Pain.com: Politics has infiltrated many aspects of medicine. Is this something you have found to be true in pain management?

Dr. Kloth: Pain management as much as any field in medicine has been affected by the politics of medicine. From the difficulty clinicians have experienced in obtaining privileges at hospitals related to restrictive covenants and contracts, to the fighting for treatment coverage through appropriate CPT coding and reimbursement. Many hospitals have elected to exclusively contract with anesthesia departments to provide pain management services, thereby excluding private practitioners from their community from working within the hospital system. This approach seems counterproductive from a business standpoint for the hospital, as they are losing business from these clinicians within their community, thereby encouraging them to develop alternative means to provide these services (for instance privately owned ambulatory surgical centers). Unfortunately this practice often leads to a lower quality of care within some of these institutions for inpatient pain management. While anesthesia departments have traditionally done a very good job with management of acute postoperative pain, often their ability to treat chronic pain patients is somewhat lacking. Many (not all) of the in-house pain management services provide cursory “block services” and do not provide comprehensive pain management treatment.

Pain management is struggling to gain recognition and respect amongst other practitioners, hospitals, and insurance carriers. This has made it difficult for physicians to get coverage for their treatments including psychosocial services, extended physical therapy courses where appropriate, and many innovative interventional treatments.
In regards to the interventional treatments, it is frequently commented that there is inadequate research or data supporting these modern procedures. Most of these involve FDA approved devices in which adequate studies have been performed in order to achieve such a rigorous approval (for instance, IDET). While it remains controversial exactly how IDET works, there are certainly enough studies that show that there appears to be an improvement in a reasonable percentage of patients. The alternative for many of these individuals is aggressive lumbar operations which have not been proven to be any more effective. These aggressive interventional procedures should be reserved for failure of more conservative approaches, but yet represent a viable treatment alternative for those individuals continuing to experience pain, despite adequate attempts at conservative management. Nevertheless, there remains an ongoing battle between physicians and insurance carriers trying to gain coverage for these treatment approaches. The majority of carriers consider IDET to be investigational despite the fact that 100,000 such procedures have been performed to date. These same carriers readily approve lumbar fusion surgery without any better evident of success. From 1998 to 2003 the incidence of lumbar fusion increased from 50,000 per year to 200,000 per year. In our State it is interesting that Workers Compensation has more readily accepted minimally invasive spine surgery techniques (i.e., annuloplasty, percutaneous discectomy, and lysis of adhesions) as they have taken a more business oriented approach towards these treatment options. Specifically they have analyzed the return to work rates with lumbar fusions and compared that to the success rates with minimally invasive techniques, and have found not only are these more cost effective, but the return to work rates appear to be higher in this difficult population of patients.

Pain.com: Doctor I understand that you have been actively involved in a number of political issues regarding pain management. Can you expand on these?
Dr. Kloth: As Executive Vice President of the American Society of Interventional Pain Physicians (ASIPP), I have been actively involved in a number of political issues. ASIPP, which was founded in 1999, is a politically oriented organization which has taken on as one of its main missions to ensure the future coverage of interventional pain procedures. In our endeavors to accomplish this we have also hopefully assisted non-interventional pain physicians as well.
Many pain physicians were unhappy with the reimbursement they were receiving based on their Medicare fee schedules, feeling that the reimbursement was inadequate to cover the level of invasiveness and the cost of these procedures. Interventional pain medicine is currently lumped with traditional anesthesia as it relates to practice expense ratios. Around 2000 we began to lobby CMS (then known as HCFA) to create a specialty designation for interventional pain management. After extensive discussions and thousands of letters, along with meetings at CMS in Baltimore, with Tom Scully, and HHS Secretary Tommy Thompson, to name just a few individuals, we were finally able to obtain a specialty designation. At the 11th hour this specialty designation was changed from “interventional pain management” to “pain medicine” to represent the entire field (specialty designation 72). While certainly this is reasonable for pain medicine in general, this did not address the higher costs that interventional pain physicians experience in their practice. For instance, the approval process for many of the procedures that interventionalists perform is complex and onerous. This increases the cost of doing business. Billing expenses are higher because it is difficult to collect from insurance carriers for many of the procedures that are performed. Therefore, ASIPP continued its lobbying efforts for an interventional pain management specialty designation. This was eventually achieved in April, 2003 (interventional pain management specialty designation 09). Physicians who are involved in pain management who have not yet selected one of these designations, are strongly encouraged to register their new specialty designation with Medicare.

