SUMMER 2007 - American Society Of Interventional Pain Physicians

Transcription

SUMMER 2007
“Coming together is a beginning. Keeping together is progress.
Working together is success.”
Henry Ford
On behalf of current president, Vijay Singh, MD, and incoming president, Andrea Trescot, MD, and
the distinguished board of directors of ASIPP and SIPMS, it is my distinct pleasure and honor to invite
you to attend the one meeting this year you won’t want to miss. —Laxmaiah Manchikanti, MD
The ninth Annual Meeting of ASIPP and second
Annual Meeting of SIPMS, June 23-27, 2007, will offer
didactics, politics, networking, and fun. I would like
to invite each and every member of the organization to
attend this pinnacle meeting and to take an active role
in the preservation of our specialty, not only for us,
but for our children, grandchildren, great-grandchildren and beyond that. Here are some of the highlights
you can focus on in your June visit with your family,
friends and colleagues.
SIPMS Annual Meeting
The second Society of Interventional Pain Management Centers (SIMPS) annual meeting will be held on
Saturday, June 23. The presentations include the development of an ASC for interventional pain management,
HOPD-based ASC payments and its impact and strategies for survival, key processes to improve effectiveness
and profitability of an ASC, selecting a practice setting
and practice software, economics of implantable therapy in ASC, choosing a practice location between ASC,
office and an HOPD, followed by SIPMS business and
elections. All of which are extremely important issues,
whether you are in training, just starting a new practice,
or have been in practice for several years. The lectures
are provided by world renowned speakers who work on
these issues on a daily basis.
Ethics Seminar
In response to numerous requests from our membership, the ASIPP Board of Directors has decided to
provide you with an ethics seminar providing three
hours of credit. The seminar will be held in the evening of Saturday, June 23, from 7-10pm. This is a
first-time event in our nine-year history. We believe
you will find the ethics seminar to be comprehensive
and understandable with an abundance of information for daily use.
This seminar is provided by James Giordano,
PhD, Scholar in Residence, Center for Clinical
Bioethics and Associate Professor at Georgetown
University Medical Center; Victor Sierpina, MD,
professor, Integrative and Family Medicine, University of Texas Medical Branch at Galveston, TX; and
our own Mark V. Boswell, MD, PhD, Professor of
Anesthesiology, Department Chair and Director of
the Messer Racz Pain Center at Texas Tech University in Lubbock, TX, Editor-in-Chief of Pain
Physician, and Executive Director of the American
Board of Interventional Pain Physicians.
This is an extremely affordable session with a registration fee of $100 for physicians, $50 for fellows or residents and $25 for medical students.
(You’re Invited, continued on p. 6)
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(Formerly Pain Physician News)
is a publication of the
American Society of
Interventional Pain Physicians ®
81 Lakeview Drive, Paducah, Kentucky 42001
(270) 554-9412
Fax: (270) 554-5394
E-Mail: asipp@asipp.org
Web Site: www.asipp.org
CHIEF EXECUTIVE OFFICER
Laxmaiah Manchikanti, MD—Paducah, KY
OFFICERS
President
Vijay Singh, MD—Niagara, WI
American Society of Interventional Pain Physicians®
inside…
From the CEO
You’re Invited: Annual Meetings and Capitol Hill Visits ..........................1
Laxmaiah Manchikanti, MD
President-Elect
Andrea M. Trescot, MD—Orange Park, FL
From the President
…And The New Challenges Keep Coming ................................................4
Vijay Singh, MD
Executive Vice President
David M. Schultz, MD—Minneapolis, MN
Membership News ............................................................................................9
Vice President – Strategic Planning
Elmer E. Dunbar, MD—Louisville, KY
Vice President – Financial Affairs
Hans C. Hansen, MD—Conover, NC
Secretary
Ramsin M. Benyamin, MD—Bloomington, IL
Treasurer
Frank J. Falco, MD—Newark, DE
LIFETIME DIRECTORS
Cyrus E. Bakhit, MD—Roanoke, VA
Laxmaiah Manchikanti, MD—Paducah, KY
Bentley A. Ogoke, MD—Springfield, MA
Vijay Singh, MD—Niagara, WI
DIRECTORS AT LARGE
Salahadin Abdi, MD, PhD—Boston, MA
Sairam Atluri, MD—Loveland, OH
Aaron K. Calodney, MD—Tyler, TX
Roger C. Cicala, MD—Memphis, TN
Standiford Helm II, MD—Mission Viejo, CA
Joseph F. Jasper, MD—Tacoma, WA
Arthur E. Jordan, MD—Myrtle Beach, SC
W. Stephen Minore, MD—Loves Park, IL
Allan T. Parr, MD—Covington, LA
Praveen K. Suchdev, MD—Nashua, NH
John R. Swicegood, MD—Fort Smith, AR
Kenneth G. Varley, MD—Birmingham, AL
DIRECTORS EMERITUS
Joseph D. Fortin, DO—Fort Wayne, IN
Gabor B. Racz, MD—Lubbock, TX
ASIPP Responses
Response: Facts and Fallacies of ...............................................................12
Chronic Back Pain and Opioid Treatment
Response: Use of Epidural Steroid Injections...........................................13
to Treat Radicular Lumbosacral Pain
Health Policy Review
Abstract: National Drug Control Policy ..................................................14
and Prescription Drug Abuse: Facts and Fallacies
Legislative Update 2007
Physician Payment Reform .......................................................................16
Ambulatory Surgery Centers ....................................................................20
NASPER .....................................................................................................22
Making Your Voice Heard . .......................................................................24
Senator Tim Hutchinson
PAIN PHYSICIAN EDITOR-IN-CHIEF
Mark V. Boswell, MD, PhD—Lubbock, TX
April 2007 Orlando Comprehensive Review Course Photos ...........................26
AMA DELEGATES
W. Stephen Minore, MD
David S. Kloth, MD
Reimbursement
Will I Be Paid for Percutaneous Intradiscal ............................................29
Electrotheral Annuloplasty?
Marvel Hammer, RN, CPC and Joanne Mehmert, CPC
STAFF
Melinda Martin, Director of Operations
Ray Lane, Director of Education & Public Relations
Holly Long, Coordinator of Editorial Services
Victoria Caldwell, Graphic Designer
Wendy Parker, Technical Editor
Government Affairs Counsel
Senator Tim Hutchinson and
Randi Hutchinson, Esq.
Dickstein Shapiro Morin & Oshinsky
Kathy M. Kulkarni, The Monument Group
Washington, DC
General Counsel
Allison Shuren, MSN, JD
Arent Fox, PLLC
1050 Connecticut Avenue NW
Washington, DC
News Briefs .....................................................................................................32
Advocacy
House of Representatives Letter to CMS . ................................................36
Senator Jim Bunning Letter to CMS ....................................................... 42
Senators Sherrod Brown and David Vitter Letter to CMS ......................43
NASPER Update ........................................................................................... 44
Interventional Techniques in Chronic Spinal Pain Order Form.......................... 46
From the President
…And The New Challenges Keep Coming
Vijay Singh, MD
I
n the new millennium, Interventional Pain Management (IPM)
has emerged as a recognized specialty. Even so, IPM still faces obstacles and is constantly under attack.
Those of us who have studied this field
closely and understand it clearly, realize how important it is to save the art
and science of IPM for the next generation. There are individuals who use
pseudoscience and try to rationalize it
as a science and by doing so hamper
the efforts of ASIPP in preserving and
advancing the field of IPM. You can
help the specialty of IPM and ASIPP
by contributing to the scientific literature, writing case reports and conducting CME lectures for colleagues
in your area.
Pain Physician, ASIPP’s journal,
is now readily available both in print
and online. The journal is listed in
Excerpta Medica, EMBASE, Index
Medicus, MEDLINE, and PubMed.
The journal is now available bimonthly and is quickly becoming one
of the most widely used and trusted
sources of information.
ASIPP also hosts a variety of continuing education lectures and cadaver
courses many times throughout the
year. These are just some examples of
the efforts made by ASIPP to educate
fellow Interventional Pain Physicians.
The society is continually providing a
forum for discussion of difficult cases
and new ideas.
We need to continue our efforts
to educate the public, the media and
other fellow physicians. ASIPP leadership has worked diligently to bring
the information to the forefront and
readily available for everyone. The
founder of ASIPP, Dr. Laxmaiah
Manchikanti, has inspired all of us.
No one can deny his tireless efforts
for the specialty of IPM and we are
comforted by his presence at the helm
of ASIPP.
Time and time again people challenge and will continue to challenge
our specialty. We have to be prepared
to face those challenges. Since the
inception of ASIPP, many leaders
have emerged, many hold high positions in academia. Some, like Dr.
Prithvi Raj and Dr. Gabor Racz, do
not know what retirement is. They
truly have dedicated their lives to the
field of IPM and provided invaluable
contributions. It is both a privilege
and an honor to work with and learn
from individuals of this caliber, who
are an inspiration to all of us. We
Vijay Singh, MD, is the President of ASIPP;
President and Executive Director of the Wisconsin Society
of Interventional Pain Physicians; and Medical Director of
Pain Diagnostics Associates in Niagara, WI.
1601 Roosevelt Road
Niagara, WI 54151
Phone: (715) 251-1780
Fax: (715) 251-1812
Email: vj@wmpnet.net
should learn from their example and
step forward to get involved.
I know one voice can be heard if
one is listening, but I also know that a
collective voice is harder to ignore and
can therefore accomplish even more.
This year we would like to improve
public awareness regarding the practice of IPM. Among the many issues,
one specific issue we are focusing on,
as an organization, is credentialing.
We want to make it very clear that
the practice of IPM is the practice
of medicine and therefore requires
the proper credentials and training.
This is an essential part of ASIPP’s
educational goals in order to protect
the patients from untrained dangerous individuals who are not qualified
physicians. As a part of public awareness, we want to empower patients
to have access to qualifications and
credentials of an individual “who is
going to stick a needle in their back!”
A patient has the right to know how
qualified and trained his “doctor” is
because a safe procedure can become
catastrophic in the hands of an
unqualified and untrained individual.
Any doctor performing a procedure
should be able to manage complications related to the procedure.
In closing, it is of the utmost
importance that we get involved with
the education process at every level:
local, state and national. YOU can
contribute in countless ways. Please
go to the ASIPP website and browse.
We have a wealth of information,
instructions and ideas on how you
can contribute. Remember we are an
organization of volunteers. Without
individual involvement, we will ultimately cease to exist.
From the ceo
(You’re Invited, continued from p. 1)
Topics covered include the following:
• History and principles of medical
ethics
• Fundamental elements of the
patient/physician relationship
• Patient responsibilities
• Evaluation in chronic pain
management
• Veracity, intellectual honesty and
nature of informed consent
• And much more.
This is an optional program providing you with a separate certificate of
completion. This unique format will
provide you with three CME credits
and requires a separate registration.
ASIPP 9th Annual Meeting
On Sunday, June 24, ASIPP’s ninth
Annual Meeting starts with a welcome and introduction by Andrea M.
Trescot, President-Elect of ASIPP. This
is followed by the Manchikanti Distinguished Lecture, presented by Michael
Stanton-Hicks, MD, recipient of the
Lifetime Achievement Award, who will
be introduced by David S. Kloth, MD,
Past-President of ASIPP. Following
this, I will discuss issues facing Interventional Pain Management in the
modern world.
Two concurrent sessions will offer
lecture on the following topics:
• Pelvic pain—a topic rarely
discussed yet a common problem
which many of us do not understand and are afraid to treat.
Establishing an interventional
practice—the focus of this discussion
will be the various elements necessary
to develop and maintain a pain center
of excellence, clinical operations, and
business operations.
Following both sessions, there will be
a helpful question and answer period.
After the morning sessions, there
will be a lunch and business meeting,
where the new officers and board of
directors will be introduced.
The early afternoon sessions include:
• Spinal cord stimulation—
credentialing, pathophysiologic
basis, patient selection, differences in technology, advances in
spinal cord stimulation, and last
but not least, billing and coding
regulations.
