R E P O R T T O T H E C O N G R E S S

Paying for Interventional

Pain Services

in Ambulatory Settings

D E C E M B E R 2 0 0 1

1730 K Street, NW • Suite 800 • Washington, DC 20006

(202) 653-7220 • Fax: (202) 653-7238 • www.medpac.gov

R E P O R T T O T H E C O N G R E S S

Paying for Interventional

 Pain Services

in Ambulatory Settings

D E C E M B E R 2 0 0 1

..................................................................................................................

Executive summary

..................................................................................................................

......................................................................................................................................................................................................................................................................................................

Paying for Interventional Pain Services in Ambulatory Settings • December 2001

Executive summary

v

Medicare’s payment policies should strive to establish rates that approximate the prices that would

prevail in the long run in competitive local health care markets to ensure that: 1) beneficiaries have

access to high-quality care; and 2) taxpayers and beneficiaries are not unnecessarily burdened through

the taxes and the premiums they pay to finance the program. The Congress asked MedPAC to report

on the barriers to payment and coverage for interventional pain services furnished in hospital outpatient

departments (HOPDs), ambulatory surgery centers (ASCs), and physicians’ offices. This report gives

our response to this question.

Medicare’s policies for paying for interventional pain services are inconsistent across ambulatory care

settings. Consequently, the Commission recommends that the Secretary evaluate payments for

ambulatory services to ensure that financial incentives do not inappropriately affect decisions regarding

where care is provided. The Commission also found that payments for interventional pain services in

ASCs probably do not reflect current costs because the rates are based on old charge and cost data.

The Commission recommends that the Secretary evaluate payment rates for ASCs using recent charge

and cost data from a sample of ASCs and update the list of procedures that are covered when

performed in ASCs. With respect to care furnished in physicians’ offices, the practice expense

allocation for interventional pain services performed in physicians’ offices is lower than the amounts paid

for the same services under the HOPD and ASC payment systems. Beginning in January 2002,

Medicare will recognize pain management as a specialty group. Consequently, the Commission

recommends that the Secretary recalculate the practice expense payments for interventional pain

procedures when data become available on the practice expenses of physicians specializing in pain

management.

Finally, MedPAC found inconsistences in coverage policies across localities because Medicare’s

contractors each set policies within a specified geographic area. In addition, the limited number of

randomized controlled studies evaluating interventional pain services is hindering the ability of

contractors to establish policies in this clinical area. The Commission recommends that the Secretary

sponsor additional research about the effectiveness of interventional pain services to strengthen the

evidence basis for Medicare’s coverage decisions. ■

..................................................................................................................

Paying for Interventional Pain

Services in Ambulatory Settings

.........................................................................................................................................
R E C O M M E N D A T I O N S

1 The Secretary should evaluate payments for services provided in hospital outpatient

departments, ambulatory surgical centers, and physicians’ offices to ensure that

financial incentives do not inappropriately affect decisions regarding where care is

provided.

* YES: 15 • NO: 0 • NOT VOTING: 0 • ABSENT: 2

 .......................................................................................................................................................................................................................................................................................................................................................................

2 The Secretary should evaluate payment rates for ambulatory surgical centers (ASCs)

using recent charge and cost data from a sample of ASCs. He also should update the

list of procedures that are covered when performed in ASCs.

* YES: 15 • NO: 0 • NOT VOTING: 0 • ABSENT: 2

 .......................................................................................................................................................................................................................................................................................................................................................................

3 The Secretary should recalculate the practice expense payments for interventional

pain procedures when data become available on the practice expenses of physicians

specializing in pain management.

* YES: 15 • NO: 0 • NOT VOTING: 0 • ABSENT: 2

 .......................................................................................................................................................................................................................................................................................................................................................................

4 The Secretary should sponsor additional research about the effectiveness of

interventional pain services to strengthen the evidence basis for Medicare’s coverage

decisions.

* YES: 15 • NO: 0 • NOT VOTING: 0 • ABSENT: 2

*COMMISSIONERS’ VOTING RESULTS
......................................................................................................................................................................................................................................................................................................

