Attack on Interventional Pain Procedures
Christopher Faubel, MD
(PGY3–Louisiana State University; chief-resident)
With health care costs continuing to escalate at a rate which exceeds inflation , it's no wonder there is intense scrutiny to cut back on wasteful spending. Who determines what is “wasteful spending?” It’s committees of “experts” appointed by private and public insurers. Ever since sacroiliac joint injections were scrutinized by insurance providers such as Blue Cross/Blue Shield of Idaho , Texas, and Florida a few years ago, reimbursement for all interventional pain procedure has been decreasing. The entire United Kingdom has excluded interventional pain procedures from their nationalized reimbursement plan, except for very few specific circumstances .
During the summer of 2009, Noridian Administrative Services (a contractor for the Centers for Medicare and Medicaid) proposed non-coverage of all facet joint interventional pain procedures (steroid injections, medial branch blocks, radiofrequency ablations) . AAPM&R, ASIPP, ISIS, NASS, AAPM, and multiple other state pain societies sent letters protesting this and suggesting reimbursement alternatives. At the end of last year, Noridian came back with their decision; Medicare and Medicaid in those states represented by Noridian would no longer reimburse for facet injections performed blindly (without fluoroscopic or CT-guidance) . This was a win for the patients who need this procedure, yet still a financial loss for interventional pain providers. Facet procedures are still covered, but the CPT code now combines the facet injection and the fluoroscopic guidance, reducing reimbursement for the physician.
What evidence are the insurance companies looking at to come to these conclusions? Unfortunately, it is not much…and that is the problem.
“…Chronic pain (costs) the nation over $61.2 billion annually in lost productivity and direct medical costs”
The interventional pain community does not have strong evidence to prove the effectiveness and the “worth” of many of their interventional procedures. Yet, in our current economic climate of cost-containment, evidence is what is required. For 2010, the National Institutes of Health (NIH) is estimating spending $341 million on studying “chronic pain,” excluding the additional funding allotted for fibromyalgia and arthritis research . While most NIH budget categories have been maintained or decreased, management of chronic pain has increased about 50% over the last few years. With chronic pain costing the nation over $61.2 billion annually in lost productivity and direct medical costs , it is clear why the federal government is investing in ways to better understand it.
However, research is a double-edged sword. Pain is difficult to investigate scientifically for many reasons. Pain is a symptom, which is by definition, subjective. It is difficult to prove the effectiveness of a therapy when there is not an objective outcome measure. The placebo effect associated with treating pain supersedes that of any other symptom. A 30% or even up to 50% placebo effect has been seen in some studies .
Clearly, two studies published last summer in the New England Journal of Medicine regarding vertebroplasties (for the treatment of painful osteoporotic compression fractures) came to a surprising ending—no significant difference than placebo [9,10]. Upon thorough examination of the study’s methods, it is apparent the validity of the author's conclusion was suspect at best. Which brings me to what I see as the most difficult obstacle to overcome in researching pain—patient selection.
Perhaps physiatrists need to collectively create diagnostic criteria for our commonly treated conditions, like rheumatology did with the infamously subjective syndrome called fibromyalgia. As you know, the American College of Rheumatology created diagnostic criteria for fibromyalgia, not for the use by clinicians to treat patients, but for researchers to have inclusion/exclusion criteria for their studies. Somehow our field as a whole must ensure that patients with sacroiliac-mediated pain are not included in a study evaluating intra-articular facet joint injections or medial branch blocks/radiofrequency ablation, and that patients with an incidental disc bulge on MRI with buttock pain are not included in a study evaluating transforaminal epidural steroid injections for radicular pain. We must select the right patient, before we can perform research and make conclusions regarding the effectiveness of our procedures.
The ultimate question is, do we collectively decide on diagnostic criteria for research purposes, or do we continue publishing studies with poor patient selection and poor outcomes? If we wait for a government agency or private insurer to decide our interventional pain procedures have no “worth,” and are not worth covering. What will that mean for our specialty and our patients?
1. The Wall Street Journal: “Health Costs and History”; Oct. 20, 2009
2. Blue Cross of Idaho: Medical Policy 6.01.23
3. National Institute for Health and Clinical Excellence: Clinical Guidelines from May 2009
4. Noridian Administrative Services: Non-Covered LCD; July 2, 2009 (PDF Download)
5. Noridian Administrative Services: LCD Non-Covered Services; Dec 17, 2009 (PDF Download)
6. National Institutes of Health: Research Portfolio: Feb. 1, 2010
7. Lost productive time and cost due to common pain conditions in the US workforce: JAMA. 2003 Nov 12;290(18):2443–54
8. Somatotopic activation of opioid systems by target-directed expectations of analgesia: J Neurosci. 1999 May 1;19(9):3639–48
9. A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures: NEJM. 2009 Aug 6; Vol 361:569–579
10. A Randomized Trial of Vertebroplasty for Painful Osteoporotic Vertebral Fractures: NEJM. 2009 Aug 6; Vol 361:557–568
Update From the Resident Physician Council Board Interim Meeting
Oluseun “Alfy” Olufade, MD (PGY3–Temple)
Your Resident Physician Council (RPC) Board met for two days on March 13–14, 2010, at the new AAPM&R national office in Rosemont, IL. The purpose of the meeting was to discuss ways that RPC can continue to serve our fellow residents within the Academy. Throughout the weekend we discussed ways the RPC Board can improve current resident initiatives and create additional projects that can serve our resident members.
