Transcript Academic Pain Medicine

Academic Pain Medicine
Rafael Miguel, M.D.
Professor and Chairman
Program Director, Pain Medicine
Department of Anesthesiology
University of South Florida
Tampa, Florida
Development of Pain Medicine
• Ralph Waters, MD: “the relief of pain is purchased
at a price” (1936)
• John Bonica, MD
– Began multidisciplinary pain care as Chief of
Anesthesiology at Madigan Army Hospital during WWII
– 1953: “The Management of Pain”
– 1960: Joined UW Faculty
– 1974: Founded International Association for the Study
of Pain
– 1975: Pain
Increased opioid use
• History of pain undertreatment
– Opioids are effective, possess no organ toxicity
– Recognition of addiction realities
• 1986: Foley and Portenoy promoted opioids
for non-cancer pain
• 1994-1997: DCA/Supreme Court ruling on
euthanasia
• 1997: Federation of State Medical Board
pain guidelines
Oral Opioids
• Morphine
– Short acting: morphine, MS-IR
– Long acting: MS-Contin, Ora-Morph, Kadian,
Avinza
• Oxy/hydrocodone
– Short acting: OxyFast, Percocet/-dan, Roxicet,
Tylox, Percolone, Vicodin, Lorcet, Vicoprofen, etc
– Long acting: Oxycontin
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Oxymorphone: long acting (pending)
Hydromorphone: Dilaudid
Fentanyl: Actiq (OTFC)
Methadone
Other opioid delivery systems
• Transdermal fentanyl: Duragesic, Ionsys
(pending)
• Epidural morphine: Duramorph,
Astramorph, DepoDerm (pending)
• Implantable spinal infusion pumps
• Externalized pumps
• Implanted sufentanil pellets (?)
• Mist carfentanil (limited to veterinary and
terrorist situations)
Adjuvant pain medications
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NSAID’s
Adrenergic antidepressants
Anticonvulsants
α2-agonists
Muscle relaxants
Local anesthetics
– Oral
– Topical
– Spinal
– Neural blockade
Advantage of Anesthesiologist
as Pain Physician
• vs. Neurologist: anatomy of neural
blockade, knowledge of local anesthetics,
resuscitation
• vs. Physiatrist: knowledge of pharmacology
and CV/Resp physiology, PM&R pain training
limited to spine, resuscitation
• vs. Psychiatrist: very limited scope of
training, no knowledge of anatomy,
procedures?, resuscitation
Interventional therapy
• Sympathetic
– Diagnostic
– Therapeutic
– Neurolytic
• Steroid injections
• Implantation technology
– Intrathecal pumps
– Neuromodulation
• Spinal cord stimulation
• Peripheral nerve stimulation
• Minimally invasive spine procedures
– Vertebro/kyphoplasty
– Percutaneous Disc Decompression (PDD)
“Every thing I do is to help you
avoid surgery”
Types of PDD
• Laser disc decompression (LASE®)
• Intradiscal electrothermy (IDET®)
• Intradiscal coblation® therapy
(Nucleoplasty®)
• Mechanical nuclear removal
(DeKompressor®)
Checking Nucleoplasty Spine-Wand placement prior to activating
Pain Societies
• American Society of Regional Anesthesia and Pain
Medicine (ASRAPM)
– AAPPD
– Spring and Fall meetings
• American Pain Society (APS)
• International Association for the Study of Pain
(IASP)
– Didactic curriculum
• American Academy of Pain Medicine
– ABPM
• American Academy of Pain Management
• American Society of Interventional Pain Physicians
• International Spine Injection Society (ISIS)
American Society of
Interventional Pain Physicians
(ASIPP)
– “The voice of interventional pain management”
– “To promote the development and practice of
safe, high quality, cost-effective interventional
pain management techniques for the diagnosis
and treatment of pain and related disorders,
and to ensure patient access to these
interventions”
– Instrumental in getting CMS to designate
“Interventional Pain Management” as a
specialty designation
International Spine Injection Society
(ISIS)
• The International Spinal Injection Society is an
association of physicians interested in the
development, implementation and standardization
of percutaneous techniques for the precision
diagnosis of spinal pain. By constituting a forum
for the exchange of ideas, by undertaking
research, and by holding public lectures, the
association seeks to consolidate developments in
diagnostic needle procedures, to identify and
resolve persisting controversies, to publicize
developments, and to recommend standards of
practice based on scientific data.
Anybody else?
American Society of
Anesthesiologists (ASA)
• Late entry
• Anesthesiology pain physicians feel ASA
was not interested in their needs
– Educational
– Legislative
– Financial
• Significant recent efforts
Training Programs
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Numbers of Programs
Numbers of Trainees
Accreditation
BC rate
Pain Medicine Training Programs
• ACGME accredited PM Training Programs:
– 97 Anesthesiology
– 8 Physical Medicine and Rehabilitation
– 1 Neurology
– 0 Psychiatry
Training Programs
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Numbers of Programs
Numbers of Trainees
Accreditation
BC rate
Numbers of trainees
• Anesthesiology-PM positions 303/272
filled
– Approximately 15% filled with nonanesthesiologists
• PM&R-PM positions 16/17 filled
• Neurology-PM positions 1/1 filled
Board Certifications
• ABA-PM (ABMS)
– Neurology/Psychiatry
• Any ABMS BC physician: “have appropriate
training in pain medicine”
– Physical Medicine and Rehabilitation
• ABPM
• American Academy of Pain Management
• World Institute of Pain
(interventional/international)
Types of Pain Medicine practices
• Private
– Office-based
• Consults and
procedures
– Hospital consults
– Acute Pain
• University
– Hospital based
• Procedures
– Hospital consults
– Acute Pain
– Office-based
Private Pain Medical Practice
• Solo
• Multispecialty group
• Single group specialty
– Neurosurgery
– Orthopedics
– Interest in PM&R PM physicians
Survey of U.S. Anesthesiologist Salaries
in the Overall Marketplace in 2003.