• Update on billing and coding—
discussions on the various aspects
of billing and coding including
incidental billing issues, coding
for interventional pain management procedures, and E&M issues
of concern in interventional pain
management.
Following a brief break, there will be
another set of concurrent sessions:
• Credentialing, pre-approvals,
and risk management—a must for
all physicians.
• Fraud, Abuse, Compliance and
Risk Management.
On Monday June 25, 2007, ASIPP
will do something which has never
been done before, we will bring to you
representatives from other four great
Laxmaiah Manchikanti, MD, is the CEO of ASIPP & SIPMS;
Associate Clinical Professor of Anesthesiology and
Perioperative Medicine at the University of Louisville in
Louisville, KY; and Medical Director of Pain Management
Center of Paducah, KY and Marion, IL.
2831 Lone Oak Road
Paducah, KY 42003
Phone: (270) 554-8373
Fax: (270) 554-8987
E-mail: drm@asipp.org
organizations to discuss the future of
interventional pain management. We
have invited the American Society of
Anesthesiologists (ASA), International
Spine Intervention Society (ISIS),
American Academy of Pain Medicine
(AAPM) and North American Spine
Society (NASS).
They all will present various views
and discuss each society’s roll in preserving the future of interventional
pain management. AAPM will be represented by President B. Todd Sitzman,
MD; ASA by President Mark Lema,
MD, PhD; ISIS by Milton H. Landers
DO, PhD; NASS by David O’Brien,
MD; and ASIPP will be represented by
Andrea M. Trescot, MD.
This session will be followed by “An
Update on Physician Payment and ASC
Payment Reform” by a representative
from CMS followed by “The Role of
DEA in Controlling Drug Abuse” by
DEA Administrator, Karen Tandy, and
finally “Diagnosis of Discogenic Pain:
Facts and Fallacies” by Richard Derby,
Jr., MD.
The lunch on Monday features the
annual award ceremony, which this year
will include the first-ever recognition of
Diamond and Platinum members.
Legislative Session and
Capitol Hill Visits
The Legislative session offers lectures on “Today’s Political Reality”
by Elmer Dunbar, MD, “Shaping The
Political Future” by Andrea Trescot,
MD, “Evolution of Legislation” by
Randy Fredholm Hutchinson, followed by “How To Get Your Voices
Heard” by Senator Tim Hutchinson,
and finally, I will discuss legislative
issues, options and solutions. A mandatory legislative preparation will follow, lasting for two hours.
The legislative agenda for this year
includes:
• Physician payment reimbursement,
• Ambulatory surgery center payment
reimbursement, and
From the ceo
• Funding for NASPER.
As you know, these issues have been
more in the forefront this year in physician payment reimbursement. We
will also be discussing issues related
to the major cuts we are facing for
interventional pain management procedures preformed in office settings.
This is the time for your voices to
be heard. If you miss this session you
will not be able to attend the legislative session on Capital Hill and visits
with your own congressional members
on these dates sponsored by ASIPP.
Remember, ASIPP will reimburse you
for two days of your stay—Monday
and Tuesday.
This sensational visit will start with
registration and continental breakfast
in the Russell Senate Office Building,
after which I will offer a short introduction, followed by congressional speeches
by invited guests:
Senator Sherrod Brown (d-oh)
Senator Norm Coleman (r-mn)
Senator Jeff Sessions (r-al)
Senator David Vitter (r-la)
Representative Rodney Alexander (r-la)
Representative Ben Chandler (d-ky)
Representative Geoff Davis (r-ky)
Representative Bart Gordon (d-tn)
Representative Frank Pallone, Jr (d-nj)
Representative Bart Stupak (d-mi)
Representative Ed Whitfield (r-ky)
Representative John Yarmuth (d-ky).
This is one of the most exciting features of our legislative session, which has
not been done by any other organization;
just imagine the most prominent and
powerful members of Congress will
be in front of us, talking to us with
only ASIPP members as the audience.
The Congressional visits will begin
on Tuesday afternoon and proceed
through Wednesday morning based
on your state’s presence.
As you can see, this is a “can’t miss”
year and I look forward to seeing you
in Washington.
Sincerely,
CEO, ASIPP and SIPMS
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Membership News
Diamond and Platinum Membership Levels
W
ith the help of many ASIPP
members, we accomplished
our first major PAC goal
for 2007. But neither time nor politics
stand still and so we must continue to
move forward in our effort to correct
the SGR, reverse our shrinking reimbursements and save patient access to
interventional pain management.
As we move to the next phase in
our 2007 PAC campaign, we ask you
to consider what membership level you
are at currently. We also would like to
challenge you to consider, unless you
are already at the top level, to take the
initiative and move up at least one level
in your participation.
Diamond Level—Life Member,
involved at the local level, actively
involved in issues and resolution, maximum contributions to PAC and lobbying ($5,000 to $10,000 each), never
misses an Annual Meeting and goes to
Capitol Hill visits.
Platinum Level—Life Member,
involved at the local level, actively
involved in issues and resolution, contributes at least $10.00 a day to PAC
($3,650), visits Washington on a regular basis, contributes $10.00 a day for
lobbying ($3,650).
Gold Level—Pays dues or a Life
Member, actively involved in local
issues, attends at least 50% of the
Washington visits, contributes $5.00 a
day for lobbying ($1,825), contributes
$5.00 a day for PAC ($1,825).
Silver Level—Pays membership
dues regularly, attempts to be involved
actively, attended at least one Washington visit and 1 annual meeting, gives
$1.00 a day for lobbying ($365), gives
$1.00 a day for PAC ($365)
Bronze Level—Active member, pays yearly dues, too busy to be
involved, does not contribute for PAC
or lobbying.
One way to move up a level today is
to register immediately to join the legislative session on June 25, 2007. You
must attend the legislative prep session.
Without preparation and appropriate
focus, even if your government officials
are your best friend, you cannot follow
through on the issues. It is imperative
that you attend the meeting and your
presence is needed.
A second way to increase your level
is to fill out a PAC form(s) and send in
your PAC or ASIPP contribution. If you
have never made a PAC contribution,
let today be the start of your involvement. Since our inception, ASIPP has
gone to battle on issue after issue for
you and your practice, now we need
you to help us carry the load.
We hope that you make the decision
today to increase your level of participation with ASIPP.
ASIPP
Membership
Reaches
ASIPP was founded in November 1998 in order to represent interventional
pain physicians dedicated to improving the delivery of interventional
pain management services to patients across the country in the various
settings of ambulatory surgical centers, offices, and hospital outpatient
departments. ASIPP reached a major milestone in early June of 2007, when
our membership roster topped 4000. As we head into our ninth Annual
Meeting this significant membership increase is cause for celebration.
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ASIPP Responses
Response: Facts and Fallacies of
Chronic Back Pain and Opioid Treatment
This letter is a response to Martell et al
2007; 146:116-27 “Facts and Fallacies
of Chronic Back Pain and Opioid Treatment” in the Annals of Internal Medicine. The response, by Laxmaiah Manchikanti, MD, was posted February 6,
2007 and can be found online at www.
annals.org/cgi/eletters/146/2/116#9584
L
etter to Editor: Martell et al
provided a systematic review
of opioid treatment for chronic
back pain that reports patterns of use,
relative outcomes’ efficacy, and association with addiction (2007; 146:116-27).
It is our earnest hope that this article
will dispel myths about failure to treat
pain, pseudo-addiction, opiophobia,
and the under-prescription of opioids.
Martell et al have addressed multiple
techniques employed in the management of chronic back pain. Of note,
however, is that they have failed to discuss interventional techniques. In the
United States, interventional techniques
are frequently used to treat chronic
back pain, despite the fact that there is
equivocal debate regarding the effectiveness of these approaches.1 Still, by most
accounts, interventional techniques do
provide moderate long-term relief.
Kuehn2 has described the contemporary trend toward the escalating
number of prescriptions for opioids and
the equally prevalent rise in both legitimate and illegitimate use. Yet, despite
these trends, it appears that the underprescription of opioids myth persists.
To date, the majority of literature that
has addressed such under-prescription
has focused on treatment(s) for postoperative, and/or malignant pain.
Recent congressional hearings on
prescription drug abuse and progress
in meeting and reducing the new
epidemic of prescription drug abuse
has revealed a number of salient facts
12
including that prescription drug abuse
is second only to marijuana abuse, and
that prescription drug abuse (especially
pain medications) is more likely than
marijuana use to lead to subsequent
abuse of illegitimate drugs.3 Thus,
while it is practically and ethically
important to confront the personal
and economic impact of chronic pain,
we must also focus on the personal toll
and costs associated with prescription
drug abuse and diversion.
Kuehn et al2 provided startling statistics that showed that 99% of the global
supply of the opioid, hydrocodone was
consumed by the American public in
2004. Do these statistics reveal some
unnoticed increase in pain? Surely, these
data do not support the notion of frank
under-prescription of opioids. Instead, it
is likely that these figures reflect a rise
in inappropriate prescription of opioids,
improper patterns of use and compliance, and/or drug diversion. Giordano4
stated that that these trends may be the
effect(s) of an increasingly pervasive
market-mentality, consumerism and
resulting acquiescence of medical practice. As Giordano noted, it may not be
that pain is under-treated, per se, but
rather that the medical system fosters
inappropriate treatment of the patient
in pain, the patient with co-morbid substance abuse issues, and ultimately constricts the therapeutic and moral roles of
the physician and healthcare.5
Federal and state governments can
improve incoherent and ineffective prescription drug monitoring programs,
and provide necessary data to enable
physicians to prescribe opioids in ways
that are both technically and ethically
appropriate. However, many current
programs remain somewhat focused
on “catching thieves” rather than protecting the public and enhancing the
public good of medicine. The National
All Schedules Prescription Electronic
Reporting (NASPER) Act of 20056 is a
law that provides for the establishment
of controlled substance monitoring program in each state, with communication between state programs. The Government Accounting Office (GAO)7
has demonstrated the effectiveness of
this program in states where its policies
are enacted with diligence and care.
Medical Director Pain Management
Center of Paducah
2831 Lone Oak Road
Paducah, Kentucky 42003
E-mail: drm@apex.net.
Financial Disclosures: None reported.
Conflict of Interest: None declared.
1. Boswell MV, Trescot AM, Datta S, Schultz
DM, Hansen HC, Abdi S, et al. Interventional Techniques: evidence-based Practice
Guidelines in the Management of chronic
spinal pain. Pain Physician. 2007; 10:7-112.
2. Kuehn BM. Opioid prescriptions soar:
increase in legitimate use as well as abuse.
JAMA. 2007; 297:249-51.
3. Manchikanti L. Prescription drug abuse:
what is being done to address this new drug
epidemic? Testimony before the Subcommittee on Criminal Justice, Drug Policy
and Human Resources. Pain Physician.
2006; 9:287-321.
4. Giordano J. Cassandra’s curse: interventional pain management and preserving
meaning against a market mentality. Pain
Physician. 2006; 9:167-170
5. Giordano J. Pain, the patient and the physician: philosophy and virtue ethics in pain
medicine. In: M. Schatman (ed.) Ethics of
Chronic Pain Management. Infortma, NY,
2006, p. 1-18.
6. Manchikanti L, Whitfield E, Pallone F.
Evolution of the National All Schedules
Prescription Electronic Reporting Act
(NASPER): a public law for balancing treatment of pain and drug abuse and diversion.
Pain Physician. 2005; 8:335-47.
7. US Department of Justice Office of the
Inspector General Evaluation and Inspections Division. Follow Up Review of the
Drug Enforcement Administration’s Efforts
to Control the Diversion of Controlled
Pharmaceuticals. July 2006.
ASIPP Responses
Response: Use of Epidural Steroid Injections
to Treat Radicular Lumbosacral Pain
This letter is a response to Armon et
al 2007; 68:723-729 “Therapeutics and
Technology Assessment Subcommittee
of the American Academy of Neurology. Assessment: use of epidural steroid
injections to treat radicular lumbosacral pain: report of the Therapeutics and
Technology Assessment Subcommittee of
the American Academy of Neurology” in
Neurology. The response will be published
at a later date and will be posted online
at www.neurology.com
To the Editor:
It would be hoped that any technology assessment would lend clarity and
direction to the field. However, we feel
that the report by Armon et al1 may generate further confusion and ambiguity.
