February, 2008

PERIPHERAL NERVE BLOCKS are not only better for patients and physicians; they also reduce health care costs. At least that's the conclusion that commercial insurers here in Western Pennsylvania have reached. They've come to believe that blocks result in better outcomes, lower costs and happier patients, and they have agreed to reimburse for two types of blocks — with more hopefully on the way. Here's advice on helping insurers in your area see the light.

After familiarizing yourself with the blocks themselves, assemble a clinical team and start building your case. I recommend selecting a service where PNBs will do the most good for your facility and patients, like prostatectomy or knee or hip arthroplasties, and recruiting one surgeon in that service. Propose a 10-patient in-house trial, and allow the surgeon to pick the patients. Compare the results with 10 similar, non-PNB patients treated by the same surgeon. Surgeons are almost always convinced well before the tenth case.

Once you have one or more surgeons on board, expand your horizons and recruit more surgeons, service by service, as well as the administration. Use your in-house data, as well as published studies, to demonstrate the benefits. Two studies in particular will show your administration that PNBs save money by reducing both length of stay and opioid-related complications.[1,2] In one of these studies, we tracked the outcomes of 100 radical prostatectomy patients treated by the same surgeon with and without paravertebral blocks, and discovered that the average hospital length of stay was 16 percent lower in blocked patients. Pain scores and opioid use were also significantly lower. The improved patient satisfaction will make your surgeon's life easier and the decreased hospital stay will impress your administration. At this point, your team may opt to approach insurance carriers to negotiate adequate compensation.

At UPMC-Shadyside, where our study was performed, the clinical and administrative team used these data to educate commercial insurers about PNBs. UPMC-Shadyside is very large and has tremendous bargaining power, and that leverage helped win reimbursement for peripheral nerve blocks from the dominant carrier in our region. Today, thanks to their efforts, insurers reimburse others in this market for at least two common peripheral nerve blocks, a single-shot brachial plexus block and a continuous infusion femoral catheter.

Although limited and minimal, it's a start.

Given this, the peripheral nerve block programs in our area are in no danger of becoming profit centers any time soon. But PNBs clearly still increase profitability by reducing lengths of stay, cutting opioid-related complications, and pleasing patients. In my experience, they also increase case volume — often substantially — due in part to increased patient demand for services (in smaller communities "word-of-mouth" public relations helped us retain patients who had previously gone to larger institutions). We'll see more supportive studies soon. With our help, insurers will see them too, and understand that PNBs are not an expense, but a tremendous benefit.

Dr. Swanson is a staff anesthesiologist with Butler Memorial Hospital's Acute Intraoperative Pain Service. Thanks to James E. Gross, CPA, for his help with this article.

1. Ben-David B, Swanson J, Nelson JB, Chelly JE. Multimodal analgesia for radical prostatectomy provides better analgesia and shortens hospital stay. J Clin Anesth. 2007 Jun;19(4):264-8.
2. De Ruyter ML et al. A pilot study on continuous femoral perineural catheter for analgesia after total knee arthroplasty: the effect on physical rehabilitation and outcomes. J Arthroplasty. 2006 Dec;21(8):1111-7.