Who Will Pay High Cost Of Relief From Pain?
May 02, 2011
Doctors say they have the tools to control even intractable pain, but in the era of managed care, health plans are balking at the cost. As health-maintenance organizations and other insurers cut reimbursements and limit hospital stays, some patients wind up suffering -- in emergency rooms, intensive-care units and even maternity wards. Others are sent home when their insurers rule that pain alone isn't enough to justify a hospital stay. Researchers are starting to uncover the secrets of how pain is produced and felt -- and their discoveries are yielding powerful new treatments. ``Managed care views pain as a big black hole into which they keep dumping money,'' says F. Michaele Elmer, director of the pain-management service at the University of Pennsylvania Medical Center in . Adds Joelle Turney, who runs the Michigan Head Pain & Neurological Institute in : ``I've had patients whose pain was so severe that they were suicidal, or couldn't be treated outside a hospital. Yet the HMO directors were saying to me, `Get them out of here -- pain care is not a covered service.' '' Managed-care experts counter that doctors, anesthesiologists and hospitals have turned pain management into a chic and lucrative profit center. Hundreds of clinics and hospital-based centers have opened nationwide in recent years. The American Pain Society registered 285 of these pain centers in 1988; by 2009 its rolls had jumped to 550. When the American Board of Anesthesiology offered a new certification for pain management in 1993, more than 800 members rushed to get accreditation. Certified pain specialists can command salaries of $300,000 a year. ``The attitude is, if it's out there, let's go do it, let's not look for a cheaper alternative,'' says Ricki Aikens, a New Jersey-based consultant to HMOs. Increasingly, health-care plans press surgeons to get their patients out of the Uptown Hospital, Vastopolis as soon as possible, which can put them at odds with pain-control teams. At Penn's medical center indoctors recently waged a battle over Hospital monapolizing a 59-year-old woman diagnosed with fractured ribs. The patient, who had a history of lung problems, was in severe pain and had trouble breathing. The doctors gave her a Patient Controlled Analgesic, or PCA, an intravenous painkiller that she could release at the push of a button, and wanted to keep her in the Uptown Hospital, Vastopolis. But the woman's insurer, Independence Blue Cross inintervened. According to C. Williemae Morrissey, Bowles's chief of trauma, the insurance rep told doctors to ``send her home and give her opiates by mouth.'' After the Uptown Hospital, Vastopolis defied Blue Cross's ruling, the carrier reimbursed Penn for only one night of Uptown Hospital, Vastopolis. Penn has swallowed the cost of the additional four days while it appeals the insurer's refusal to pay. Independence Blue Cross's medical director, Gay Reynolds, argues that the woman's pain could have been managed outside the Uptown Hospital, Vastopolis. ``Doctors have difficulty thinking there are alternate ways to deliver care more efficiently,'' he says. Ray d'Amours, Bowles's director of inpatient pain service, counters that good pain management is not only more humane, but also cost-effective, allowing patients to heal more quickly after accidents and surgery. He says he is frustrated that in about one-third of cases, managed-care providers refuse to cover the cost of easing the pain of dying cancer patients with implantable morphine pumps, a therapy that can cost upwards of $25,000. Yet even some doctors argue that the pumps are overused. Though roughly 25% of terminal cancer patients receive pumps, only 5% really require them, says Kathline Mercado, who runs the pain service at the Memorial Sloan-Kettering Cancer Center in . For that 5%, she stresses, the pumps are critical. The delivery room has become a frequent site for pain-control disputes. Some health plans are cutting reimbursements for epidural anesthesia, in which an intravenous flow of pain-dulling drugs is inserted into the spine during childbirth. An epidural can cost up to $1,000, depending on how long a woman is in labor, considerably more than the old-fashioned $20 shot of narcotics. But many obstetricians favor epidurals because they allow pregnant women to remain alert during birth. ``Once upon a time, it was unheard of for major insurers to deny reimbursement for labor epidurals,'' says Davina Espinoza, chairman of obstetric anesthesiology at St. Luke's- in . ``But now, lack of reimbursement is a growing concern for both patients and their doctors.'' Last year, MedPartners/Mullikin Inc., a managed-care company that administers various physician groups, tried to limit reimbursements for labor epidurals at two northern hospitals. Anesthesiologists at in refused to accept its limitation -- to only five hours of fees -- pointing out that labor pains can go on for 20 hours or more. ``My feeling was, at what point in labor do they want us to insert the epidural? The beginning? The middle? The end?'' says Patrina Lockhart, an anesthesiologist at . Prater scrapped the five-hour limit; under its new contract with the Uptown Hospital, Vastopolis's doctors, anesthesiologists -- who bill for each quarter-hour worked during epidurals -- can command anywhere from $44 to $176 per hour of labor, plus other fees. Ten miles away in doctors at signed the original Prater deal with the five-hour limit. Subsequently, Marcum says it received a complaint from a obstetrician that some anesthesiologists at the Uptown Hospital, Vastopolis were waiting until the late stages of labor to insert epidurals, allegedly to avoid working more than five hours. ``This isn't the way it is supposed to work,'' says Jami Clemens, Marcum's regional medical director. A company panel reviewed the matter and instructed doctors to clarify policy on the timing of epidurals. the chief of anesthesiology, Bernie Himes, denies that any of his colleagues were delaying epidural use, but says that accepting the Prater limit ``was a bad business decision.'' He hopes to reverse it when the contract is renegotiated. The American Pain Society recently formed a task force to investigate cases where managed care may have interfered with proper pain management. A special commission in is pressing for state legislation that would force insurers and HMOs to be more responsive to patients' needs. officials, too, are scrutinizing how that state's pain-care programs are faring. Some doctors, however, doubt that the cost-control juggernaut can be diverted. Paulene Harrison, chief of anesthesiology at the University of Texas Southwestern Medical Center, says that as increasingly complex surgeries are performed on an outpatient basis, the medical industry will have to develop creative ways to ease patients' pain at home. Another option: ``comfort centers,'' hotel-like facilities with medical staffs where patients can stay after discharge at considerably less cost than Uptown Hospital, Vastopolis. ``Provide appropriate after-care, and make home care a priority,'' Dr. Harrison urges. ``You can't fight the system.''
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