$800,000.00
$600,000.00
Anesthesiologists - General
$400,000.00
Anesthesiologists - Pain Medicine
$200,000.00
$Years 1-2
Maximum
SOURCE: Allied Physicians, Inc., Los Angeles Times and Rand McNally *Updated August 25, 2003
P. Staats: SAAC, 2003
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Pain Medicine office start-up
costs
Refurbishing
– Allowance from lessor
• Procedure Room vs. OR
– Licensed surgery center
• Back-up power ($10-20k)
• Emergency call system ($1-2k)
• Defibrillator ($2-3k)
• Rent ($15-25/sf/year)
• Personnel (minimum)
– Nurse
– Billing front office
• Billing company 4-7%
– Medical assistant
• Dictation costs
– $0.06-0.1/line
Pain Medicine office start-up
costs (cont.)
• Equipment
– Fluoroscopy C-arm
– RFA machine
– Crash Cart
$85-120k new
$22-30k new
$6k
• Supplies
– Block/Epidural kits
– Medications
• Steroids: Depo-Medrol
• Contrast:Omnipaque-300
$15-25/each
$10/40mg
$21/10ml
– About $35/procedure in supply costs
Actual Office/ASC
• 4000sf SE-USA suburban facility in new
medical office building
• 3 exam rooms
– 3 OR prep rooms
– 3 PACU bays (rare sedation)
– Chaise Phase II area
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C-Arm, RFA
Preprinted procedure forms
240 procedures/month (15/d x 4 days/week)
6 FTE
Actual office/ASC
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Legal/architectural fees: $60k
Buildout $131k + $37/sf allowance = $279k
Rent $21sf/yr
Sterilizer = $3k
Miscellaneous
– Copying $500/month
– Equipment costs = $3600/month
– Medication/contrast/needle/sterile gloves = $2400/month
• Insurance (property, umbrella) = $200/month
• Laundry = $200/month
• 50% overhead
– Minimum 70 blocks/month
Particularities of private
office pain practice
• No salary while building practice
– Multiple sites
– Who pays off the loans?
– Great personal cost
• Payor mix
• Lack of call support
• “Schmooze” factor
Academic pain practice
• Practice scenarios vary
– Pure Pain Medicine
• Clinic space (per patient surcharge +/- Clinic tax)
• Hospital (usually free or nominal charge)
• Office
– Pain Medicine + Anesthesiology
• Earn while building practice
– Department shoulders all costs
– Little personal investment
• Less control over payor mix
• Teaching/Research
• What? Me worry?
Pain Medicine and Anesthesiology:
Oil and Water? Or Do They Mix?
ASA Newsletter August 2004
PRO (Rathmell)
CON (Deer)
• This Is a Democratic Group, • Different as Night and
Right? (“Let’s Vote on It.”)
Day.
• Is the Work Equivalent?
• The Paper Chase.
(“You’re Goofing Off in the
• Communication
Pain Clinic, While I’m
Breakdown.
Working Hard.”)
• Are We Equally Productive?
(“I Should Be Paid More
Than You.”)
• Can Clinicians Effectively
Master Both Pain and O.R.
Practice?
• Can We Be Expected
to Share Call?
Academic pain practice
• Practice scenarios vary
– Pure Pain Medicine
• Clinic space (per patient surcharge)
• Hospital (usually free or nominal charge)
• Office
– Pain Medicine + Anesthesiology
• Earn while building practice
– Department shoulders all costs
– Little personal investment
• Less control over payor mix
• Teaching/Research: a good thing
Compensation/Incentive Plans
• Based on:
– Academic productivity
– Financial productivity
• Charges vs. collections
– Different for Pain Physician?
– Institution doesn’t need pain program
• Reward:
– Money
– Time
– ???
CPT
Charge MCR
MCD MCO
99201
NP/Straight
50
23
31
33
99203
99205
99211
99213
99215
99201
99203
99205
99211
99213
99215
NP/Low
NP/High
EP/Minimal
EP/Low
EP/High
NP/Straight
NP/Low
NP/High
EP/Minimal
EP/Low
EP/High
154
301
19
76
200
78
206
369
46
113
255
72
140
9
35
93
35
95
170
21
52
117
49
87
12
27
60
21
49
87
13
27
60
84
175
20
49
119
40
106
192
23
58
124
Black = Facility Charge
Red = Office Charge
Figures in $
Florida Academy of Pain Medicine:
2004 Survey on Practice Patterns
• Anesthesiologists: 24, Neurologists: 1,
PM&R: 3, PSY: 1, FP: 1
• Board certified? A: 65%, PM&R: 66%, N:
100%, FP: 100%
• BC in Pain Medicine? A: 45%, PM&R: 33%,
N: 100%, FP: 0
Florida Academy of Pain Medicine:
2004 Survey on Practice Patterns
Office visits/d
Average
20.6/13.5
Range
4-40
OV days/week
4/3.5
2.5-5
Procedures/d
13.6/7
5-30
Procedure days/wk
3/1.5
2-5
Procedures/wk
40/13
10-100
Own Fluoro?
Yes = 13
No = 7
Own RFA?
Yes = 11
No = 9
ASC financial
interest?
Yes = 8
No = 7
Accept Medicaid?
Yes = 2/4
No = 24
Academic Pain Physicians
Summary
• Pain Medicine is a natural extension of
Anesthesiology
• Being an Anesthesiologist provides an “edge”
• Integration with Department of
Anesthesiology is necessary and requires
patient understanding
• Academic Pain Medicine physicians warrant
different incentive considerations but need to
understand financial responsibility