There appears to be little question that pain represents a significant American public health problem. A recent Gallup poll reported that an estimated 26 million Americans suffer with severe pain, with half of those reporting daily occurrence. Six in ten Americans with severe or moderate pain have lived with the condition for at least seven months. More than half report poor pain control despite having consulted with physicians. Interestingly, four in five Americans believe that aches and pains are a natural part of getting older, and 64% will see a doctor only when they cannot stand the pain any longer. Fifty-five percent are uncomfortable with the idea of taking medications for pain.1 Why then, in the face of such an obvious need for care, do pain specialists find themselves in such a struggle for survival? While there are numerous reasons, some of which will be detailed elsewhere in this symposium, this paper will focus on managed care and the role it plays in denying access to pain patients.
The social and economic forces that have combined to create the present chaos in American health care are complex. Among those forces was the societal determination that medicine delivered in the old fee-for-service model was becoming too costly, whether it was underwritten by employers, self-paid patients, government, or any other payer source. In this setting, a whole variety of cost-cutting mechanisms began to develop under the rubric of "managed care." According to E. F. X. Hughes, MD, Professor of Business at Northwestern University, managed care is nothing more than the application of standard business practices to the delivery of health care in the tradition of the free enterprise system.2 Managed care organizations that deliver such care (e.g. HMO's and PPO's) are nothing more than expressions of that process. Because there are so many permutations in a constantly changing environment, "managed care" really defies precise definition. It generally refers to any situation where health care is organized and delivered to individuals who are enrolled in health plans (whether that be traditional health insurance, Medicare, Medicaid, Worker's Compensation, etc.), so that more cost-effective and (ideally) high quality care can be accessed and achieved. That is supposed to be accomplished by how the plan influences the selection, utilization of and access to products and services from contracted providers.
It is useful to broadly define two kinds of managed care that exist today: risk-based and non-risk-based.3 In the latter, managed care organizations attempt to coordinate and channel the use of health providers and services to achieve desired success and outcomes while controlling costs. Such techniques as pre-authorization, copayment, utilization management, and the use of select network physicians are common. Providers may be paid under this system in a contractually determined fee-for-service or discounted fee-for-service model, and access to specialists is controlled by the utilization management structures of the plan. In the risk sharing type of managed care, the technique of shifting the burden of controlling costs is operationalized by asking providers to take a capitation fee and/or other incentive arrangements. Within the plan, various providers may be paid in a variety of ways; commonly, the primary care physicians accepting capitation payments while specialists work under a fee-for-service type of arrangement. These two general models of managed care are seen with increasing penetration in all areas of the country and in all payment venues.
The managed care market place is traditionally discussed in the literature as existing in five stages.3 Each stage represents a developmental process with specific markers for each stage. They are as follows:
In this stage, there is almost no managed care. Hospitals and physicians function independently with few if any affiliations or consolidations. Utilization is high, and overuse of inpatient care and over-supply of beds is common. Payment in this system is usually fee-for-service. Managed care organizations account for less than 25% of the insurance market.
In this stage, consolidations and affiliations of hospitals and providers begin. Some forms of discounted fee-for-service and capitation may appear. Purchasers have more options and power. Managed care organizations account for 25-50% of the market.
Recognized consolidated structures such as HMO's and PPO's appear. More risk sharing arrangements, including capitation, occur. Integrated hospital systems and physician-hospital organizations begin. Doctors begin to form multi-specialty and single specialty groups.
Managed care accounts for more than 50% of the market. There is little fee-for-service. A few large coalitions dominate the market. Providers and insurers align. They use the development of networks, often leaving behind solo practice physicians. Specialists' fees drop, and pressure is put on primary care physicians to manage utilization. Pressure is also put on hospitals to lower inpatient utilization and increase outpatient utilization.
Various managed care networks begin to form partnerships with purchasers. Emphasis now focuses on population management. Physicians are asked to assume even more risk.
Developmental stages of managed care vary geographically. Some areas are experiencing a regression from more to less developed managed care systems as health care organizations fail. Resistance on the part of physicians to managed care generally falls with increased maturation.