Namely, the abstract reports that there
is insufficient evidence to recommend
the use of epidural steroid injections to
treat radicular cervical pain (Level U),
even though: 1) the focus of the review
is the use of epidural steroid injections
to treat radicular lumbosacral pain, and
2) the studies included in the synthesis
related solely to this focus.
To be sure, principles of evidencesynthesis, and specifically evidencesynthesis and evidence-based interventional pain management have been
described.2 The process of evidencebased medicine involves 3 critical tasks:
1) systematic review of appropriate
studies to support the clinical decision
process, 2) integration of knowledge
with the clinicians‚ training and practical experience, and 3) active use of this
information by patients and physicians
in shared decision-making.
Toward these ends, a recent study
by Abdi et al3 is exemplary; the authors
performed a systematic review that
separated lumbar epidural steroid injections into caudal (8 randomized trials),
interlaminar (11 randomized trials), and
transforaminal (6 randomized trials), as
these approaches are distinct techniques
with variable effectiveness and separate
applications. As well, the study included
observational studies and an examination of the methodologies and criteria
of both AHRQ, as well as Cochrane
reviews. It was concluded that there
was moderate evidence to support the
long-term (i.e., 6 weeks) effectiveness
of caudal and transforaminal epidural
steroid injections, and limited evidence
to support the effectiveness of lumbar
interlaminar epidural steroid injections.
In contrast, Armon et al1 included only
4 studies that were considered to have
met the predetermined inclusion criteria,
although previous studies have included
larger numbers of randomized trials in
systematic evaluations (e.g., Cochrane
review4 and European guidelines.5)
Thus, we believe that the report of
Armon and co-authors could lead to
inappropriate decisions by physicians,
patients and payers, and negatively
affect the conduct of interventional pain
management that is both pragmatically
successful and ethically appropriate.
References
1. Armon C, Argoff CE, Samuels J, Backonja MM. Therapeutics and Technology
Assessment Subcommittee of the American
Academy of Neurology. Assessment: use of
epidural steroid injections to treat radicular
lumbosacral pain: report of the Therapeutics
and Technology Assessment Subcommittee
of the American Academy of Neurology.
Neurology 2007; 68:723-729.
2. Manchikanti L, Boswell MV, Giordano J.
Evidence-based interventional pain management: principles, problems, potential
and applications. Pain Physician 2007;
10:329-356.
3. Abdi S, Datta S, Trescot AM et al. Epidural
steroids in the management of chronic spinal pain: a systematic review. Pain Physician
2007; 10:185-212.
4. Nelemans PJ, Debie RA, DeVet HC, Sturmans F. Injection therapy for subacute and
chronic benign low back pain. Spine 2001;
26:501-515.
5. Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F.,
et al. Chapter 4: European guidelines
for the management of chronic nonspecific low back pain. Eur Spine J 2006; 15:
S192-S300.
CEO, ASIPP
Medical Director, Pain Management Center of Paducah
Paducah, Kentucky
Associate Clinical Professor of Anesthesiology and
Perioperative Medicine
University of Louisville, Kentucky
James Giordano, PhD
Scholar in Residence,
Center for Clinical Bioethics
Associate Professor
Division of Palliative Medicine
Georgetown University Medical Center
Washington, D.C.
Mark V. Boswell, MD, PhD
Professor of Anesthesiology,
Department Chair and Director
Messer Racz Pain Center Department of Anesthesiology
Texas Tech University Health Sciences Center
Lubbock, Texas
Eugene Kaplan, MD, MSc
Director, Neurological and Stroke Care
600 McClellan Street, Suite 342
Schenectady, New York
13
Health Policy Review
Abstract: National Drug Control Policy and
Prescription Drug Abuse: Facts and Fallacies
Pain Physician 2007; 10:399-424
I
n a recent press release Joseph
A. Califano, Jr., Chairman and
President of the National Center
on Addiction and Substance Abuse
at Columbia University called for
a major shift in American attitudes
about substance abuse and addiction
and a top to bottom overhaul in the
nation’s healthcare, criminal justice,
social service, and eduction systems to
curtail the rise in illegal drug use and
other substance abuse.
Califano, in 2005, also noted that
while America has been congratulating itself on curbing increases in
alcohol and illicit drug use and in the
decline in teen smoking, abuse and
addition of controlled prescription
drugs-opioids, central nervous system
depressants and stimulants-have been
stealthily, but sharply rising. All the
statistics continue to show that prescription drug abuse is escalating with
14
increasing emergency department
visits and unintentional deaths due to
prescription controlled substances.
While the problem of drug prescriptions for controlled substances continues to soar, so are the arguments of
undertreatment of pain. The present
state of affairs show that there were 6.4
million or 2.6% Americans using prescription-type psychotherapeutic drugs
nonmedically in the past month. Of
these, 4.7 million used pain relievers.
Current nonmedical use of prescriptiontype drugs among young adults aged
18-25 increased from 5.4% in 2002 to
6.3% in 2005. The past year, nonmedical use of psychotherapeutic drugs has
increased to 6.2% in the population of
12 years or older with 15.172 million
persons, second only to marijuana use
and three times the use of cocaine.
Parallel to opioid supply and nonmedical prescription drug use, the epidemic of medical drug use is also escalating with Americans using 80% of
world’s supply of all opioids and 99%
of hydrocodone.
Opioids are used extensively despite
a lack of evidence of their effectiveness
in improving pain or functional status
with potential side effects of hyperalgesia, negative hormonal and immune
effects, addiction and abuse. The multiple reasons for continued escalation of
prescription drug abuse and overuse are
lack of education among all segments
including physicians, pharmacists, and
the public; ineffective and incoherent
prescription monitoring programs with
lack of funding for a national prescription monitoring program NASPER;
and a reactive approach on behalf of
numerous agencies.
This review focuses on the problem of prescription drug abuse with a
discussion of facts and fallacies, along
with proposed solutions.
Key words: Prescription drug abuse, opioid abuse,
opioid misuse, National Drug Control Policy,
NASPER, prescription drug monitoring programs.
Physician Payment Reform
Prevention of Medicare and Medicaid Cuts
Forecast of 10% Cut in
Physician Payments for 2008
u The Congressional Budget Office (CBO) recently forecast
that Medicare physician payment rates would be reduced
by 10% in 2008 under current law.
• Medicare Trustees Report predicts cumulative reduction in Medicare physician payment rates of nearly
46% by the year 2015.
• These successive annual reductions are due to a
statutory formula governing annual Medicare payment rates that is broken beyond repair and must be
replaced, known as sustained growth rate formula.
u The recent years have been quite eventful with numerous
changes in the Medicare payment system.
• In the waning hours of the 2006 session, Congress,
by reducing the stabilization fund, repealed the schedule of 5% in Medicare payments to physicians, which
would have taken effect on January 1, 2007.
• However, this formula failed to take into consider-
ation of the effect of 0% conversion factor for 2007,
leading to disastrous 10% projected cut for 2008.
• The Deficit Reduction Act of 2005 provided a one year
0% conversion factor updating payments for physician
services in 2006 freezing the conversion factor 2005
levels for services rendered on or after January 1, 2006,
based on a Bill by Ed Whitfield and Charlie Norwood,
which took into effect the impact of the 0% conversion
factor through future years.
uThe 2006 Medicare Trustees report announced that the
projected physician fee update would be about -5% for
seven consecutive years beginning in 2008.
• The result of this on physician reimbursement is a
cumulative reduction in physician fees of more than
40% from 2008 to 2015.
• During the same period it is estimated that the costs to
physicians for providing services, as measured by MEI,
are projected to rise by 20%.
Fig. 1. Comparison of
increase in practice costs
and proposed Medicare
cuts.
Sources: Physician cost data is
from the MEI, a conservative
index of practice cost growth
maintained by the Centers for
Medicare & Medicaid Services
(CMS). Conversion factor
updates are from the 2006
Medicare Trustees report and
the CMS Office of the Actuary.
Actual practice cost inflation is
calculated at a modest 6% pear
year. Practice costs are expected
to increase 10% in 2008.
16
• According to projections made by CMS Office of
Chief Actuary (OACT) in July 2006, maximum fee
reductions will be in effect from 2008 through 2015,
while fee updates will be positive in 2016.
Déjà Vu
u The
historic challenge for Medicare has been to find
ways to moderate the rapid growth in spending for physician services.
• Before 1992, the fees that Medicare paid for those services
were largely based on physicians’ historical charges.
• Spending for physician services grew rapidly in the 1980s,
at a rate that was characterized as “out of control.”
• Despite the actions of Congress to freeze or limit the fee
increases, spending continued to rise because of increases
in the volume and intensity of physician services.
• Medicare spending per beneficiary for physician services grew at an average annual rate of 11.6% from
1980 through 1991.
• Consequently, Congress reformed the way that Medicare sets physician fees due to the ineffectiveness of fee
controls and reductions.
The Unsustainable Sustainable
Growth Rate Formula
u The
sustainable growth rate is the product of the estimated percentage change in:
• Input prices for physician services.
• The average number of Medicare beneficiaries in the
traditional fee for service (FFS) program.
• National economic output, as measured by real inflationadjusted Gross Domestic Product (GDP) per capita.
• Expected expenditures for physician services resulting
from changes in laws or regulations.
• If cumulative spending on physician services is in line
with the SGR target, the physician fee schedule update
for the next calendar year is set equal to the estimate
increase in the average cost of providing physician services
as measured by the Medicare Economic Index (MEI).
• If cumulative spending exceeds the target, the fee
update will be less than the change in the MEI or may
even be negative.
• If cumulative spending falls short of the target the
update will exceed the change in MEI. The SGR
system places bounds on the extent to which the fee
updates can deviate from MEI. Overall, with an MEI
of above 2%, the largest allowable fee decrease or
increase would be about 5%.
uThere are several fatal flaws in the SGR:
• Utilization of physician services grows more rapidly than
GDP, so using GDP as the standard for utilization growth
in the SGR means that the target is always set too low.
• The “law and regulation” factor has not been appropriately adjusted to reflect new Medicare coverage
policies, such as macular degeneration treatment and
implantable cardiac defibrillators. Omitting the costs
of such treatments from the SGR targets increases the
likelihood of pay cuts.
• None of the factors in the SGR recognize Medicare
spending due to technological advances, shifts from
care being provided in hospitals to being provided in
physician offices and other medical practice trends.
Services that may save money for the Medicare program as a whole or improve quality, therefore, can still
lead to cuts in Medicare physician payment rates.
• Spending for Part B drugs has been improperly
included in the SGR calculations and is growing much
more rapidly than physician service. As a result, drug
spending consumes and ever-increasing share of a target that is already too low, increasing the likelihood
of SGR-driven pay cuts. Physician groups continue to
call for the Administration to remove drug spending
from its SGR calculations.
An Unfair and Unbalanced Approach
u Physician
services have extended patient’s lives and
improved senior citizen’s quality of life, despite a significant rise in chronic disease among elderly:
• The Centers for Disease Control reported 50,000
fewer deaths in 2004, the biggest single-year reduction
in mortality since 1930s.
• A 2006 Health Affairs article by Thorpe and Howard
reported, “Virtually all of the growth in spending
from 1987 to 2002 can be traced to the 20 percentage point increase in the share of Medicare patients
receiving medical treatment for five or more conditions during a year.”
• Medical advances added about half a year to senior’s
life spans between 1999 and 2002 alone.
• In a 2006 New England Journal of Medicine article by
Curtler et al mentioned that, “although medical spending has increased over time, the return on spending has
been high…concern about high medical cost needs to
be balanced against the benefits of the care received.”
• Utilization of physician services is not the cause of the
Medicare program’s financial predicament, and cuts in
physician payment rates are not the way to improve
Medicare’s financial sustainability.
u For physicians compared to other providers, from 2004 to
2007, Medicare payment updates have been unfair.