Pain.com: Why is this so important?

Dr. Kloth: Reimbursement from CMS is based on three factors: physician work, malpractice costs and practice expense. Approximately a third of your reimbursement comes from practice expense valuation. Currently pain management is lumped with anesthesia which has the lowest practice expense ratio of any specialty; approximately half of that for internal medicine or the average physician specialty. For instance, interventional radiology is valued over three times higher in terms of practice expense compared to interventional pain management. Until such time there are enough physicians who convert to these new specialty designations, the government cannot collect adequate information in order to assess true practice expenses. Therefore if you are currently an interventional pain physician you should notify Medicare to change your specialty designation to 09. If you are a non-interventionalist you should register with a specialty designation of 72. This can be accomplished very easily by completing CMS Form 855I (Sections 1, 2 and 15) and sending it to your local Medicare carrier . It should not result in more than a 1-2 week interruption in reimbursement which should not be onerous to any practice. This changeover is extremely important to allow the government to collect the appropriate information that they need to reassess our practice expenses. This reassessment of expenses will result in increased reimbursement from Medicare (which will be fought by the other specialties given that Medicare is a “zero sum game”), but will also translate into increased reimbursement from all of the carriers that reimburse you on a percentage of Medicare. When one does the math, it is obvious how important this can be for the future survival of our specialty.
ASIPP has also worked very hard with the AMA-CPT Committee, the RUC Committee, and CMS to ensure continued access for patients to interventional pain management treatments at ambulatory surgical centers, hospitals, and office settings. The organization is responsible for over 40,000 letters and thousands of meetings with legislators and CMS officials. Currently I am working with CMS to resolve problems with pump refill reimbursement, which continues to be an issue in about half of the states in this country. Specifically half the states are receiving such low reimbursement that it does not cover the cost of the drugs, supplies, and staff, and therefore physicians are often refilling pumps at a loss. If this continues this very important treatment modality for those outlier pain patients who have no other treatment alternative will disappear. It is extremely important that we preserve this treatment modality, which although only servicing less than one percent of chronic pain patients, still remains an important treatment modality for those who have failed to respond to conservative measures.

Pain.com: Today physicians are often reluctant to prescribe pain medications due to government scrutiny. What is happening in this area of the political arena?

