With more than 2 percent of US adults suffering from chronic pain and an elderly population that is rapidly expanding, a pain management service proffers great potential to help people and sustain profitability. Yet, the chronic pain management landscape is fraught with unique challenges that facility managers must seriously consider. Clinical philosophies can differ significantly among pain specialists. Physician fee reimbursements can vary greatly by facility type, and doctors are finding themselves under intensified scrutiny thanks to a newly energized Medicare fraud and abuse campaign directed at pain management specialists. This article provides a guide to the current challenges of running a pain management service and offers some insights that may help you pave the way to a successful future.

Challenge #1: Ensuring Ethical Care

Among pain management specialists, clinical philosophies can vary widely. To keep your facility running smoothly, I believe it is important to partner with physicians who make an effort to minimize unnecessary procedures.

There are numerous ways to manage chronic pain (pain that persists for longer than three months), and the approach usually depends on the treating physician's specialty and clinical philosophy. Common approaches include psychological intervention, acupuncture, physical therapy, minimally invasive outpatient interventions (drug injections/ continuous drug delivery, spinal cord stimulation, electrothermal therapy), and/or surgery. Like other pain management specialists in the outpatient surgery community (primarily anesthesiologists like me or physiatrists), I subscribe to the latter two approaches. However, this does not mean we all have the same clinical philosophy.

To ensure ethical care, I endorse a "diagnostic therapeutics" approach in which I aim to pinpoint the pain source, evaluate the response to each drug injection, and change the treatment approach if pain persists or recurs repeatedly. By making the diagnosis early, I minimize the potential for repeat injections that provide only transient or no pain relief.

Challenge #2: Guaranteeing Compliance

Last summer, a federal court convicted a Michigan anesthesiologist who was running a large pain management practice on 33 counts of mail fraud and sentenced him to a 36-month prison term plus three years of probation and 600 hours of community service. The court also ordered him to pay a $25,000 fine, a $3,300 assessment, and $411,060 in restitution to Medicare, Medicaid, Blue Cross/Blue Shield of Michigan, and several private third-party payors.

Although cases like this are rare, they illustrate the seriousness of HCFA's intensified fraud and abuse enforcement effort, which is targeted to pain management specialists. Besides fines and imprisonment, expulsion from the Medicare program is a possible consequence of Medicare fraud and abuse, and expulsion can force resignation from a hospital staff position. Importantly, these penalties can stick regardless of the degree of physician involvement or awareness. Ignorance of the billing regulations is grounds for criminal conviction no matter now incomprehensible or illogical the rules may seem.

Unfortunately, the activities that landed the Michigan anesthesiologist in prison-including billing Medicare for medical direction while personally performing other services, upcoding, and recommending and performing medically unnecessary surgical procedures-are thought to be fairly common. To ensure compliance, I recommend getting help from reputable billing and legal services and disregarding all vendor billing recommendations.

Procure reputable services. Because Medicare billing codes are so complex, it's altogether easy to make serious coding mistakes without even knowing it. I have procured the services of a billing company that can supply the expertise I need and won't upcode or double-bill to increase its commission. This is an extremely important point because the physician and the facility owners are always accountable.

Ignore vendor billing recommendations. Some vendors may suggest certain billing codes to encourage you to buy their products. I recommend ignoring these recommendations altogether and relying instead on a trustworthy billing expert. Vendor recommendations can be inconsistent with your Medicare carrier's requirements. In fact, this is one of the most common billing mistakes, according to JoAnne Burkhardt, a compliance expert with PMC Solutions, Inc.

Challenge #3: Keeping Your Physicians Happy
Although physician satisfaction is always a priority for facility managers, keeping your pain management specialists happy may soon become a greater challenge. Currently, Medicare and other insurers that strictly follow the Medicare schedule reimburse physicians significantly more for some pain management procedures performed in the office suite. For example, in locality 16, Medicare approves a physician fee of $443.70 for an in-office sacroiliac joint injection, yet approves just $61.28 for the same injection performed in a surgery facility. In my practice, SI joint injection is the sixth most common procedure. Even worse, Medicare does not approve reimbursements for certain other pain management procedures, such as a cervical epidural, when performed in a freestanding ASC.

If other plans follow suit, facility managers may need to make some short-term concessions. Under this scenario, pain management specialists will perform some of the simpler procedures in the office setting but should continue to perform the more complex procedures-such as video discography and newer techniques that will arise in the near future-in the surgical facility.

Challenge #4: Maintaining Case Volume
Although filling the schedule is a challenge regardless of specialty, the key to maintaining case volume in the area of pain management is referrals. I currently do a significant portion of the pain management procedures performed at the Poplar Creek Center for Pain Management, thanks primarily to both surgeon and patient referrals.

Surgeon referrals. Referrals from spine surgeons comprise the majority of my patient base. To keep these referrals coming, pain management specialists need to work hard at maintaining physician relationships. For me, this harkens back to providing ethical care. For the most part, specialists who provide care with the patient's needs foremost in mind gain the lasting respect of their referring physicians.

Patient referrals. Word-of-mouth referrals comprise an additional 20 percent of my patient population. To promote patient satisfaction, pain management specialists need to maintain a high degree of empathy while handling patients firmly. In my experience, pain patients can be somewhat evasive, perhaps because many have experienced pain for so long despite other therapies such as chronic NSAID use and physical therapy. In addition, a small portion of pain patients may try to abuse the system, and the physician needs to remain empathetic yet unwavering.

I get an additional 5 percent of my patients through the Internet, and if you don't have a good web site, I recommend creating one. Our web site (www.painmngt.com) is patient-friendly and educational, and I believe it will generate more growth in the future.

I also recommend staying away from mass mailings if your intent is to attract new patients; for me, mass mailings have been entirely ineffective for this purpose.

Outlook: Bleak or Bright?
Despite these unique challenges, the field of pain management holds much promise. Along with gastroenterology and orthopedics, it is one of the fastest-growing outpatient specialties. While numerous factors influence financial success, facility managers can reasonably expect to generate $500,000 in annual revenue from a well-run pain management service. More importantly, there are a growing number of patients in need of help, and new diagnostic and therapeutic breakthroughs like epiduroscopy hold great potential to improve outcomes. Thanks to advances like this, we will be better equipped than ever to help chronic pain patients in the future-provided we are equipped to overcome the hurdles that face us today.