• Physicians receive below inflation updates in 2004 and
2005 and 0% updates in 2006 and 2007, while other
Medicare providers payment updates have kept pace
with their costs.
17
Fig. 2. Physician vs. other
providers: 2004-2007
Medicare payment updates.
An Access Issue
u It
is critical that a permanent, long-term replacement
for this payment formula be identified as it is producing
disastrous effects.
• The present forecast of 40% pay cuts by 2015 secondary to SGR formula is disastrous.
• In addition, average 2007 Medicare physician payment rates have been kept the same or below as they
were in 2001.
• Payment cuts have prevented physicians from making
needed investments in staff and health information
technology to support quality measurement—it is just
not an issue of profit.
• SGR-driven pay cuts would hurt seniors’ access to
physician care, not only for Medicare patients, but
also for Tricare patients, state aid patients, followed by
Blue Cross Blue Shield and all other private insurers
as everyone is basing their payment rate on Medicare
payment rates (Fig. 3).
Fixing The Formula
u Fixing
the formula is an expensive issue on the face of
increasing healthcare costs.
• The National Health Expenditure’s data continues to
extend the spending pattern with healthcare portion of
Gross Domestic Product of 16% in 2005.
• Medicare spending reached $342 billion in 2005,
growing 9.3%.
• Medicare spending for physicians and clinical services
was slower than other arenas.
18
Fig. 3. Spending distribution by contributor.*
*Estimates of spending by contributor are organized according
to the underlying entity (business, households, and government) financing the health care bill payer. CMS refers to these
contributors as “sponsors.”
Source: Centers for Medicare and Medicaid Services (CMS).
Office of the Actuary.
• Since 2002, spending as measured by the SGR method
has consistently been above the targets established by
the formula.
• In 2005, expenditures counted under the method
total, $94.5 billion, about $14 billion more than $80.4
billion expenditure target for that year.
• At the end of 2005, total spending since the SGR
mechanism was put into place was around $30 billion above the SGR’s cumulative target.
• Based on the CBO projections, Medicare spending for
physicians’ services will grow in the coming years, but
in 2012, it will be only 13% higher than it was in 2005,
reflecting an average annual growth rate of less than 2%.
• However, the spending growth was, on average, 7.7
annually from 1997 to 1995.
• The CBO estimates that spending for physician services will continue to exceed the cumulative target
for the next several years.
• Thus, unless it is modified permanently, the SGR
method will reduce payment rates beginning in
2008 and keep updates below inflation through at
least 2015.
Legislation
u The
only way this issue can be fixed is through legislation
by Congress.
u Please support legislation in 2007 to stop Medicare physician payment cuts triggered by the SGR and replace it
with a formula that provides annual updates that reflect
increases in physician practice costs.
u The following figure shows Medicare payment cuts for
physicians services by state from 2008-2015 in millions.
• The first number represents payment cuts due to the
negative 10% update in 2008, whereas the number in
parenthesis is total cuts due to negative updates from
2008 to 2018.
Fig. 4. Physicians vs. other providers 2004-2007 Medicare payment updates (in millions).
19
Outpatient Interventional Procedures in
Ambulatory Surgery Centers
W
ith a membership of over 4,000, the American
Society of Interventional Pain Physicians (ASIPP)
is the largest organization in the country that
represents physicians and others involved in the alleviation of
intractable pain experienced by millions of Americans.
Background
u Interventional
pain management is defined as the discipline of medicine devoted to the diagnosis and treatment
of pain related disorders principally with the application
of interventional techniques in managing sub acute,
chronic, persistent, and intractable pain, independently
or in conjunction with other modalities of treatment.
u Interventional pain management techniques are defined
as minimally invasive procedures including, percutaneous precision needle placement, with placement of drugs
in targeted areas or ablation of targeted nerves; and some
surgical techniques such as laser or endoscopic diskectomy, intrathecal infusion pumps and spinal cord stimulators, for the diagnosis and management of chronic,
persistent or intractable pain.
u In June 1998, the Centers for Medicare and Medicaid
Services (CMS) proposed an Ambulatory Surgery Center
(ASC) rule in which at least 60% of the interventional
procedures were eliminated from the ASCs and the
remaining 40% faced substantial cuts. The cuts were so
substantial, it would have been impossible for independent interventional pain management centers to survive
and multispecialty centers would have stopped interventional techniques from being performed.
u Since 1998, many interventions were made by Congress,
eventually reversing this proposal and the final proposal.
The Present Landscape
u The
Medicare Prescription Drug Improvement and
Modernization Act of 2003 directed CMS to implement
a new Ambulatory Surgery Center (ASC) payment system to take effect no later than January 2008. It also
directed the Government Accountability Office (GAO)
to compare ASC and Hospital Outpatient Department
(HOPD) payments.
u On August 8, 2006, CMS issued the Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery
20
Center proposed rule. CMS proposed a more significant
expansion of the approved list of procedures that can be
safely performed in an ASC setting. Since the proposed
rule must be budget neutral, certain procedures will see
an increase, while others will be decreased.
The Findings of GAO on ASC
procedural costs
u The
report to Congressional Committees from United
States Government Accountability Office (GAO) released
in November 2006 entitled Payment for Ambulatory Surgical Centers should be based on the hospital outpatient
payment system.
• The differences in the cost of procedures in hospital
outpatient setting versus ambulatory surgery center
settings were not significant.
• Cost ratio of ASC procedures when weighted by Medicaid claims value was 0.84.
• Thus, cost of the procedures in ASCs is 26% lower
than the corresponding cost in hospital outpatient
department, if all types of procedures are considered.
• Interventional procedures are low paid and high volume as shown by 15% of the procedures constituting
only 7% of the payments.
• It is estimated that cost of care is higher than 84%
of HOPD for these procedures.
The Problem with HOPD Payment System
u HOPD
payment system has historically disadvantaged
interventional pain management.
• Under the HOPD system, low payments to hospitals
for these services resulted in hospital closure of their
interventional pain management centers.
• In August 2000, CMS implemented the HOPD payment system in which interventional pain management
ambulatory payment classifications (APCs) were inconsistent with the mandate that the groups include services
that are alike clinically and in resource utilization.
• This resulted in hospitals refusing to schedule necessary interventional pain management procedures in
their operating rooms.
u ASIPP testified before the APC panel, and presented new APC
groupings for interventional pain management procedures.
• ASIPP reclassification of APC groups for interventional pain procedures has resulted in improved
reimbursement.
u Even
if ASCs are paid at 80% of the present HOPD
payment rate, it will reduce the payments for interventional procedures.
• The break even point would be at 90% of HOPD payment rate. However, payment rates of 90% of HOPD
will increase the ASC budget substantially.
Impact of CMS Proposed Rule on IPM
u For 2008, CMS currently estimates that the revised ASC rates
would be 62% of the corresponding OPPS payment rates.
• Interventional pain management (IPM) treatments
will be particularly hard hit under this new system.
• Despite the fact that IPM accounts for only 15% of all
ASC procedures and 7% of all payments, 9 top IPM
procedures will face a permanent reduction of approximately 27% starting in 2009 (135% over five years).
• Most IPM treatments would see a cut of at least 20%
for 2008 and 2009 and as high as a 40% cut for 2009
onwards.
u The top 9 procedures of the top 50 from 2004 ASC utilization data for interventional pain management procedures
include epidural injections (CPT 62310, 62311, 64483,
64484), facet joint injections (CPT 64470, 64472, 64475,
64476), and sacroiliac joint injection (CPT 27096).
• These constitute only 9 procedures of the top 50 and
less than 0.3% of total expanded ASC list of 3,300
procedures.
• Economically, the payments for these procedures of
642,058 in 2004 constituted approximately $161 million. With a 10% increase on a yearly basis by 2010,
these procedures will constitute approximately 1.1 million with payments of approximately $285 million.
HCPC
Short Description
ASC 2007
Payment
Rate
ASC 2008
Proposed
Payment
Negative Effect on Patient Care
u Even
if the decision were made to pay ASCs 80% of the
payment rates paid for hospital outpatient department
services, all IPM services would be paid well below current ASC rates, in fact, less than it costs to purchase the
supplies to perform the procedure.
• Doctors will no longer perform these procedures in
an ASC and patients seeking help for chronic pain
would be forced to receive care in the hospital outpatient setting. Using the HOPD for these procedures
will ultimately drive up overall costs in the Medicare
program—the exact opposite effect that CMS was
hoping to ensure.
Recommendation
u As
CMS completes the final rule, we need to ensure that
those patients suffering from chronic and severe pain
continue to have access to the procedures necessary to
lead full and productive lives.
• We would ask CMS to reevaluate its proposed rule to
ensure that IPM procedures can continue to be available in an ASC setting.
% change
from 2007
(with 50/50
Transition)
ASC 2009
Proposed
Payment
% change
from 2007
(62% of 2007
HOPD final Rate)
2004
Total
Allowed
Services
2004 Total
Allowed
Charges
62310
Inject spine c/t
$333
$293.08
-12%
$242.39
-27%
36388
$11,081,642
62311
Inject spine l/s (cd)
$333
$293.08
-12%
$242.39
-27%
230413
$70,249,466
64483
Inj foramen epidural l/s
$333
$293.08
-12%
$242.39
-27%
107713
$30,447,849
64484
Inj foramen epidural add-on
$333
$293.08
-12%
$242.39
-27%
47094
$7,932,487
64470
Inj paravertebral c/t
$333
$293.08
-12%
$242.39
-27%
13718
$3,389,326
64472
Inj paravertebral c/t add-on
$333
$276.51
-17%
$218.19
-34%
23379
$3,614,976
64476
Inj paravertebral l/s add-on
$333
$276.51
-17%
$218.19
-34%
100563
$14,686,352
64475
Inj paravertebral l/s
$333
$293.08
-12%
$242.39
-27%
63126
$14,675,192
27096
Inj for sacroiliac joint anesth
(G0260)
$333
$276.51
-17%
$218.19
-34%
19664
$4,706,290
642,058
$160,783,580
Total
Table 1. Top 9 Procedures from ASC 2004 Utilization data for IPM.
21
NASPER
National All Schedules Prescription Electronic Reporting Act
I
n a recent press release Joseph A. Califano, Jr., Chairman and President of the National Center on Addiction
and Substance Abuse at Columbia University called for a
major shift in American attitudes about substance abuse and
addiction and a top to bottom overhaul in the nation’s healthcare, criminal justice, social service, and eduction systems to
curtail the rise in illegal drug use and other substance abuse.
• Califano, in 2005, also noted that while America
has been congratulating itself on curbing increases in
alcohol and illicit drug use and in the decline in teen
smoking, abuse and addition of controlled prescription
drugs-opioids, central nervous system depressants and
stimulants-have been stealthily, but sharply rising.
• All the statistics continue to show that prescription
drug abuse is escalating with increasing emergency
department visits and unintentional deaths due to prescription controlled substances.
• While the problem of drug prescriptions for controlled
substances continues to soar, so are the arguments of
undertreatment of pain.
• The present state of affairs show that there were
6.4 million or 2.6% Americans using prescriptiontype psychotherapeutic drugs nonmedically in the
past month. Of these, 4.7 million used pain relievers.
• Current nonmedical use of prescription-type drugs
among young adults aged 18-25 increased from 5.4%
in 2002 to 6.3% in 2005.
• The past year, nonmedical use of psychotherapeutic
drugs has increased to 6.2% in the population of 12
years or older with 15.172 million persons, second only
to marijuana use and three times the use of cocaine.
• Parallel to opioid supply and nonmedical prescription
drug use, the epidemic of medical drug use is also
escalating with Americans using over 80% of world’s
supply of all opioids and 99% of hydrocodone.
uOpioids are used extensively despite a lack of evidence of
their effectiveness in improving pain or functional status
with potential side effects of hyperalgesia, negative hormonal and immune effects, addiction and abuse.
• The multiple reasons for continued escalation of prescription drug abuse and overuse are lack of education
22
among all segments including physicians, pharmacists,
and the public; ineffective and incoherent prescription
monitoring programs with lack of funding for a national
prescription monitoring program NASPER; and a reactive approach on behalf of numerous agencies.
u NASPER was signed into law on August 11, 2005 making
it the only statutorily authorized program to assist states in
combating prescription drug abuse of controlled substances
through a prescription monitoring program (PDMPs).
