Declining Value of Work of Interventional Pain Physicians

Abstract

threats for facets, epidurals, and spinal cord stimulation (1); certified registered nurse anesthetists (CRNAs) entering the full arena of interventional pain management (2-4); Center for Disease control supported single-dose vial policy being created without products to reasonably support it (5); Food and Drug Administration (FDA) regulating procedural standards of interventional techniques; Noridian led local coverage determinations (LCDs) prepared by Multi-Specialty Pain Workgroup (MPW) (6-8); threatened cuts of cervical epidural injections and facet joint interventions in Tennessee (9,10); empowered insurers limiting interventional pain management (IPM) services (11); usual sustained growth rate (SGR) cut fiasco (12,13); and finally the Thanksgiving gift of draconian cuts for epidural injections amounting to 33% for cervical epidural when in a facility and 56% when performed in a physicians office, and 19% for lumbar interlaminar epidural injection in a facility setting for physician fee and 49% when performed in a physicians office (14). Thus, CMS determined the work value of highly trained and skilled IPM physicians to be a whopping $42 to assess a patient preoperatively, to perform a high risk procedure of cervical epidural injection, and follow post-operatively for next 24 hours. There were successes to match these challenges. Facet joints are not on a national coverage determination (NCD) list. We provided our opinions to the FDA and they are considering them on performance of interventional procedures; the Government Accountability Office (GAO) has started a study to assess if, in fact, CRNAs are qualified to perform interventional techniques (15,16); creation of a group purchasing organization (GPO) with Henry Schein (17); published evidence-based guidelines for interventional techniques listed on Agency for Healthcare Research and Quality’s (AHRQ) National Guideline Clearinghouse (NGC) website (18); reversal of noncoverage decision on cervical epidurals and facet joint interventions in Tennessee (19,20); continuing negotiations with Cigna with evidence submission signed by 684 physicians (21); progress in negotiations with Noridian to revise LCDs based on evidence and reasonable and medically necessary; and finally with a 3 month fix for proposed 24% SGR cut (22). The above referenced challenges have led some to enter 2014 with lackluster enthusiasm, frustration, and dismay. Issues continue, most importantly draconian cuts proposed by the Centers for Medicare and Medicaid Services (CMS) for lumbar and cervical interlaminar epidural injections CPT 62310 and CPT 62311 with a physician payment of $42 for preoperative assessment, performance of the procedure intraoperatively, and post operative management. It is true a physician’s work is valued at $42 or 1.18 or 1.17 physician relative value units (RVUs) by CMS. A national rate of physician reimbursement is $72.72 when performed for each procedure in a facility setting and $108.90 for cervical epidural and $110.69 for lumbar epidural when performed in an office setting. Using simple arithmetic, the reimbursement has dropped to $36 for Health Policy Opinion