Scott Glaser, MD, is a director on the national board of the American Society of Interventional Pain Physicians, where he has also served as vice president. He is heavily involved with the group’s lobbying and advocacy efforts for the practice of interventional pain management, and here he discusses the field’s most pressing issues and problems.
Q: What has been the focus of ASIPP’s advocacy efforts this year?
Dr. Scott Glaser: The main focus of our legal efforts this year has been fighting recent actions by the Centers for Medicare & Medicaid that are classic bureaucratic decisions made in a vacuum without knowledge of consequences. CMS is stating that we need to use single dose vial for each patient of all medications we inject, including steroids, contrast, and local anesthesia. They are doing this based on a few anecdotal reports of infections following injections. There is no science behind this. It is an inappropriate, over-reaching governmental response to a problem. In each of the anecdotal cases, there was evidence that appropriate sterile technique was not followed. The complications were terrible, but there is no evidence that using single dose vials would have prevented those cases. Also, there is no supportive scientific evidence that using a single dose vial will prevent infection. It is just not in the literature. In the anecdotal cases that have led to this recommendation, infections are just as likely to have occurred had single dose vials been utilized. Lastly, there is no evidence that single dose vials which are used in multiple patients are a cause of infection, if you use the proper infection control. It is really an insult to physicians and nurses who have been performing these procedures for years using safe technique.
Q: What problems could result from this regulation?
SG: This practice of using only single dose vials for each patient will lead to a shortage of drugs that are already in short supply. It will lead to incredible waste. The contrast is bio hazardous and more of it will be thrown away. The greatest consequence will be a reduction in access to care secondary to the cost of supplies. The estimated cost of implementing this will be each procedure costs $80 more, and that is a huge number. This will lead many practices to stop performing these procedures and many ASCs and hospital outpatient departments to disallow them thereby reducing access to care.
Q: What are you and ASIPP doing to fight the regulation?
SG: We are educating our legislators. Many have already written letters or signed on to letters to CMS stating this is a bureaucratic error where they don’t understand the whole situation. Prior to making this decision CMS consulted an infectious disease group and some other parties but they didn’t consult people actually doing the procedures. Hopefully that decision will be overturned.
Q: What are other pressing issues in the pain management field?
SG: Another significant issue for us right now deals with certified registered nurse anesthetists. CMS in the affordable healthcare act is proposing a policy where CRNAs would be reimbursed and allowed to perform interventional pain management procedures. We strongly oppose this. The practice of interventional pain management is the practice of medicine and should only be practiced by appropriately trained physicians. The training for a CRNA does not include any training in pain management. Their schooling consists of providing anesthesia IV sedation for surgical and other procedures. There is no formal training of any kind regarding the diagnosis and treatment of patients suffering chronic pain. There is also no formal training regarding the provision of interventional procedures for chronic pain using diagnostic and therapeutic image guided interventional techniques, which have significant risks that are materially different than the risks of procedures used to provide anesthesia in the OR. Even in well trained and experienced hands severe complications continue to occur because of the nature of this field.
Q: What do you think is the reason for this ruling?
SG: They are basing the reasoning on two flawed ideas or assumptions. They think it will save money because nurses are treating patients, not doctors, when actually it will have the opposite effect. If CRNAs will be allowed to bill, they will bill the same amount physicians do for consults and procedures. There is no special fee schedule for nurses. With more procedures on more patients that will increase the cost of care. It’s also based on the flawed assumption that there is a lack of access to care for pain management procedures. We have no evidence of that. In Illinois they’ve done studies that show the farthest drive is 75 miles for access to pain management services provided by a physician.
Lastly, the treatment of chronic pain with opioids and other controlled substance by inadequately trained doctors has led to an epidemic of prescription drug abuse and accidental poisoning. The training of CRNAs does not include training in this complex area and will expose chronic pain patients to more providers without the appropriate knowledge and training to treat them with the powerful medications. This will further exacerbate this already tragic problem.
Q: What problems do you see with the practice?
SG: This practice raises several concerns. One is public safety. These procedures are minimally invasive but they are maximally dangerous. The number of people becoming quadriplegic or dying is increasing even when they are performed by doctors who are specifically trained in interventional pain management. In other words, if these complications may occur to a well trained doctor, then one can only imagine the increased incidence with inadequately trained CRNAs. It is truly a frightening concept to those of us practicing and board certified in interventional pain management.
Two, it’s a fraud and abuse issue. Pain management issues are already tainted because they are over utilized by some members of the medical profession. Fraud will only get worse when more providers are reimbursed for these procedures. This is especially true when those providers are untrained and don’t have the knowledge to perform the procedures in the appropriate algorithmic fashion get the maximum benefit. Lastly, the treatment of pain with opioids by physicians not trained appropriately has led to an epidemic of prescription drug abuse and accidental poisoning. This phenomenon will only be exacerbated by allowing another group of providers without appropriate training to provide and be reimbursed for the treatment of chronic pain.
Q: Have you made any progress in contesting the decision?
SG: The provision of these services will be decided on a state-by-state basis. There was a court case in Louisiana in which ASIPP and specifically current president Dr. Frank Falco and CEO Dr. Lax Manchikant was intimately involved and gave direct testimony which set an important precedent. The judge declared after long trial that CRNAs could not practice pain management and that interventional pain management was the practice of medicine. In addition, ASIPP members across the country are actively involved in educating their legislators about this issue.
Q: What other advocacy actions are you currently taking?
SG: The biggest thing was the ASIPP yearly meeting in June. After our scientific meeting, we had visits arranged with legislators from every state represented by interventional pain management physician. This issue was one of the specific issues we discussed with the legislators and their aides. We also have a letter writing campaign for many of our offices. We and our staff send letters to legislators, and we instruct our patients about these issues and have patients send letters as well. We support our leadership at ASIPP who are talking to legislators more often. The fact is, when it comes to some of these issues, we can’t go straight to CMS; we have to inform a legislator who then brings it to CMS’ attention to get it changed. Importantly, more and more legislators are being elected to Congress who have medical backgrounds. The legislators and the aides who are the most helpful, who really get it and understand the gravity of the issues, and who take an interest in pain management, have family members or friends who have required the services of a pain management doctor. They realize being a physician and being in pain management is extremely difficult these days. They understand the importance of training in the provision of these services, and they are grateful for what interventional pain management physicians do.