• NASPER fosters interstate communication by providing grants to set up or improve state systems that meet
basic standards of information collection and privacy
protections that will make it easier for states to share
information. This will enable authorities to identify prescription drug abusers as well as the “problem doctors”
who betray the high ethical standards of their profession
by over or incorrectly prescribing prescription drugs.
• The Secretary of Health and Human Services (HHS)
in support of the new grant program is charged with
developing minimum standards to safeguard personal information. The Secretary will only be able to
approve an application for a NASPER grant if a state
meets these requirements, which must include use of
encryption technology, limiting access to approved
personnel, and defined penalties for unauthorized use
or disclosure of information contained in the database.
Furthermore, states are also welcome to enact privacy
protections above and beyond federal requirements.
• Although NASPER has been signed into law, Congress
has yet to appropriate funds to HHS. Without this appropriation, although authorized, NASPER is unfunded.
u NASPER is currently administered by the Department of Health and Human Services (HHS) and provides grants to states to establish and improve prescription
drug monitoring programs (PDMPs). The law authorized
$15 million in FY 07 and $10 million each year through
FY 10. Authorization of the full allowed amount of $15
million is vital to the grant awards process.
• Multiple letters from Congressional leaders both in
the House of Representatives and Senate have failed to
produce any results.
Present Status
u In
2005, Congress emphasized its concern regarding
the diversion of controlled pharmaceuticals. The House
Report on the Justice Departments FY 2005 appropriations stated… “DEA has demonstrated a lack of effort to
address this problem.”
• In a July 2006 Justice Department OIG Report it
was shown that while the DEA has taken important
steps to improve its ability to control the diversion of
controlled pharmaceuticals, especially pharmaceutical
diversion using the internet, several shortcomings in
the DEAs diversion control efforts that were identified
and reported in 2002 still exist.
u NASPER has been afflicted by the DEA and Harold
Rogers sponsored state monitoring programs that were
initiated by the Department of Justice in 2003 to promote the development of prescription drug monitoring
programs by states.
• This commitment continues as part of the administrations National Drug Control Strategy for 2008,
though, these programs have been extremely incoherent and largely ineffective.
• A recent evaluation showed only a modest 10% decrease
in prescription drug use on a per capita basis in states
with their prescription monitoring programs.
u From 1940 to 1999, states have been able to establish only
15 functioning programs.
• The number of states with prescription drug monitoring programs has grown only slightly over the
past decade from 10 in 1992 to 15 in 2002 and 27
in 2006.
• With increase funding and resources, these programs
have been able to improve the statistics of the DEA,
however, have been a major failure in providing
assistance to the prevention of drug abuse, educating physicians, or preventing doctor shopping and
drug diversion.
• The fundamental flaw of DEA sponsored prescription drug
monitoring programs is that these programs are created to
help law enforcement identify and prevent prescription
drug abuse only after the fact.
• Program design is highly variable across the states.
Eighteen of the 27 state programs monitor Schedule IV
drugs and 20 of 27 monitor Schedule III drugs which
are the subject of major controlled substance abuse.
• Of all the available programs, only three programs are
physician friendly and work proactively.
u Thus, NASPER is the only solution to provide not only prevention, assist physicians and will reduce drug abuse substantially by at least 20% or more.
ASIPP’s Concerns and Recommendations:
u As
Congress moves into making its appropriations for FY
2008, two programs are authorized to receive funding for
prescription drug monitoring: the Harold Rogers Grant
Program (under the US Department of Justice) and the
NASPER program (under HHS).
u We are concerned that National Drug Control Policy
with regards to prescription drug abuse has been a failure
and it does not include any funding for NASPER.
u Funding under the current DOJ program, will create confusion among states applying for funding as well as for both
DOJ and HHS as they try to administer similar programs.
Solutions to Drug Abuse Epidemic
u A
revised national drug control strategy with a threepronged approach is essential in combating the epidemic
of prescription drug abuse with:
• Immediate implementation of NASPER with
enhancements
• Widespread educational programs for physicians, pharmacists, and the general public emphasizing the deleterious effects of controlled substance use and abuse.
• Implementation of Synthetic Drug Control Strategy
along with multiple other programs.
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23
Making Your Voice Heard
How-To’s for Your Visit to Capitol Hill
Y
our bags are packed. Your hotel reservation is made
and you have your plane ticket in hand. It’s time for
ASIPP’s 2007 Legislative Conference and you are
coming to Washington, DC to participate in the legislative
process. At this point you may be wondering, “How did I
get myself into this?”
The opportunity to meet with your elected representatives is one of the greatest privileges we have as Americans.
In fact, this right is protected by the First Amendment to the
Constitution of the United States:
Amendment I: Freedom of speech, religion, press, petition and assembly.
Congress shall make no law respecting an establishment of
religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the
people peaceably to assemble, and to petition the Government for a redress of grievances.
Although lobbying Congress is a right and privilege, it
can also be a very daunting prospect. The legislative process
can often appear slow and cumbersome. It can feel like no
one is listening to your concerns. However, take heart—the
process really does work and you can make a difference in
our nation’s health care policy.
As a representative of ASIPP you will be visiting with your
elected representatives and their staff to discuss health care
issues that affect your everyday practice. Remember—you
are the experts on these issues. View these visits as an opportunity to educate Members and their staffs about interventional pain medicine.
Below are some guidelines to keep in mind when you
have your meetings:
Senior Advisor, Dickstein Shapiro LLP
ASIPP Government Affairs Counsel
1825 Eye Street NW
Washington, DC 20006
Phone: (202) 420-3600
Fax: (202) 420-2201
hutchinsont@dicksteinshapiro.com
24
Be on Time
Congressional schedules are incredibly busy. Please be
on time for your appointment. If you happen to be running late, call the office and let them know you are coming.
Even more important, if you need to cancel your appointment, please call the office—don’t just be a “No Show.”
Nothing harms the reputation of ASIPP on Capitol Hill
more than to leave a Member or staffer sitting there waiting for ASIPP members who never show up. Remember,
you expect your patients to call you when they need to
cancel an appointment, so please return that courtesy to
congressional offices.
Keep it Simple
Many of your meetings will be with Congressional staff
who may not be familiar with ASIPP issues. Most will not
have medical backgrounds. Do not assume that the people
with whom you meet are familiar with the work of interventional pain physicians. Therefore, be prepared to explain
ASIPP issues in layman’s terms.
In addition, since Congressional schedules are usually
packed, you should be prepared to make your points in
15 minutes if you are meeting with a staff member. Think
about what you want to say ahead of time and how you can
be as brief as possible. If you are meeting personally with the
Congressman or Senator, be prepared for 5 minutes of “face
time.” Recently, a CEO was in a meeting with Senate staff.
The Senator walked into the room, never sat down, looked
at the CEO and said “What is the one thing I need to take
away from this meeting.” The CEO had about two minutes
to communicate his greatest concern to the Senator before
the Senator left the room. Chances are that you will have
a longer period of time for your meetings, but you never
know—be prepared to be brief.
If you are part of a large group, it is often helpful to designate a lead speaker for each ASIPP issue. The rest of the
group can join in with their thoughts and be available to
answers questions, but it keeps the discussion organized if
you decide ahead of time who is going to lead the discussion
of each issue. It is also helpful if you review the ASIPP issue
papers the night before your Congressional visits. Become
familiar with the issues so you can intelligently discuss them
the next day.
Anticipate the need for follow up
As you discuss the ASIPP issues, you will have specific
action items that you will request of your representative.
Sometimes you can get an answer or commitment right
away. However, most of the time the Member will want
to study the issue a little further. If you are meeting with
staff, they will need to talk with their boss before you get
an answer. It’s okay if you don’t get a commitment during
the meeting. Just make sure you have the name and contact
information for the health staffer, so you can check back
with the office. Wait up to a week after your visit and then
contact the office, again, to see if a decision has been made.
It may take several attempts, but you should get a response
from your representative.
Enjoy yourself
As you enter your congressman’s office, remember “You
are the boss.” You and your fellow citizens are the ones who
“hired” this person to represent you in Congress. Your vote
is a very powerful tool and your representative will want you
to have a great experience in their office. Remember to enjoy
yourself and have fun on your day visiting Capitol Hill.
9th ASIPP Annual Meeting, 2nd SIPMS Annual Meeting,
Legislative Session, and Capitol Hill Visits
Washington, DC
July 13-16, 2007
Comprehensive Imaging Review Course in Interventional
Pain Management and ABIPP Competency Certification in
Fluoroscopic Interpretation and Radiation Safety Exam
Las Vegas, Nevada
August 5-11, 2007
Comprehensive Pain Medicine Board Review Course and
ABIPP Part 1 Exam
Nashville, Tennessee
October 5-7, 2007
Interventional Techniques Review Course and
Comprehensive Interventional Cadaver Workshop
Memphis, Tennessee
2007 ASIPP Meeting Calendar
June 23-27, 2007
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November 30–December 2, 2007
Discography and Intradiscal Therapies Interventional
Techniques Review Course and Comprehensive
Interventional Cadaver Workshop
Memphis, Tennessee
25
Comprehensive Review Courses
The comprehensive review courses in Controlled Substance Management and in Coding, Compliance and Practice Managment were held
April 12-16, 2007 at the Caribe Royale Resort & Convention Center in
Orlando, Florida. The review courses were designed as a refresher in information regarding the ever-chaging rules and regulations associated with
interventional pain management. Many participants at the review courses
were also preparing for the ABIPP Competency Certification Exams in
the same subject areas, which were held on April 17.
The lectures covered subject areas that many physicians may not have
studied, but which are crucial to understanding the regulations and litigations that are part of the business of medicine. The courses featured many
nationally recognized experts in pain management billing and coding;
and practice management, as well as controlled substance management.
Marcy T. Rogers, M.Ed.
Arthur E. Jordan, MD
Joel M. Blau, CFP
Sanford M. Silverman, MD
26
Mark V. Boswell, MD, PhD
Lora Brown, MD
Marvel J. Hammer, RN, CPC
Ralph E. Martinez, Esq.
April 12-16, 2007—Orlando, FL
Roger S. Cicala, MD
Andrea M. Trescot, MD
Lloyd Vest, II, MD
John F. Brandt, MD
Vicki Myckowiak, Esq.
Alan S. Whiteman, PhD
William Allen, JD
Judith H. Holmes, JD
Hans C. Hansen, MD
Erin Brisbay McMahon, JD
27
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Reimbursement
Will I Be Paid for Percutaneous Intradiscal
Electrotheral Annuloplasty?
Marvel Hammer, RN, CPC and Joanne Mehmert, CPC
E
ffective January 1, 2007, the
American Medical Association
(AMA) moved the IDET disc
procedure from the Category III Section (0062T, 0063T) to the CPT Category I section and assigned new CPT
codes 22526 (single level) and 22527
(one or more additional levels). A code
moved from Category III to Category
I, or a new Category I code is always
welcomed by the medical community.
Adding to our delight, the Centers
for Medicare and Medicaid (CMS)
assigned relative value units (RVUs),
and designated the status of the IDET
codes Active (A). “A” indicates that the
code is paid separately under the Medicare Physician Fee Schedule (MPFS).
The presence of the “A” does not mean
that there is a CMS National Coverage Determination (NCD). Rather
it merely means the CPT code is an
active code and paid separately under
the physician fee schedule, if covered.
Local Medicare carriers are responsible
for coverage decisions in the absence of
an NCD.
Specific criterion must be met to
warrant the assignment of a Category
I CPT code. One requirement for a
Category I CPT code that is listed
on the AMA web site: “that the clinical efficacy of the service/procedure has
been well established and documented,”
provides us with the illusion that the
service will be paid for by third party
payers. Albeit this is a myth; however,
it is not due to a misrepresentation by
the AMA. The AMA states clearly in
the Introduction to the CPT Manual
that inclusion or exclusion of a procedure does not imply health coverage or
reimbursement policy.