Paying for Interventional Pain Services in Ambulatory Settings • December 2001 3

The Medicare Payment Advisory Commission (MedPAC) examined the consistency and

appropriateness of payment for interventional pain services across ambulatory settings—hospital

outpatient departments (HOPDs), ambulatory surgical centers (ASCs), and physicians’ offices. The

Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) required

that MedPAC report on the barriers to payment and coverage for outpatient interventional pain

management procedures.

Based on our evaluation and the findings of a study conducted by Project HOPE on behalf of

MedPAC, we found no hard evidence that access is compromised (Mohr and Milet 2001).

MedPAC’s analysis of trend data shows, with a few exceptions, that spending for interventional pain

services has generally kept pace with or exceeded spending growth for all physician services. However,

it is possible that some of these services, such as spinal punctures or trigger point injections, may have

been administered as adjuncts to surgical procedures rather than for the management of chronic pain.

As such, these data may confound evaluation of the use of interventional pain services. Medicare’s

newly created pain management specialty for physician services should improve efforts to monitor

trends in the use of these services.

We highlight three conclusions based on our analysis of Medicare’s policies for paying for interventional

pain services in ambulatory settings:

• Payment rates for some interventional pain services vary greatly across ambulatory settings. The

Commission reiterates our March 1999 recommendation that the Secretary evaluate payments for

services provided in HOPDs, ASCs, and physicians’ offices to ensure that financial incentives do not

inappropriately affect decisions regarding where care is provided.

• Payment rates for services furnished by ASCs are probably not consistent with their costs because

the rates are based on dated charge and cost data. In addition, certain interventional pain services

are not paid for when performed at ASCs. This lack of payment may be due to delays by the

Centers for Medicare & Medicaid Services (CMS) in updating the list of covered procedures in

ASCs. Consequently, the Commission recommends that the Secretary evaluate ASC payment rates

and update the list of ASC-approved procedures.

• Physician practice expense allocations for interventional pain services are, on average, lower than the

rates paid to ASCs and HOPDs. We do not know if payments are adequate or if the cost of providing these services in offices is lower than that in facilities. CMS recently recognized pain management

as a physician specialty, but it is too soon to tell whether this will affect the physician practice expense

allocation for interventional pain services. The Commission recommends that the Secretary recalculate practice expense payments for interventional pain services when data become available on the

expenses of physicians specializing in pain management.

MedPAC also examined the effect of Medicare’s coverage policies on access. Substantial variation

exists in the local medical review policies (LMRPs) made by Medicare’s contractors about coverage of

interventional pain services in ambulatory settings. The paucity of information in the medical literature

about the use of interventional pain services has contributed to the inconsistencies in these policies.

Consequently, MedPAC recommends that the Secretary sponsor additional research about the

effectiveness of interventional pain services to strengthen the evidence basis for Medicare’s coverage

decisions.
.......................................................................................................................................................................................................................................................................................................

4 Paying for Interventional Pain Services in Ambulatory Settings • December 2001

What is interventional pain management?

Pain is widespread among Medicare beneficiaries, many of whom suffer from osteoarthritis, joint

disease, and other chronic medical conditions. Between 25 and 50 percent of the noninstitutionalized

elderly suffer from significant pain at some time, and estimates of the rate for nursing home residents

reach as high as 80 percent (American Geriatric Society Panel on Chronic Pain in Older Persons 1998,

Magni et al. 1993, Mobily et al. 1994).

Interventional pain management procedures consist of minimally invasive procedures such as needle

placement of drugs in targeted areas, ablation of targeted nerves, and some surgical techniques such as

diskectomy and the implantation of intrathecal infusion pumps and spinal cord stimulators. (See Table 1

for the interventional pain procedures considered in MedPAC’s analysis.) Many clinicians believe that

these procedures are useful in diagnosing and treating chronic, localized pain that does not respond well

to other treatments. Researchers estimate that 10 to 20 percent of persons suffering from pain will not

find adequate relief from less invasive care (Krames 1999).

Improving Medicare’s payment policies across ambulatory care settings

Because the basis for payment varies across ambulatory settings, large differences exist in the payment

rates for many types of services, including interventional pain services. Payments in ASCs are generally

higher than those in other settings, while physician practice expenses are generally lower. For example,

in 2001, the payment to hospitals for a trigeminal nerve block was $166.80; by comparison, the ASC

rate for the same procedure was $323.00, and the practice expense payment under the Medicare’s

physician schedule was $97.56 when the procedure was provided in the office setting.