“The RPC Board has created multiple projects with the hopes of building a stronger resident community within the Academy.”
One of the highlights of the meeting was an address by Academy Past President, Joel Press, MD. Dr. Press humbly narrated his unexpected course from a resident to becoming president of AAPM&R, and the North American Spine Society. He explained his leadership style and how an essential strength of leadership included getting the right people on your team.
RPC and the Annual Assembly
Over the past year, the RPC Board has created multiple projects with the hopes of building a stronger resident community within the Academy. For example, the RPC Board has helped organize new events at the AAPM&R Annual Assembly to improve the experience for resident attendees. In addition to the traditional resident track of lectures and the Residents’ Reception, we held our first ever Resident and Fellow Town Hall and Chief Residents Meetings at the AAPM&R 2009 Annual Assembly in Austin, TX.
The Resident and Fellow Town Hall Meeting was successful as it provided an opportunity for all residents at the Annual Assembly to get a closer look at what the RPC Board has been doing on their behalf within the past year. The town hall style forum gave residents the opportunity to provide feedback to the RPC Board. The Chief Residents Meeting allowed chiefs from around the country to meet, exchange ideas, and discuss ways the RPC can use the current Academy structure to serve them as local resident leaders. We plan to use our chief resident listserve to continue this dialogue.
Resident attendees at the 2009 Annual Assembly gave us some constructive feedback about the resident educational sessions, including timing and locations of the events. These suggestions will be used to adapt the programming in order to make the sessions even stronger in 2010. At this year’s Annual Assembly in Seattle, the resident educational track has been expanded to a day and a half. We also plan to increase the number of resident social events in order to give residents from around the country a better chance to meet and network throughout the meetings.
RPC and Medical Students
At our board meeting, we also discussed our collaborative effort with the AAPM&R Public and Professional Awareness Committee (PPAC) and the AAPM&R Membership Committee. We have been working with PPAC to improve the Medical Student Symposium held each year during the Annual Assembly; to improve the visibility of PM&R in medical schools; and to enhance the current medical student guide to PM&R. The RPC has been instrumental in creating a contact list of medical schools across the country in order to improve the Academy’s ability to connect with medical students and introduce them to PM&R. We have also provided feedback to the Membership Committee in developing a marketing plan to attract new resident and medical student members; we have also provided the committee with feedback about how the Academy can better serve its current resident members.
Looking toward the future, we have set goals on what we hope to accomplish within the next six months. We believe it will be an exciting year for residents within the Academy, and we look forward to continuing to serve you.
Stay tuned to the PM&R Resident newsletter for more resident news. For a copy of the RPC board meeting minutes, go to the RPC page of the AAPM&R Web site.
Make Employer Connections at the AAPM&R Job Fair
Where can you meet and greet 70+ PM&R employers in one location? The AAPM&R Job Fair, November 3, 2010, in Seattle. If you are looking for a job or looking to hire PM&R specialists, plan to attend the popular Job Fair. There is no substitute for making connections in person.
“There is no substitute for making connections in person.”
Held in conjunction with the AAPM&R 2010 Annual Assembly, the Job Fair brings together more than 70 employers from around the world. For the convenience of job seekers, employers are divided geographically into regions.
If you are currently seeking a PM&R position, register today for the Annual Assembly to attend the Job Fair, and take note of these important reminders:
- The Job Fair is held one day prior to the start of the Annual Assembly. Please make your hotel and air travel reservations with this in mind.
- The fee for job seekers to attend is included in the Annual Assembly registration fee. Job seekers do not need to register for this event, but must register for the Annual Assembly.
- Interviews are possible and can be conducted at the Job Fair. Applicants should bring at least 25 copies of their curricula vitae, a pen/pencil, and a notepad.
- Pick up a booth map at the door and route your path to the future.
Stay tuned for more Job Fair tips in future issues of the PM&R Resident. Plan to participate! For more information, please visit www.aapmr.org/assembly or contact Cassandra Tulipano at (847) 737-6032, or firstname.lastname@example.org.
Prepare Yourself for the Job Search
When residents talk, your Academy listens! Responding to overwhelming resident feedback last year, the 2010 Annual Assembly resident track has been expanded to over a full day and a half. You also asked for essential sessions related to the job search before the Job Fair. On November 3, 2010, in Seattle, the informative session Preparing Yourself for Physiatric Practice will take place at 3 pm, prior to the popular Job Fair.
Learn job search essentials, including interviewing skills, preparing an attractive curriculum vitae, and evaluating a physiatric practice. Upon completion of this program attendees will be able to map a strategy for selecting a practice opportunity that fits their needs. Participants will learn how to prepare an attractive vita, how to optimally prepare for job interviews, and how to discern the value of fellowships versus establishing a physiatric practice. This resident track session takes place one day prior to the start of the AAPM&R 2010 Annual Assembly, so plan your travel accordingly.
2010 Abridged Self-Assessment Exam for Residents is Available Now
The 2010 abridged version of the Self-Assessment Examination for Residents (SAE-R) is now available on acadeME® (www.me.aapmr.org), AAPM&R’s online educational portal. By completing this online version of the SAE-R, residents will get immediate feedback, including explanation and references for each question. This exam is available free for residents. Log on to acadeME to take advantage of this resource today.
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