Medical providers currently face an
Marvel Hammer, RN ,CPC, CCS-P, ACS-PM, CHCO
MJH Consulting
1295 S. Vine St.
Denver, CO 80210-1819
Phone: (303) 871-9484
Fax: (303) 871-9484
E-mail: marvelh@aol.com
Joanne Mehmert, CORT, CPC
Joanne Mehmert & Associates, LLC
1613 NE 77th Terrace
Kansas City, MO 64118
Phone: (816) 436-4271
Fax: (816) 436-9125
E-mail: fmeh@aol.com
environment where third party payers
are inundated with innovative medical
techniques and emerging technology
to improve the health and lifestyle of
the lives that they insure. Add to the
number of new and/or improved medical devices and services, the increasing
expense associated with these services
and we have a recipe for payers to seek
a reason to deny coverage.
As of May 2007, the authors’
research of published payer policies for
IDET produced information that a
significant number of payers consider
IDET ‘investigational’ and do not provide benefits. The Authors have listed
the payers that have web based policies,
which can be found simply by a web
search engine using the CPT codes
and/or the name of the procedure.
Investigational/Non Coverage
Medicare Contractors
Noridian Administrative Services and
WPS Medicare.
Non-Medicare payers
Aetna, Cigna, Harvard Pilgrim
Humana, Oxford, Tufts Health Plan,
Unicare, United Health Care.
Blue Shield Plans
Highmark BCBS in Pennsylvania,
BCBS of Arkansas Fiscal Intermediary,
BCBS of North Carolina, California,
BCBS Florida, BCBS Massachusetts,
Empire BCBS New York, Regence
Oregon, Washington, Utah and Idaho,
Wellmark BCBS for North and South
Dakota, Iowa.
Worker’s Compensation
Ohio and Mississippi.
Full or Limited Coverage
Ohio and Montana Medicaid, Colorado
Worker’s Compensation, BCBS of NE.
(continued on p. 30)
29
Reimbursement
(continued from p. 29)
The Authors believe that the conflicting information often found in
peer reviewed medical literature often
contributes to the payers’ determination that a new procedure and/or new
technology is ‘investigational’ and has
not been ‘proven effective’. Third party
payer policies are allegedly based on the
results of clinical outcome studies and
articles published in medical literature.
The question is whether the IDET
procedure is effective or whether the
payers are using the rationale of the German Philosopher Frederich Nietzsche:
“There are no facts, only interpretations.”
The Authors of this article are independent consultants that work with a
significant number of Interventional
Pain Specialists in all regions of the
United States. Few of the clients they
polled currently perform the IDET
procedure. The reasons the physicians and/or administrators provided
included but were not limited to:
1. “I am not doing it because the
results have not been impressive,”
2. “The neurosurgeons in our area will
be doing it,”
3. “Our doctors don’t do it any more;
if they did they would include
coverage in their contracts,”
4. “We stopped doing it because no
one was paying for it,”
5. “The results were not that good and
I can’t get paid for it” and
6. “We did one IDET in fall of 2006
using the category III codes on a
patient covered by a commercial
payer. We had to appeal to two different levels, received a partial payment
and have had the patient participate
with discussions with the payer about
the effectiveness of the treatment.”
Providers that offer, or wish to offer,
the IDET procedure to their patients
because it is the most effective treatment option for their carefully selected
patients should not give up on their
efforts to secure payment from third
party payers.
30
Providers can compile clinical studies
and articles by recognized experts that
endorse the procedure, ask for outcome
studies from their peers who perform
IDET, work with their local Medicare
Carrier Advisory Committee, lobby
with other ASIPP members in their state
as well as other areas of the country, and
get acquainted with the Medical Directors and coverage committee members
of the non-Medicare payers in their
region to lobby for coverage.
Additionally, a payer non-coverage policy may not necessarily equate
to non-performance of a treatment.
Patients need to be educated on their
treatment options and given the option
of electing to proceed with a procedure
that may not be covered by their insurance carrier. This should always be carried out prior to the actual procedure.
Similar to informed consent forms for
the procedure itself, some payers have
forms that providers should use to have
the patient acknowledge that a service or
procedure may not be covered by their
insurance carrier. This would allow
the patient to agree to their potential
responsibility for the expense if they
elect to proceed with the service.
CMS currently uses an Advanced
Beneficiary Notice (ABN) for this
purpose. The link for the CMS website with additional information on
the ABN form is: http://www.cms.hhs.
gov/BNI/
If a patient elects to have the noncovered treatment and has completed
the appropriate acknowledgement of
responsibility, the GA modifier would
be appended to the IDET CPT codes
indicating that the signed waiver of
liability is on file. Dependent upon
payer policy, the allowed amount may
be transferred to the patient’s responsibility. Most secondary insurance policies, that may have a coverage policy in
place for the IDET procedure, require
that the balance be deemed patient
responsibility prior to considering the
balance due for adjudication.
Harper Lee said, “Real courage is
when you know you’re licked before
you begin, but you begin anyway.”
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News Briefs
ASIPP, AAPM, ISIS with AMA to
Conduct Physician Practice Survey
F
or the first time in nearly a
decade, ASIPP, AAPM, ISIS,
the American Medical Association (AMA), and more than 70 other
medical specialty societies, have worked
together to coordinate a comprehensive
multispecialty survey of America’s
physician practices during 2007. The
purpose of the survey is to collect upto-date information on physician practice characteristics in order to positively
influence national decision makers
while further developing and refining
AMA and ASIPP policy. Thousands of
practices will be surveyed from virtu-
ally all physician specialties to ensure
accurate and fair representation for all
physicians and their patients.
The Gallup Organization has been
retained to conduct the PPI survey
among a representative sample of practices in each of the participating specialties. The Physician Practice Information survey is an important and
necessary vehicle for positive change.
Please watch for this survey in the coming weeks and do your part in completing it in a thorough and accurate manner if randomly selected to represent
our specialty.
2007 Guidelines
Accepted in the
National Guideline
Clearinghouse
T
he 2007 Guidelines have
recently been accepted for
inclusion in the National
Guideline Clearinghouse and are now
available on the to be NGC Web site.
If you are interested in working on
future articles or systematic reviews for
the Pain Physician journal, please contact Holly Long at hlong@asipp.org
See 2007 Guidelines National
Guideline Clearing House—http:
www.guideline.gov
Press Release: Addison Health Systems
A
ddison Health Systems, Inc.
(AHS) recently became a new
Bronze Sponsor of ASIPP.
AHS is the developer the WritePad™
Pain Management EMR System that is
being used by hundreds of pain management doctors and over 4,500 physical medicine doctors nationwide.
The Pain Management EMR Mission:
Pain management practices are
under greater scrutiny from Medicare
and insurance companies due to many
factors such as the high cost of procedures, the complex nature and greater
risk of evaluating/treating patients
in pain and the narcotics prescribed.
Correct documentation is key in
minimizing exposure and maximizing
reimbursement. AHS is committed to
the continued development to provide
ASIPP clients with state of the art technology tools to help make their clinics
paperless while incorporating proven
documentation tools as well as ASIPP
protocols to achieve compliance.
AHS’s WritePad™ EMR offers these
unique advantages to pain management practices:
• Software architecture that is specific to physical medicine. Primary
32
care EMR systems have the wrong
architecture! Primary care doctors
see patients for isolated condition(s)
(i.e. cold, physical, etc.). Pain management doctors see patients on a
condition recurrent basis thus have
to manage and re-report data that
relates to the condition(s). WritePad™
has specific screen architecture for
easy and fast re-reporting for pain
management doctors!
• Primary care EMRs ship empty!
They do not offer pain management
specific content thus you have to
build all your own information. The
WritePad™ has over 100 pain management content specific screens created from years of development
• WritePad™ offer screen architecture
versus templates of text. Screen
architecture allows the changing of
specific data elements, which is a
much faster and safer way to document. Templates of text cause more
reading, cut/pasting and errors due
to the volume of text to review.
• “Randomized” note verbiages so
your documentation does not look
like it was Cut/Paste.
AHS’s WritePad™ EMR offers inte-
gration of pain management and ASIPP
protocols:
• WritePad™ offers workflows to guide
compliance with Evaluation and
Management levels and instructions
for completing components for each
section.
• Protocols are set up to manage
administrative and clinical requirements (ASCs, interventional pain
offices, outpatient hospital) in the
form of alerts and reminders.
• Required documentation with CPT
codes for interventional procedures.
• Documentation requirements for
controlled substance use.
WritePad™ provides modules for
pain management, PT, chiropractic,
rehab, primary care, etc. It is compatible with desktops, laptops, pen tablets,
scanning, and voice recognition.
Call 1-800-496-2001 or go to website www.writepad.com
News Briefs
Bush Nominates Kerry Weems for
Medicare Chief
K
erry N. Weems, a longtime
federal health official, is President Bush’s choice to oversee
the Medicare and Medicaid programs.
If confirmed by the Senate, Weems
would succeed Mark McClellan, who
resigned in October. Weems is deputy
chief of staff to Health and Human
Services Secretary Mike Leavitt.
Leslie Norwalk has served as the
acting CMS administrator since
McClellan’s resignation. At the time
Norwalk accepted the interim posi-
tion, she stated she would not commit
to staying throughout the president’s
second term and also is reported having indicated to Leavitt early on that
she did not want to be considered for
the position.
“If you’re looking for somebody who
knows the programs inside and out,
and knows also how to get things done
in the government with no transition
period, he’s it. He’s been at the center
of all that,” Alex Azar, former HHS
Deputy Secretary, said of Weems.
James W. Holsinger, Jr, MD
Nominated for Surgeon General
O
n Thursday, May 24, 2007,
President George W. Bush
nominated James W. Holsinger, Jr., MD for the position of Surgeon General of the United States.
Dr. Holsinger will become the United
States’ 18th Surgeon General if his
nomination is approved by the US Senate. The office of Surgeon General was
created in 1871.
The Surgeon General is the most visable public health official in this country. Dr. Holsinger will serve as an advisor to the President and the Secretary of
Health and Human Services (HHS) on
public health policy. The Surgeon General also educates the public on health
issues, advocates for effective disease
prevention, and promotes health programs and activities. Dr. Holsinger will
also be responsible for the administration of the U.S. Public Health Service
(PHS) Commissioned Corps.
Dr. Holsinger previously served as
Secretary for Kentucky’s Cabinet for
Health and Family Services. He has
also been the Chancellor of the University of Kentucky Medical Center
and taught at several medical schools.
His current title is Chair of the Health
Sciences at the University of Kentucky.
His faculty appointments include Preventive Medicine and Environmental
Health and Health Services Management in the College of Public Health;
and Internal Medicine, Surgery, and
Anatomy in the College of Medicine.
Dr. Holsinger retired in 1993 after
more than three decades of service in
the United States Army Reserve, having earned the rank of Major General.
He also served 26 years in the Department of Veterans Affairs, which culminated in his appointment as the chief
medical director in 1990.
Holsinger has a doctorate in anatomy
and physiology and a medical degree
from Duke University. He also holds
a master’s degree in hospital financial
management from, a bachelor’s degree
in human studies, and a master’s degree
in biblical studies.
Dr. Holsinger was one of the expert
witnesses who testified before Congress
regarding monitoring prescription
drugs and preventive abuse, specifically
on the success of the system established in Kentucky (March 4, 2004).
This hearning helped to get the federal
NASPER legislation passed.
Addison and
Clint Join ASIPP
as Sponsors
A
SIPP is proud to welcome two
new companies to our family
of corporate sponsors. A complete list of all our sponsors is available
online at www.asipp.org/sponsors.htm
Addison joined ASIPP as a Bronze
Sponsor. The WritePad EMR System is
the flagship product of Addison Health
Systems, currently used daily by over
4,500 doctors to track patients, create exam notes, and compile detailed
patient reports. (www.writepad.com)
Clint Pharmaceuticals has also
joined ASIPP as a Membership Sponsor. Clint Pharmaceuticals is committed to offering practical solutions to the
Interventional Pain Physicians’ needs.
They provide a wide variety of pharmaceutical and orthopaedic products.