Many long for the old ways of practice, but Millenson,4 among many others, points out that this "golden age" was not really so golden. While it was true that physicians were free to use their best clinical judgment, and to use unusual or investigational treatments if they thought it was in their patients' best interests, and while patients were free (if they had the requisite financial resources) to choose their own physicians, there were some significant missing ingredients. For example, there were few incentives (the public health sector excepted) for population-based diagnostic testing, preventive care, quality control, or development of outcomes-based medical treatment guidelines. There is ample evidence today that such measures are needed because, left to their own devices, physicians apply their skills with little uniformity. In the field of Pain Medicine, for example, it has been pointed out that there is great ambiguity in highly variable definitions, assessment methods, practice pattern and treatment preferences with respect to musculoskeletal back pain.. There is equally distressing evidence for tremendous variability in utilization of surgery for the treatment of chronic back pain based only on geography.6
Given those kinds of information, there is little reason to believe that this same variability and between-physician reliability in making clinical judgments does not exist for all types of clinical pain practice. Therefore, I believe that it behooves pain specialists to become involved with those medical organizations that are interested in developing the kinds of information that is necessary to bring about less variability in practice patterns and better quality outcomes. The question then arises: Who has the best resources and the most interest in doing so? I would argue that all payer sources, including the federal government, have some degree of interest but are limited not only by available financial and human resources but also by lack of claims information that can help them to even begin to understand the prevalence and cost of the pain problem within their own system. I will discuss that further under the section entitled "Talking with managed care entities." For now, suffice it to say that there is merit and value in dealing with managed care organizations that may also represent the source of payment in order to educate them about your patient's needs.
I believe that only pain specialists, acting through their local and national professional organizations, have the interest and can develop the resources necessary to tackle the problem of pain treatment within our American health care system. Before discussing how, let's first turn to some economic realities.
"Managed care" has evolved as previously discussed because of a perceived need to control costs and quality of health care delivery. That need has been driven by a variety of factors, including an aging population, the development and proliferation of new technologies (both in communication and in health care products), absence of treatment guidelines to ensure more uniformity and delivery of care, and insufficient data on treatment effectiveness. The general feeling about scarcity in available financial resources is coupled with the kinds of attitudes that were previously discussed in the Gallup study, which equally apply to Americans working in the managed care industry as they do to patients. Among these attitudes is that pain is a part of life, will be poorly controlled and will require medical attention only when out of control. It is going to take education of the public and the health care industry at large to realize that this does not have to be. There is a growing cadre of pain specialists that can help to relieve suffering earlier, more effectively, and with more judicious use of resources. The American Academy of Pain Medicine, which has the most vested interest in creating a new public perception about pain, is becoming better organized and may be able to play this important societal role.7
It is foolish to believe that the economic forces shaping the American health care scene operate independently of the global economy. Most of American health care is now underwritten by the federal government or by employers. As the health of the economy goes, so goes the interest and resources to deal with societal issues such as health care. Government officials and business executives will never have the interest that pain specialists do in tackling the public health problem of pain, especially in times of economic stress. It is therefore incumbent upon us, the specialists, to evolve new and creative ways to deal with the problem. For now, that means necessarily interacting with the managed care industry on both an individual level and through our professional organizations.
Largely because of their training and practice patterns, physicians have been generally unsuccessful in organizing themselves for positive action when they are threatened.8 Their efforts to do so have largely been reactionary to the forces of change. Curling up into a fetal position and thinking about the evils of "managed care" serves no useful purpose and alienates medical professionals, even driving them away from their calling. Taking a more proactive stance, on the other hand, requires courage, fortitude, acquisition of knowledge and, above all, a willingness to develop trust and cooperation within the profession.9 It is going to be easier to withstand the buffeting winds of an ever changing managed care world if you are armed with knowledge and united for action.7 Here are some of your options:
(1) Physicians in increasing numbers have been acquiring business and leadership skills not learned in medical school. For example, the American College of Physician Executives, numbering in the thousands and holding a seat in the American Medical Association's house of delegates, represents this new class of professionals, most of whom maintain their interest in clinical medicine by spending at least part of their time in practice.10 PAIN SPECIALISTS SHOULD ALIGN THEMSELVES WITH BUSINESS-ORIENTED DOCTORS AND LEADERS. Some work in the managed care industry and are usually much more accessible than is generally perceived. They often represent your contact point as you attempt to deal with organizations on an individual level. Others have assumed positions of leadership in the medical community or function as consultants to their colleagues. If you do not have time to develop the requisite business skills yourself, use them and learn to trust that the majority of them share your concerns about health care and your ability to survive the current environment.
(2) TAKE THE TIME TO EDUCATE YOUR MANAGED CARE CONTACTS about their exposure to pain. This requires non-billable time on your part. Use information like the Gallup poll that was discussed earlier in pointing out to managed care contacts the unseen problem they likely have within their population, and the needs of your patients and indicate your desire (and it had better be genuine) to work with managed care professionals cooperatively to try to find solutions to helping the needy to access your services without having to sacrifice much of your own income in the process. This is tricky business that is usually best accomplished by aligning yourself with knowledgeable business consultants. Few doctors in private practice have the time or financial resources to do this successfully on their own. The solution? To consider creating/joining networks of either multi-disciplinary or same-specialty physicians who can pool their resources and hire the prerequisite consultants to get the job done.
