Laxmaiah Manchikanti, MD, is the chairman of the board and CEO of the American Society of Interventional Pain Physicians (ASIPP) and the Society of Interventional Pain Management Surgery Centers (SIPMS); medical director of the Pain Management Center of Paducah (Ky.); and associate clinical professor of anesthesiology and perioperative medicine at the University of Louisville, Kentucky.
Q: What do you see as the top issues facing pain management now?
Dr. Laxmaiah Manchikanti: The top issues facing pain management are different for different specialties, even though they do have some similarities. In broad, general terms, pain management is divided into pain medicine and interventional pain management. While both specialties have substantial similarities, they also have significant differences. In pain medicine, there are providers who focus on utilizing opioids only or cognitive behavioral therapy only; some physicians combine these two and also utilize interventional techniques. Similarly, interventional pain management could be practiced by only utilizing interventional techniques, or with opioids, or with cognitive therapy, or combination of two or three.
Overall, the important issues facing pain management are access and survival. Unfortunately, access may become difficult because of the Affordable Care Act (ACA), despite its being touted as improving access. In my opinion, ACA has empowered private insurers. Multiple organizations, such as the Patient-centered Outcomes Research Institute (PCORI) and the Independent Payment Advisory Board, will introduce restrictions on Medicare with certain safety valves. However, those safety valves do not prevent private insurers and all other government payors, except Medicare, to implement their cost-based regulations. Patient access and the survival of interventional pain management practices will be jeopardized due to reduced reimbursement, increased regulations, and increasing costs.
Evidence-based medicine and comparative effectiveness have been touted as the new phenomenon; however, there is no evidence supporting these regulations, neither from the administration, nor from the private healthcare industry which follows and supports them. The costs of managing a practice are tremendous, with increasing inflation, increasing benefit packages, reducing reimbursement, mandatory requirements of electronic medical records, various quality issues and ICD-10. With the May 14, 2009, administrative regulation, interventional pain management has come under attack with expensive infection control measures, which increase the cost of drugs and wipe away all the differential paid for the procedures for offices, and wipe away all the available profits for surgery centers. Hospitals still do reasonably well with higher reimbursement and whole basket rates.
Q: What do you see as the top issues that pain management will likely face over the next year? Over the next five years?
LM: Over the next year, the issues will remain the same. However, they will be complicated by the strengthening of regulations by the authorities, and private payors attempting to influence further reduce Medicare payments.
Within the next five years, we will see numerous changes, but no more major changes. The major changes that have already been implemented will never be reversed even though they have caused irreversible damage. Unfortunately, repealing ACA now will only result in more deleterious effects. However, its repeal would probably help to reduce the budget deficit.
In the next five years, it is imperative that interventionalists develop appropriate evidence-based principles and apply them to our practices and also to our reimbursements for services.
Q: What do you think will be the key clinical/technological developments likely to shape the specialty? What is the future of pain management?
LM: The clinical and technological developments likely to shape the specialty will be related to evidence-based medicine and making sure the policymakers understand what evidence-based medicine is.
It is essential for all medical groups to stop their in-fighting and support real evidence-based principles. Once the principles are laid out, they should be followed.
Overall, I am hopeful but have guarded optimism for the future of interventional pain management.
Q: Are there any regulatory changes you would like to see made concerning pain management?
LM: I would like to see changes in the application of evidence-based medicine principles and the elimination of bias. So-called non-biased individuals are actually full of bias. Just as interventional pain management is considered biased because we provide these services, others who are employed in these organizations also depend on an income. If they do not provide the opinions insurers want, they will never be used again. Consequently, they will lose all their funding, jobs, etc. Thus, bias exists on all sides, at all levels. This has to change.
PCORI is my major concern. It needs to be eliminated or severely restricted. By the same token, the Agency for Healthcare Research and Quality effectiveness programs and the Institute of Medicine are receiving tremendous amounts of funding; funding which is being wasted. Further, the National Institutes of Health is providing research grants to China and other countries for techniques not even performed in America.
ICD-10 is another problem. This is expected to be implemented Oct. 1, 2013. This is extremely complex, taking a human toll, and very expensive. The bottom line is it does not provide any improvement in coding. It will only negatively affect the reimbursements and increase unnecessary fraud and abuse investigations. It has been estimated that this may cost per physician $25,000-$50,000 to implement, which is a large amount considering the cost complexity, declining reimbursements and lack of its need. The bottom line is this has not even been enacted by Congress. On Jan. 16, 2009, HHS issued a regulation that ICD-10 will be introduced as the HIPAA-named code set. The original language in HIPAA of 1996 required the use of ICD-9, not ICD-10.
We are looking at questioning this authority of the administration to change the Congressional approval.
Q: What excites you most about the specialty right now? What concerns you the most?
LM: The developments in the specialty and the coming together of multiple specialties are exciting issues. Recently, the five specialty groups involved in interventional pain management came together and started a Council of Pain Physician Societies. That is a major achievement.
The major concern is the attack on interventional pain management from inside, as well as outside. All eyes are on interventional pain management. While it is said in general if healthcare growth can be reduced by 1.5 percent, that curve can be bent. In fact, interventional pain management has been reduced much more than that — by 10-14 percent. Even so, the curve is not bending and interventional pain management is under attack. This attack is sometimes justifiable; however, it is extended to a level where it is no longer productive.
Q: What would you like to see more of from ASIPP members?
LM: I would like to see more ASIPP members get involved in the following three processes:
- Ownership: All physicians have to take ownership of their specialty and treat it as their asset.
- Research: Research is crucial for the survival of interventional pain management and its developments into the future. Research has to be increased by at least five-fold to improve survival and meet necessary changes.
- Public relations: Public relations is extremely important as all politics are local. Lobbying is an extremely important phenomenon for the survival of not only ASIPP, but also medicine in general — it is not as dirty as it looks.
Q: What would you say the best pain management physicians are doing now that elevate them above their peers?
LM: The best pain management physicians are constantly providing new literature based on evidence-based principles; providing education to insurers, administration and Congress — though unsuccessfully at times — and donating their resources to prevent further erosion into access issues and working on survival for future.
Learn more about ASIPP and SIPMS.
More Articles Featuring Dr. Laxmaiah Manchikanti:
Impact on Pain Management of the New Outcomes Research Institute: Q&A With Dr. Laxmaiah Manchikanti
70 of the Best Pain Management Physicians in America