(www.clintpharmaceuticals.com)
Blue Cross to
Pay Doctors
$128 Million
F
or a cash payment of $128 million, about 900,000 physicians
nationwide have settled their
disputes about slow pay or nonpayment of claims with 23 Blue Cross and
Blue Shield organizations, the parties
announced Friday (Dorschner—Miami
Herald, Apil 27, 2007)
Agreeing to end the 4-year-old classaction case based in a Miami federal
court, the insurers agreed to implement “important and valuable business
practice changes,” streamlining claims
communications between insurers and
doctors. The settlement covers more
than 90 percent of all Blues plans in
the country, covering 77 million lives,
as well as the Blue Cross Blue Shield
Association, according to a release by
the doctors’ lawyers.’
33
Intrathecal Pump Refills
NECC provides Pain Management Physicians with Intrathecal Pump
Refills based on a valid patient-specific prescription. IT Pump refills may
be customized to best meet your patient’s medical need.
Typical intrathecal pump refills contain:
Baclofen • Bupivacaine • Tetracaine • Ropivacaine
Morphine • Hydromorphone • Sufentanil • Fentanyl
Meperidine • Clonidine • Methadone • Droperidol
Please note: All intrathecal pump refills may be customized to contain various medications and various concentrations to best meet your patient’s medical need. Medications may also be provided in other forms and strengths which are not commercially
available. Please call for further details.
697 Waverly Street • Framingham, Massachusetts 01702
Telephone: (508) 820-0606, (800) 994-6322 • Fax: (508) 820-1616
www.neccrx.com
mail@neccrx.com
34
Quality
NECC has earned a national reputation as a provider of
high quality compounded medications and excellent
service to patients and prescribers:
• All intrathecal pump refills are compounded in a Class
10 MicroEnvironment by Registered Pharmacists extensively trained in aseptic compounding
• NECC’s Registered Pharmacists and Certified Technicians adhere to comprehensive Sterile Compounding
Standard Operating Procedures
• NECC maintains an organization-wide Continuous
Quality Improvement Program, including on-going
Quality Assurance Meetings
• All compounding areas are subjected to vigorous Environmental Testing to ensure sterility
• Compounded medications are prepared using only
USP quality ingredients
• NECC complies with USP 797 regulations
• NECC has grown into a nationally recognized provider
of high quality customized compounded medications.
We are state licensed as a pharmacy, registered with
the DEA, and provide service to all 50 states as well as
Puerto Rico, Guam and the Virgin Islands
ASIPP invites
Corporate Sponsors
As a not-for-profit organization, ASIPP
depends on corporate sponsors. Becoming
an ASIPP sponsor is not only an investment
in the preservation and growth of patient
access to quality, cost-effective interventional
pain management services, but also a marketing opportunity to expand your corporate
growth. ASIPP sponsorship puts you in
direct contact with those at the forefront of
this rapidly growing specialty.
Here are several levels of ASIPP corporate
sponsorship and the benefits and exposure
each offers. All sponsors are recognized
on the asipp.org website.
Join our growing list
of Corporate Sponsors:
GOLD
Medtronic
Smith & Nephew
SILVER
Advanced Bionics
ANS
BRONZE
Addison Health Systems
Baylis Medical
Cardinal Health
Epimed
NeuroTherm
New England
Compounding Center
Pain Care
Stryker Interventional Pain
Titan Health Care
MEMBERSHIP
Clint Pharmaceuticals
ASIPP thanks these
distinguished Corporate Sponsors!
Your company can
become a sponsor today!
Call 270-554-9412
DIAMOND sponsor
Annual sponsor rate: $100,000 per year or $10,000 per month
• Logo and link to website in each weekly eNews e-mail to members
• Total of 12 full-color, full-page ads annually in Pain Physician journal and first priority level in
reserving advertising positions on an alternating schedule with same level sponsors
• Two full-color, full-page ads in each quarterly issue of ASIPP News
• 100 copies of each issue of Pain Physician journal and ASIPP News
• Table top exhibits at ASIPP annual meeting and four additional meetings
• Associate ASIPP membership for ten members of your corporation
• Access to the ASIPP Board of Directors, Executive Committee, and ASIPP lobbyist
Platinum sponsor
• Logo and link to website in each weekly eNews e-mail to members
• Total of 10 full-color, full-page ads annually in Pain Physician journal and second priority level
in reserving advertising positions on an alternating schedule with same level sponsors
• Table top exhibits at ASIPP annual meeting and three additional meetings
• Associate ASIPP membership for eight members of your corporation
Gold sponsor
• Total of 8 full-color, full-page ads annually in Pain Physician journal and third priority level in
• Table top exhibits at ASIPP annual meeting and two additional meetings
• Associate ASIPP membership for five members of your corporation
SILVER sponsor
• Total of 8 full-color, full-page ads annually in Pain Physician journal and fourth priority level in
• One full-page ad in each quarterly issue of ASIPP News
• Table top exhibits at ASIPP annual meeting and one additional meeting
• Associate ASIPP membership for five members of your corporation
• Access to the ASIPP Board of Directors
BRONZE sponsor
• Total of 4 full-color, full-page ads annually in Pain Physician journal and fifth priority level in
• One half-page ad in each quarterly issue of ASIPP News
• 50% discount for table top exhibits at ASIPP annual meeting and one additional meeting
• Associate ASIPP membership for three members of your corporation
• Access to the ASIPP Board of Directors
membership sponsor
Annual sponsor rate: $5,000 per year or $500 per month
• Total of 4 black-and-white, full-page ads annually in Pain Physician journal and sixth priority level
in reserving advertising positions on an alternating schedule with same level sponsors
• One quarter-page ad in each quarterly issue of ASIPP News
• 25% discount for table top exhibits at ASIPP annual meeting and one additional meeting
• Associate ASIPP membership for two members of your corporation
35
Advocacy
On April 2, 2007, 66 representatives of the House signed a letter addressed to CMS. This letter was an amazing accomplishment
and sent a very strong message to CMS. It is proof that the pending
ASC cuts are unacceptable to physicians and patients alike. Thanks
go to all our members who worked diligently writing letters and
making calls. We are especially thankful to Reps. Frank Pallone
and Ed Whitfield who took the lead on this project.
Because it is such a rare occasion to have the support and solidarity of this many government officials on an issue, we felt compelled to publish the letter for all ASIPP members to witness.
April 2,2007
Ms. Leslie Norwalk
Acting Administrator
U.S. Department of Health and Human Services
Centers for Medicare and Medicaid Services
200 Independence Avenue
Washington, D.C. 20201
Dear Ms. Norwalk:
We are writing to express our concern over proposed changes to the Ambulatory Surgical Center (ASC) payment system
currently under review by your agency.
As you know, the Medicare Prescription Drug Improvement and Modernization Act of 2003, directed the Centers for
Medicare and Medicaid Services (CMS) to implement a new ASC payment system to take effect no later than January 2008.
It also directed the GAO to compare ASC and Hospital Outpatient Department (HOPD) payments. While we do not
disagree with GAO’s conclusion that ASC payments should reflect the lower cost of performing certain procedures in that
setting as compared to an HOPD, we are concerned that the proposed rule will have a disproportionate effect on procedures
used frequently by physicians practicing interventional pain management (IPM) procedures.
Despite the fact that IPM represents only 15% of all ASC procedures and 7% of payments, it is our understanding that
under the proposed rule 10 of the top 11 procedures performed by interventional pain physicians in an ASC will face a permanent reduction of approximately 27% starting in 2009 (135% over five years). Even during the phase-in period of 2008,
cuts will be approximately 12%. While the proposed rule must be budget neutral and therefore adjusts ASC payments such
that certain procedures will see an increase, while others will be decreased, other specialties will not see the type of severe
across the board cuts.
Further, we are concerned that these reductions will have the effect of driving individuals who are seeking treatment for
chronic pain to an HOPD which over the long term will drive up utilization in that setting thereby increasing overall costs
in the Medicare program.
As you work to complete the final rule, we ask that you re-evaluate the proposed rule’s payment formula to ensure that
Medicare beneficiaries suffering from pain will continue to receive high quality treatment in the ASC setting. Thank you
for your consideration of our views and we look forward to hearing what steps CMS is taking on this issue.
Sincerely,
36
Advocacy
37
Advocacy
38
Advocacy
39
Advocacy
40
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4:43 PM
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Advocacy
In our ongoing effort to stop the pending ASC cuts ASIPP
members have also convinced three senators to contact CMS.
Senators Sherrod Brown (D-OH) and David Vitter (R-LA)
took the lead on this initiative by urging CMS to re-evalu-
42
ate the proposed rule’s payment formula. Sen. Jim Bunning
(R-KY) followed by sending his letter to CMS on April 23.
If you wish to contact your senators and representative, you
can do so by going to: http://capwiz.com/asipp/home/
Advocacy
43
NASPER Update
Florida passes prescription monitoring bill
F
LASPER, the Florida version of
NASPER, made it through the
House and the Senate recently
for signing by Gov. Charlie Crist.
Over the past four years, many have
worked diligently to get this legislation passed included among these are
the Florida State Society (FSIPP) of
Interventional Pain Physicians and
Rep. Gayle Harrell.
The FSIPP Board members in particular worked aggressively on FLASER.
Thanks and congratulations to Lora
Brown, MD, President; Harold Cordner, MD, President-elect; Raymond
Priewe, MD, Vice President; Deborah
Tracy, MD, Secretary; and Andrea
Trescot, MD (Immediate Past President) and Rafael Miguel, MD, Executive Co-chairs for Legislative Affairs.
Also on the board are Marshall Bedder,
MD; James Worden, MD; Scott Dramarich, MD; Chuck Gruden, MD;
Rob Dehgan, MD; Frank Zondlo,
MD; and Francisco Torres, MD.
The bill relies on the growing use of
“e-prescribing,” which allows a direct
link between doctors and pharmacies
and eliminates the need for paper prescriptions, which can often be forged.
NASPER signed into law in Minnesota
A
fter much work and aggressive
lobbying by the Minnesota
Society of Interventional Pain
Physicians, on Saturday Gov. Pawlenty
signed the Health and Human Services (HHS) bill bringing NASPER to
Minnesota. Although Pawlenty lineitem vetoed a few Minnesota Care
provisions, most of the bill was left
44
intact, including the NASPER language. The first HHS bill was vetoed
by Gov. Pawlenty and House File
1078 was used as the vehicle for the
new HHS bill.
Congratulations to MSIPP. Special
thanks go to MSIPP President David
Schultz, MD and the MAPS team,
Georgann Gillund, Marsha Theil,
Heather Kennan, and others. Without
their hard work, persistence and dedication, the NASPER bill would likely
never come to fruition.
On the facing page, an article from
the Summer 2006 edition of ASIPP
News is reprinted, detailing the struggle MSIPP went through to see their
state’s version of NASPER passed.
NASPER Update
NASPER in Minnesota: The Ultimate Grassroots Adventure
Minnesota remained undeterred.
They spoke to every member of
each committee that the bill went
he NASPER (National All
before. Dr. Thomas Cohn and MarSchedules Prescription Elecsha Theil testified at several Senate
tronic Reporting) Act, which
hearings. There was some opposiASIPP initiated and worked through
tion to overcome and they worked
three sessions of Congress to pass, was
to gain support from these groups.
signed into law on August 11, 2006.
The bill never received a hearing in the
It authorizes spending $60 million
House but because of its strength in
from FY 2006 to 2010 to create federal
the Senate and its ultimate attachment
grants at the US Department of Health
to the Senate Omnibus bill, they were
and Human Services to establish or
confident it would be passed this
improve state-run prescription
year. Unfortunately at the elevdrug monitoring programs.
enth hour it was pulled from the
The program aims to identify
Omnibus bill.
abuses such as “doctor shopMSIPP feels that as the bill went
ping,” the practice of going from
through the process and as amenddoctor to doctor to acquire more
ments were made to suit the oppomedication, such as painkillers.
sition, the language and the intent
“This will really help physiof the bill became clearer. This
cians to weed out the people abusfailure to pass gives the group coning drugs,” Manchikanti told the
fidence that they will have an even
Washington Post. Twenty states
better bill to stand on next session.
that already have programs can
Minnesota acknowledges that they
apply for grants to expand and
have learned a great deal about the
improve them. Other states can
process and with this new-found
apply for startup funds.
political knowledge, they hope to
Minnesota is one of the many
realize success in 2007.
states trying to establish Con———————
trolled Substance Monitoring
The NASPER experience has
Programs (CSMPs). According
been invaluable to ASIPP in not
to Randi Hutchinson, ASIPP’s
only dealing with Congress, but
government affairs counsel, this
also with various agencies, includis one of the next steps in impleing the Drug Enforcement Adminmenting NASPER nationwide.