(3) Along with the need to educate the managed care industry and the practitioner's own medical and lay community come corollary issues: the need to learn how to negotiate managed care contracts, the need to learn how to create value in the mind of the payer for the services that you render, the need to help create outcomes information that is meaningful to both lay and business communities and the need to structure one's own practice, whether it remains solo or in a group, in such a way as to maximize your services and break down the barriers of access to your care for people in pain.7 YOU MUST HIRE BUSINESS CONSULTANTS IF YOU CANNOT ACQUIRE THE SKILLS YOURSELF if you are going to effectively survive the current environment.
(4) Your world has changed right before your eyes. The old fee-for-service model, unencumbered by any kind of oversight, is dead forever. The health care scene will continue to change unless the government steps in (very unlikely in the U.S.) to impose a single payer system. If you are going to be successful, then MAKE A COGNITIVE SWITCH. Realize that population-based disease management (an old public health concept now being revitalized), use of medical treatment guidelines, risk sharing, utilization management, creation of meaningful outcomes measures based on emerging informatics technology and other "managed care" techniques are here in some form for your lifetime. DEAL WITH IT. If you believe, as I do, that change is an opportunity rather than an insurmountable challenge, then rededicate yourself to your profession and to your patients and decide to find ways to continue caring for them in the current environment.
(5) If you have not already done so, JOIN THE AMERICAN ACADEMY OF PAIN MEDICINE. The organization is working very hard to represent Pain Medicine specialists effectively, to develop the necessary human and financial resources to educate the public about the needs of people in pain and to help shape the future of American health care in ways that will allow better ways to access pain specialists. They need your help in becoming part of this worthwhile effort.
Most futurists believe that the current marketplace cannot solve the health care delivery system.11, 8 It is very likely that the system will "re-size" and reconfigure itself in response to true consumer market pressures,12 and we are already seeing that in the form of a vociferous "managed care backlash" in the media and in the halls of Congress. The best that can be said about the future of health care in America is that it is uncertain and that several scenarios are possible.13, 7 This future in part can be successfully changed by the individual and collective efforts of pain specialists who should have the interest of people in pain close to their hearts. It is time to stop complaining and to start acting in keeping with your calling as part of a very special, talented, and dedicated group of physicians.
1. "Pain in America." A research report prepared for Merck. April 2000.
2. Hughes, E. F. X. "Managed care." Address to the Colorado Medical Society; February 18, 1999; Denver, Colo.
3. Tindall, W. N., et al. "Paving the pathway to managed care medicine." An online CME unit from the American College of Managed Care Medicine and the National Association of Managed Care Physicians: http://www.hcmcm.org/CME/Pathway_Course_1.htm. January 2000.
4. Millenson, M. L. Demanding Medical Excellence. Chicago, Ill.: University of Chicago Press; 1997.
5. Chidnall, G. T., Dabney, A., and Tait, R. C. "Internist judgments of chronic low back pain." Pain Medicine 1 (3) 2000. (In print)
6. Wenneberg, J. E. "Practice variations and challenge to leadership." Spine 21: 1472-1478, 1996.
7. Stieg, R. L. "Financing the treatment of chronic pain: Models for risk sharing among pain medicine physicians, health care payers, and consumers." Pain Medicine 1 (1) 78-88, 2000.
8. Van Amerongen, D. Networks and the future of medical practice. Chicago, Ill.: Health Administration Press; 1998.
9. Gosfield, A. G. Quality and clinical culture: The clinical role of physicians in accountable health care organizations. Chicago, Ill.: American Medical Association; 1998.
10. Moff, T. "The New Breed." Physician Exec 23 (8) 31-36, 1997
11. Relman, A. S. "The future of medical practice." Physician Exec 22 (1): 23-25, 1996.
12. Herzlinger, R. Market Driven Health Care. Redding, Pa.: Perseus Books; 1997.
13. Coddington, D. C., Moore, G. P., Fischer, E. A., and Clarke, R. L. Four health care scenarios. Beyond managed care: Financing and marketplace scenarios for the new millennium. Philadelphia, Pa.: McGraw-Hill; 2000.
Dr. Richard Stieg is board certified in Neurology, Pain Medicine, and Addiction Medicine. He is a founding member and tenth President of the American Academy of Pain Medicine. He has also served the American Pain Society in various board capacities and as co-founder of their journal, Pain Forum.
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