The Impact of Emerging Policy and Regulation on Pain Management

As the U.S. population ages, healthcare expenditures are skyrocketing, causing the percentage of gross domestic product devoted to healthcare to grow at an unsustainable rate. In an effort to stem the upward trend, the federal government has instituted a number of measures designed to reduce payments, control expenses and modify access to care. Collectively, these measures are known as “healthcare reform.”

On March 5, 2016, Richard W. Rosenquist, MD, Chairman of Pain Management at Cleveland Clinic, discussed the effect of emerging healthcare reform policy and regulation on the practice of pain management at the 18th Annual Cleveland Clinic Pain Management Symposium in Coronado, California.

The practice of pain medicine is under scrutiny, primarily because the management of chronic pain and postoperative pain is extremely costly. Chronic pain costs the government up to $635 billion a year in medical treatment and lost productivity. Procedures such as hip and knee replacements are significantly associated with postoperative pain and cost the government more than $7 billion a year in hospitalization alone.

At the same time costs are growing, the number of patients with governmental insurance, for whom the cost of care exceeds associated revenues, is increasing. For this reason, new payment models are being developed and implemented.

Multiple options to fee-for-service are being tested. The model that will ultimately succeed may not be determined for several years. What is sure, however, is that healthcare reform will have a significant impact on the practice of pain medicine in the form of reduced payments, modified access to care, changes in who delivers care, and the quality and type of care provided. As a result, we must become more efficient in delivering care, take greater control over expenses and accept being paid less to do more.

Reimbursement based on outcome

The Affordable Care Act (ACA) was the first major step in healthcare reform. It was designed to reduce the cost of healthcare, as well as the number of uninsured. The government’s goal was to create higher quality, more affordable healthcare under Medicare by replacing the Medicare sustainable growth rate formula (SGR) with an outcomes-based method of payment through Accountable Care Organizations (ACOs).

An ACO is a payment and care delivery model that ties provider payments to quality metrics and reductions in the total cost of care for an assigned population of patients. In the new equation, value is defined as the sum of superior outcomes plus patient-centered care plus efficiency—all delivered at a lower cost.

The metrics used to define quality, however, fail to take into account different skill sets, resources, insurance approval, the patient’s age or general state of health, or patient participation in plan of care. Although increased use of patient satisfaction surveys and high patient satisfaction scores have not been associated with better outcomes or reduced healthcare utilization, these value judgments are likely here to stay. In the absence of common or well-established functional outcomes metrics, we must develop them ourselves.

Strategies for redesigning pain care delivery

With fee-for-service days numbered, it behooves pain specialists to redesign their workflow processes, even in the absence of an immediate return on investment.

This will be easier to accomplish with perioperative pain than with chronic pain services, since the diagnosis of chronic pain is often elusive and cure is rare. Sources of potential revenue for perioperative pain care include:

• Hospital or surgeon payment to provide care for non-covered but desirable services; for example, spine surgery patients
• Hospital investment in opportunity cost, loss avoidance for CMS penalties or safety issues or improved community image
• Inclusion of pain management in a bundled payment package

Pain physicians may consider such innovative approaches as:

• Increasing the use of a team approach to improve access and reduce overall cost of care delivery
• Delivering care or follow-up in new ways that may increase patient satisfaction and compliance, while allowing for better use of face-to-face time. Examples include email, healthcare apps or telehealth (a CPT code is under development)
• Collecting a common set of outcomes measures that have significant buy-in for ease of use and relevance to clinical outcome
• Incorporating a secure IT system that allows patients to input data prior to a visit and provides data for measuring outcomes
• Adopting programs designed to increase patient accountability for participation in their plan of care

I would advise pain management physicians to monitor Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) pain related scores and Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS) scores so that interdisciplinary plans to address poor performance areas can be developed. They should also examine surgical complications, recovery milestones, length of stay and drug and personnel costs, and document other cost savings and other desirable improvements. This data should then be presented to hospital administrators, surgeons and nursing groups.

Healthcare policies and regulations are changing almost daily. For this reason, pain physicians should use the strategies proposed in this article as a reminder of the pressing need to develop new ways of reducing expenses and increasing efficiency. What is certain today is that we will have to be clever, creative and flexible to succeed in the new healthcare environment.