Georgann
Gillund
prepares
to
drop
the
house
bill
into
the
istration and state governments,
State CSMPs must be in place
the box into which a proposed legislative bill is
as Minnesota so clearly indicates.
before the state can apply for fed- hopper;
placed to officially be introduced.
Further, it provides a great insight
eral funding.
———————
After the language was drafted, the into multiple professional organizations
Minnesota Society of Interven- Senate lobbying process began. Next, and their inner workings.
Everyone should remember that
tional Pain Physicians set a goal to pass the MSIPP moved on to the House.
NASPER legislation in their state and They chose an author in the House funding for NASPER is crucial to the
were determined to do this on their and gave him the bill to sign onto as implementation of the program and will
own without paying a lobbyist. The the chief author. He gladly accepted; allow states to apply for grant funds to
first step they undertook was to find unfortunately they then learned that have, among other things, penalties for
an author and champion for their bill. he had authored 11% of the bills in the the unauthorized use and disclosure of
Knowing this, their legislative “grass- house that same session. It was clear he information, as well as criteria for availroots” adventure started with a lob- would not be able to invest the neces- ability of information and limitation
on access to program personnel.
bying campaign in January of 2006. sary time to promote their bill.
(Reprinted from the Summer 2006 ASIPP News)
T
Minnesota representatives began in
the Senate where they chose Senator
Linda Berglin. From there they spent
time gathering support from the Board
of Pharmacy, the Minnesota Medical
Association, the Governors office, and
the Department of Health. Representatives from each of these offices
met with Senator Berglin, Dr. David
Schultz, Marsha Theil, Georgann Gillund, and Heather Keenan to discuss
the language of the bill.
45
ASIPP BOOKSTORE
Stay on the cutting edge:
Get these ‘must-have’ books from ASIPP
original titles from ASIPP Publications
Documentation, Billing,
Coding & Practice Management
Low Back Pain:
Diagnosis & Treatment
Pain Physician Journal
also featuring…
• Model Compliance Plans
• Policy & Procedure Manuals
favorites from the American Medical Association
CPT 2007
CPT Changes 2007
HCPCS 2007
Physician ICD-9-CM
2007 (Vol. 1 & 2)
Order online at www.asipp.org or see the order form on the back of this page
Going to an ASIPP meeting soon? Pick up a copy there and save the cost of shipping.
47
ASIPP BOOKSTORE Order Form
product description
code
price and quantity
shipping/
handling
total
ASIPP Publications
COMPLIANCE PLANS AND MANUALS ON CD
Model Compliance Plan
MCP
m $250 Member (____ copies)
m $450 Non-Member (____ copies)
m $5 regular
m $10 two day
m $20 next day
Model Compliance Plan for the
HIPPA Privacy Standards
HIPPA
m $5 regular
m $10 two day
m $20 next day
Pain Management Policy and Procedure
Manual—Vol. 1 & 2
PM-CD
m $5 regular
m $10 two day
m $20 next day
Ambulatory Surgery Policy & Procedure
Manual—Vol. 1 & 2
ASC-CD
m $5 regular
m $10 two day
m $20 next day
One year subscription to Pain Physician journal and
ASIPP News
SUB-1
FREE Member
included
Pain Physician journal—back issues
(indicate issue ____________________)
BIPP-J
included
ASIPP News—back issues
(indicate issue ____________________)
BIPP-N
included
Principles of Documentation, Billing,
Coding & Practice Management for the Interventional Pain Physician
DCB2-Book
m $1000 Member (____ x 5 copies)
m $1250 Non-Member (____ x 5 copies)
m $20 first copy
m $10 each
add’tl copy
Interventional Pain Management:
Low Back Pain—Diagnosis and Treatment
LBP-Book
m $20 first copy
m $10 each
add’tl copy
PAIN PHYSICIAN and ASIPP NEWS
ASIPP BOOKS
American Medical Association Books
AMA—CPT 2007 Professional Edition
AMACPT
m $72.95 Member (____ copies)
m $98.95 Non-Member (____ copies)
m $10
AMA—CPT Changes 2007: An Insider’s View
AMACPTX
m $12
AMA HCPCS 2007 Level II
AMAHCP
m $12
AMA Physician ICD-9-CM 2007—Vol. 1 & 2
AMAPH-SP
m $10
Get a discount rate by becoming an ASIPP member!
SUBTOTAL
Fill out the membership form on page 49 and include the application with your publication order
and payment. Costs listed below are for annual memberships.
m Active (Physician) $350
m Active Multi-Year (Physician) $300/year (≥3 years)
m Military (Physician) $150 m Fellow or Resident $100
m Medical Student $25
m Associate (Non-Physician) $100
KY: add 6% sales tax
It’s easy to make an additional contribution to support ASIPP! Just indicate your donation to the right.
GRAND TOTAL
MEMBERSHIP
DUES
DONATION
ship to:
method of payment:
Name ___________________________________________________________
m Mastercard m Visa m American Express m Discover
m Check (Enclosed, Payable to ASIPP) Check number _____________
Address ________________________________________________________
________________________________________________________
City ____________________________ State _____ Zip ____________
Phone _________________________ Fax ___________________________
NO RETURNS policy: Items
cannnot be returned for a refund
48
________________________________________________ _________________
Credit Card Number
Expiration Date
___________________________________________________________________
Authorized Signature (required on all credit card orders)
Mail order to: ASIPP, 81 Lakeview Dr., Paducah, KY 42001 Fax order to: (270) 554-5394
Order online: www.asipp.org Order by email: asipp@asipp.org
asipp Membership Application
American Society of
Interventional Pain Physicians®
The Voice of Interventional Pain Management Since 1998
Professional Membership Application
Please type or print your information clearly
When completed, mail to: ASIPP, 81 Lakeview Drive, Paducah, KY 42001 or Fax: (270) 554-5394
For your convenience, you may also register online at www.asipp.org/join
1
2
_______________________________________________________________________________________________
Name
(Last)
(First)
(Middle Initial)
______________________________________________________________________
PReferred mailing address m Organization m Home
Organization
______________________________________________________________________
______________________________________________________________________
HOME Address
ORGANIZATION Address
______________________________________________________________________
______________________________________________________________________
City
State
Zip
City
State
Zip
______________________________________________________________________
______________________________________________________________________
Phone
Fax
Phone
Fax
______________________________________________________________________
______________________________________________________________________
Email
Email
Date of birth ______/______/______
m MALE m FEMALE
Personal Data: (for statistical purposes only)
3 MEDICal degree: m MD
m DO m Other (specify) ________________________
m Residency in Specialty of _______________________
Accredited Pain Management Fellowship m YES m NO
Grandfathered (Pain Medicine) m YEAR _________
4 I AM currently certified by the following board(s)
m American Board of Anesthesiology
m Fellowship of Interventional Pain Practice (FIPP)
m American Board of Interventional Pain Physicians (ABIPP)
m American Board of Psychiatry and Neurology
m American Board of PMR
m American Medical Association (AMA) Member m ABA Subspecialty in Pain Medicine
m Other ABMS Primary Board(s) _______________________________________________
5 specialty designation: m 09 Interventional Pain Management
m 72 Pain Medicine m Other ________________________
6
What percentage of your clinical practice is in the field of Interventional Pain Management: m 0% m 1–49% m 50–100%
7
Primary professional practice setting (please check all that apply): m Ambulatory surgery m Hospital m Office Practice
8
I hereby make application for
m ACTIVE MEMBERSHIP
(must be a physician specializing in Pain Management, Spinal Injections, or Neural Blockade)
Life Membership Dues
m $5,000 (or $500/month for 1 year)
m $350
Annual Membership Dues
m ____ years at $300/year
Annual Membership Dues (≥3 years)
m $150
Military
m $100
Fellows and Residents
m $25
Medical Student
m $100 m $250 m $500 m $1000 m other $_______
Additional Contribution
Total:
______________________
9
m ASSOCIATE MEMBERSHIP
(Non-Pain Management Physicians, Scientists, Nurses, Physician Assistants,
Nurse Practitioners, Administrators, Pharmacists, Physical Therapists,
Psychologists, etc. associated with active practice of Pain Management)
Life Associate Membership Dues
m $2,500
m $100
Associate Membership Dues
m I am a member of ______________________________________________________________________________ State Association(s)
m I am interested in joining _______________________________________________________________________ State Association(s)
Method of Payment
m Check (Enclosed, Payable to ASIPP) Check number ____________________
____________________________________________________________________________________________________________________________________________________
Credit Card Number
Expiration Datename On Card
______________________________________________________________________________________________
(Your application will not be processed if payment
does not accompany registration form)
Signature OF APPLICANT_____________________________________________________ SPONSORING MEMBER_____________________________________________
49
sipms Membership Application
Society of Interventional Pain
Management Surgery Centers
The Voice of Interventional Pain Management Ambulatory Surgery Centers
Membership Application
Please type or print your information clearly
When completed, mail to: SIPMS, 81 Lakeview Drive, Paducah, KY 42001 or Fax: (270) 554-5394
A PDF version of this form is available online at www.sipms.org
______________________________________________________________________________________
Center name
______________________________________________________________________________________
Address
______________________________________________________________________________________
City
State
Zip
______________________________________________________________________________________
Phone
Fax
______________________________________________________________________________________
Email
_______________________________________________________________
Medical director
Number of surgery centers: ________
TYPE of Center
m Single Specialty (IPM)
m Predominantly Single Specialty (IPM)
m Multi-specialty
m Other __________________________
TYPE of Ownership
m Physician owned
m Corporate owned
m Hospital collaboration
m Other __________________________
_______________________________________________________________
administrator
NUMBER OF PHYSICIANS: _______________
Number of interventional procedures performed in 2005
m <1,000 m 1,000–1,459 m 1,500–1,999 m 2,000–2,999 m 3,000–3,999
m 4,000–5,000
Number of o.r. rooms: ______________
m Other ___________________
Types of Membership
surgery center
Center memberships include complimentary individual memberships for 2–25 members of staff
m $25,000
Life Member for SIPMS (fee is per center) with yearly dues of $5,000
—includes membership for 25 staff members
m $5,000/year Center is 100% IPM and does 1000+ IPM procedures a year
m $2,000/year Center does fewer than 1000 IPM procedures a year
for surgery center applications:
Attach list of individuals to be named
members on a separate sheet(s)
of paper and submit with application
(up to 25, depending on level of
membership to the left). Include information asked of individuals (see
below) including title and/or degree.
INDIVIDUALs
Annual Membership (physician, administrator, coordinator, nurse)
m $500/year
Name _____________________________________________________________
degree (MD, DO, RN, LPN, etc) ___________________________
position ________________________________________________________________________________________________________________________
Address (if different from above) ______________________________________________________________________________________________________
City ________________________________________________________________
State ___________
Zip ____________________________
Phone ____________________________
Fax ____________________________
EMAIL ____________________________________________
Specialty designation: m 09 Interventional Pain Management
m 72 Pain Medicine
m Other _________________________________
Method of Payment
m Check (Enclosed, Payable to ASIPP) Check number ____________________
____________________________________________________________________________________________________________________________________________________
Credit Card Number
Expiration Datename On Card
______________________________________________________________________________________________
50
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81 LAKEVIEW DRIVE
PADUCAH, KY 42001
PHONE (270) 554-9412
WWW.ASIPP.ORG
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• American Board of Interventional Pain Physicians—Part I Certification Examination—August 11, 2007
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