Dr. Kloth: Physicians today are challenged by their training and beliefs that it is appropriate to prescribe pain medications for their patients, while also feeling like they are under intense scrutiny by the government. It is fairly accepted practice today to use chronic narcotic pain medications for the management of chronic pain. Different physicians feel comfortable with different levels of prescribing, but most physicians do understand the importance of this treatment approach for certain patients. Physicians today are unfortunately being sued when they under-treat pain, but also for over-treating pain. Many physicians also come under scrutiny for prescribing medications to patients who ultimately divert their medications (unbeknownst to the treating physician). Balancing these various factors is extraordinarily difficult.
ASIPP has been lobbying for approximately three years for the passage of a bill called NASPER (National All Substance Prescription Electronic Reporting). This is a program that is modeled after the KASPER program in Kentucky. This would provide the pain physician access to important prescribing information. More specifically, when patients receive controlled scheduled 2, 3, and 4 medications, these would be reported to a central data bank and registered by their social security number. This would prevent the patient from doctor shopping, and thereby hopefully decrease diversion of medications to our streets and decrease controlled substance abuse. If we can get some of the medications out of the hands of the street addicts, we can decrease the poor press regarding these medications, improve the reputation of the pain community, eliminate the negative feeling towards patients who desperately deserve access to these medications and hence improve access. In addition we will save lives by decreasing the number of drug overdoses. In this program the physician will be able to electronically (through a secure internet connection) check their patient’s prescription records to determine if they are getting medications from more than one doctor, and also with new patients determine what they were receiving previously to better aid in their initial assessment. By doing this the clinician can protect themselves from government investigations, and yet also improve the quality of care that they are delivering. Some physicians have raised concerns that this will provide the government another avenue to scrutinize prescribing habits, but the government can already obtain this information if they want. Law enforcement will not have access to these records, except by appropriately obtained subpoenas that must show just cause. Therefore if the physician is operating under the law, using proper prescribing habits, this should not be an issue. As we all know, often it turns out that it is the patient who has done something illegal (i.e., diversion) and not the physician, and the hope is that this will place the burden back on the patient and away from the physician. Others have raised concerns about privacy. This databank will be protected, but there will also be very significant fines for those who violate the privacy safeguards. For instance, if you try to obtain information about a patient who is not yours or who has not granted you permission to access their information (thank you HIPAA), each offense will be subject to a $25,000 fine. This should hopefully prevent others from accessing this information inappropriately. It is our opinion that this bill is extremely important in order to improve the safety of prescribing practices in this country. This bill now has bipartisan support. It has passed the House and it will hopefully come to a vote in the Senate in the lame-duck session this November. For more information on this subject go to www. NASPER.org.

Pain.com: Doctor what about the malpractice crisis? What is going on with that at the National and State level?

Dr. Kloth: Pain physicians are experiencing rapidly escalating malpractice rates in many areas of the country. In some areas, interventional pain physicians are being reclassified as neurosurgeons if they perform intradiscal procedures (IDET or percutaneous discectomy) or even radiofrequency denervations. This will obviously begin to place a significant burden on pain practices due to the high cost of this malpractice insurance. There are pain physicians in this country who are now seeing malpractice premiums of over $100,000 per year. This will ultimately begin to drive physicians out of practice. Unfortunately, despite President Bush’s desire to pass tort reform on a federal level, it is unlikely to get through the US Senate at this juncture due to the heavy bias of the legal community in that chamber of Congress. Malpractice reform has already passed the House on 2-3 occasions, only to be defeated in the Senate. Our best hope for malpractice reform continues to be on a state by state level, and will require active involvement of physicians. Every state points to California’s 1975 MICRA Bill as the standard with which to follow. This comprehensive bill which not only included caps on non-economic damages, but multiple other forms of malpractice reform, has resulted in better malpractice premium controls in the State of California than in other areas of the country. This type of comprehensive malpractice reform must be achieved in other states.

Pain.com: How can a physician get involved on the political level?

Dr. Kloth: This can occur through multiple fronts. Write to your Senators, Congressmen, (both on the State and Federal levels) and Medicare. It is very important for you to develop relationships with your Legislators, both on the State and Federal level. These people are approachable and would like to hear your issues. Write to them, meet with them, talk with them. Unfortunately, it is also important that you donate to their political campaigns, too. While many people have a distaste for this part of the political process, it is how America works today, like it or not. To win the game, you must play the game. The average attorney in this country donates $5,200/year to political campaigns, the average physician $178/year. Do the math, they will not listen to us until we step up to the plate and become a more influential part of the political process. Like it or not this means donating to political campaigns, getting involved on a political level by meeting and talking to our Legislators, and lobbying both on the State and Federal level in order to make our voices heard, not only to protect the future of our specialty, but also to ensure our patients have access to pain management treatments in the future.

Pain.com: Dr. Kloth, thank you for sharing your insights into the political arena.
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