regulation and accreditation
of pain centers and the certification of pain specialists.
The commission found that much fear exists among physicians
in prescribing opioids for chronic nonmalignant pain. The issues
of concern to physicians involve state and federal guidelines
for prescriptions to patients including those covered by Medicare
and Medicaid. Generally, physicians agreed to liberally prescribe
opioids to terminally ill cancer patients; however, hospice representatives
reported that physicians continue to be reluctant to prescribe
appropriately for the terminally ill.
Reimbursement was a major issue among health care providers.
Both consumers and providers testified that there was no uniformity
among third-party payers for reimbursement of pain management
services. Payment for many types of pain management care was customarily
denied by insurers, including Medicare, Medicaid and Workers'
Compensation. Testimony of pain patients suggested that insurers
are biased toward reimbursement for surgery in the treatment of
pain. The "system" is often reluctant to reimburse for medication,
equipment and psychosocial services. There is, then, a tendency
for acute care coverage rather than a long-term commitment focusing
on the chronic needs of the pain patient.
The Pain Management Commission found no uniformity in
the services offered by pain centers. The only accrediting organizations
are the Commission for the Accreditation of Rehabilitation Facilities
and the Joint Commission on Accreditation of Healthcare Organizations.
Many pain centers do not offer the specific programs required
for accreditation by these groups. It was suggested that a system
be created for determining the services in the pain centers.
The commission stressed that there is little follow-up
outcome data available to determine the effectiveness of the different
pain management techniques. There was specifically no statewide
computerized data to use in research or evaluation of services.
The final report of the Commission made the following
recommendations:
- Guidelines need to be established for pain management.
- Guidelines need to be established for opioid use.
- Insurance companies must recognize pain management and reimburse
providers for their services.
- Insurance companies must recognize the long-term needs of
the chronic pain patient.
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- Courses on pain and pain management should be included in
university curricula.
- A statewide system of outcome data should be developed.
- A system for determining the types of services offered by
pain centers needs to be created.
- The public needs to be educated regarding the alternatives
available to them for pain management.
- Physicians need to be trained to recognize and deal appropriately
with patients experiencing acute and chronic pain.
The Florida Pain Management Commission has met several
times since publication of its report. The commission has further
recommended that funding be made available to continue the work
of making pain management available to all citizens of the state
of Florida. AHCA has established initiatives to evaluate the adherence
to and effectiveness of certain AHCA-endorsed pain management
guidelines and to develop a consumer education publication and
Internet site related to the management of chronic pain.
The commission is working at receiving further funding
and implementing the recommendations it has presented in its report
to the Florida legislature.
Lawrence S. Gorfine, M.D., is a practicing
physician in pain medicine and anesthesiology and the Director
of the Pain Center, Columbia J.F.K. Medical Center, Lake Worth,
Florida. He is Chair of the Committee on Pain Medicine for the
Florida Society of Anesthesiologists.
E-mail the author.
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