Unfortunately the trend for demand of acute pain services and for reimbursement for these services is moving in opposite directions. Demand has increased steadily. Over the last 20 years, pain medicine specialists within anesthesiology have demonstrated the efficacy and value of excellent acute pain control. As with any consumer goods or services, patients have begun to expect excellent pain management after any surgery. The Joint Commission on Accreditation of Healthcare Organizations has declared pain to be the fifth vital sign and has established analgesia as a universal entitlement. Not to be left out, the legal community has begun to file malpractice actions based on inadequate postoperative analgesia with some successful judgments already recorded. All of this creates an expectation of acute pain services by hospitals and health care systems. With the sustained excellent service they have received from anesthesiology groups, it is natural that these services have become an expectation.

The growth of acute pain services was stimulated by reasonable reimbursement for professional services and technical charges, thus creating an incentive for anesthesiology groups to encourage patient-controlled analgesia (PCA) pump use. With the acceptance by surgeons, pumps were bought and systems created for safe use in large numbers of patients. In medium- and large-sized hospitals, full-time equivalents for staff and nurse practitioners were easily justified by busy PCA services. Parallel to the surge in PCA usage, acute pain management using epidural and peripheral nerve catheters was shown to be safe and highly effective. Professional and technical reimbursement for placement and maintenance of these catheters was reasonable and justified the increased level of physician service necessary for safe use of this approach to analgesia.

The process of supply and demand created a rapid growth in acute pain services. Surgeons became comfortable with excellent service for their patients that required minimal effort on their part. Surgeons began to choose hospitals based on the level of acute pain services available. Patients also began to make choices based on these criteria, including the surgeon and the hospital. All of the above led to the first “birth” phase in acute pain reimbursement.

If there is a “death” in this story, it is a political death. At the high-water point for the Clinton Administration’s effort to redesign health care in the United States, reform became synonymous with reduction in reimbursement. HMOs became aggressive about refusals of any service that was identified as unnecessary. On November 25, 1991, Medicare published a rule in the Federal Register that eliminated reimbursement for PCA services, allowing only reimbursement for consultation to manage severe pain or unusual cases (e.g., opiate addiction). The refusal, appeal and justification steps had the effect of virtually eliminating billing for these services. The bundling of charges into the “global surgical fee” had a further effect in reducing reimbursement for acute pain services. Although surgeons recognize the value of the service, few were willing to share global fees to pay for the service. Some centers transferred PCA services to the surgeons either directly or via hospital nursing. Patient demand did not change, service was less predictable, and PCA availability became less dependable. In other institutions, the patient demand resulted in pressure for anesthesiology groups to provide the service despite revenue shortfall. The financial burden of the service led to lower staffing of both physicians and nurses and reduced professional satisfaction.

Although not to the same extent as PCA, reimbursement for continuous regional anesthesia for acute pain control decreased steadily. When catheters are used for intraoperative anesthesia, reimbursement for pain services on the day of surgery was eliminated despite the professional and technical services required for optimum, safe analgesia. Since many surgeons were convinced that continuous analgesia was the best postoperative option for their patients, the reduced enthusiasm in anesthesiology groups to place and maintain catheters led to friction. The reduced unit price had a direct impact on those services billed by units. For those with defined fees, reductions of 5 percent to 10 percent yearly have become common among Medicare carriers and private insurance.

Just considering the reduced workforce commitment to acute pain management, reduction in service was inevitable. Combined with the national shortage of anesthesia providers, the pull away from acute pain management was strong. Ironically, this reduction in services coincided with an increasing body of scientific evidence that excellent analgesia has a favorable influence on many aspects of perioperative outcome. Financial incentives have driven many pain medicine specialists to abandon acute pain management in favor of exclusive practice of chronic pain management; others returned to providing surgical anesthesia exclusively.

If there is a “rebirth” in this story, it has been driven by outcome data. Excellent analgesia improves pulmonary function, may decrease thromboembolic complications and decreases perioperative myocardial ischemia that may be induced by severe pain. In particular, the value of peripheral nerve catheters for postoperative pain control has become obvious, and billing codes have been created for these services. With these codes, unfortunately, billing for placement eliminates billing for daily professional service for maintenance, and only technical charges are allowed. Evidence of the early return of bowel function and decreased length of hospital stay support the value of reimbursement for the use of epidural analgesia after abdominal surgery.

The test of the rebirth phase of acute pain reimbursement will be determined by the actions of the new workforce wave entering anesthesiology. Sustained growth of acute pain services will occur if a sufficient physician workforce is allocated to acute pain management. Convincing outcome data will support the reimbursement for the service. On the other hand, if the movement of pain experts toward interventional chronic pain management continues, this rebirth may take the opposite direction with reduced levels of both service and reimbursement.

As anesthesiology groups achieve the staffing levels for optimum operating room coverage, increased interest in regional anesthesia may lead to the creation of groups within these departments willing to provide regional anesthesia for optimum postoperative analgesia. It is also possible that this alternative pathway to the rebirth of acute pain reimbursement could coincide with the push toward the anesthesiologist as the provider of perioperative medicine.

John E. Tetzlaff, M.D., is a Staff Anesthesiologist and Director of the Center for Anesthesiology Education, The Cleveland Clinic Foundation, Cleveland, Ohio.