Interventional pain procedures

• Facet joint blocks and neurolysis (diagnostic and therapeutic)

• Sympathetic blocks and neurolysis

• Intercostal nerve blocks and neurolysis

• Trigeminal nerve blocks and neurolysis

• Other nerve blocks

• Epidural injections

• Trigger point injections

• Other neurolytic injections

• Percutaneous lysis of epidural adhesions

• Discography

• Annuloplasty

• Implantable drug delivery systems

• Spinal cord stimulation (implantable transcutaneous electrical nerve stimulation)

• Chemodenervation of muscles

Procedures performed adjunct to interventional procedures

• Fluoroscopic guidance

• Arthrography

• Epidurography

• Myelography

• Catheter placement

• Spinal puncture

• Arthrocentesis

Interventional pain services considered in MedPAC’s analysis TABLE

1

Source: Data compiled by MedPAC.

 .......................................................................................................................................................................................................................................................................................................................................................................

 ..................................................................................................................................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................................................................

Paying for Interventional Pain Services in Ambulatory Settings • December 2001

Variations in payment could lead to shifting of care to inappropriate settings. MedPAC examined the

issue of potential shifts among ambulatory settings by calculating the share of spending, by setting, for

physicians’ services in 1995 and 1999. The results, detailed in Table 2 (page 6), show the potential for

shifting services among ambulatory care settings. For example, in the case of trigeminal nerve blocks

and facet joint blocks, the data suggest that procedures have shifted to HOPDs and ASCs from

physicians’ offices. The data also show the potential for shifting of spinal cord stimulation and spinal

puncture services to HOPDs from physicians’ offices. Finally, data suggest that for intercostal nerve

blocks and neurolysis and other nerve blocks, decreasing shares for services in HOPDs are offset by

increasing spending shares for physicians’ offices.

The Commission is concerned that financial considerations could lead to undesirable shifts of services.

If care is shifted among settings, it should occur for clinical reasons and not because of payment rates.

Consequently, we reiterate our recommendation from March 1999:

The Secretary should evaluate payments for services provided in hospital outpatient

departments, ambulatory surgical centers, and physicians’ offices to ensure that

financial incentives do not inappropriately affect decisions regarding where care is

provided.

The Secretary’s evaluation should focus primarily on services commonly provided in more than one

ambulatory setting and should include both an analysis of the payments and costs and an analysis of the

appropriateness of care performed in particular settings. In the event that inappropriate payment

differences are found, the Secretary should begin to develop a means of recalibrating payment amounts

to reduce their potential impacts on choice of setting.

In addition to affecting program spending, shifts in site of care can have unintended consequences on

beneficiary coinsurance. Beneficiary coinsurance is 20 percent for services provided in physicians’

offices and ASCs. By contrast, MedPAC estimated that the average coinsurance for HOPD services

was just under 50 percent of total payment for services in 2001 (MedPAC 2001a).

Improving payment policies for services

provided in ambulatory surgical centers

ASC payment rates probably do not reflect current ASC costs because the rates are based on old

charge and cost data. Medicare pays ASCs based on a fee schedule, which sets payment rates

(median charges adjusted to costs) for eight procedure groups.1 CMS last conducted a survey of

ASC’s costs and charges in the late 1980s.

In addition, Medicare only pays for certain interventional pain procedures when they are performed in

ASCs. CMS has not updated the list of these covered procedures since 1998.

RECOMMENDATION 1

1 ASC payment rates are adjusted to reflect geographic differences in input prices.

......................................................................................................................................................................................................................................................................................................

5
.......................................................................................................................................................................................................................................................................................................

Paying for Interventional Pain Services in Ambulatory Settings • December 2001

.............................................................................................................

6

Share of physicians’ expenditures for interventional

pain services by site of care, 1995 and 1999

TABLE

2

Type of service 1995 1999 ..................................................................................................................................................................................................................................................................................................................................................................

Chemodenervation of muscles

• HOPD

• office

• ASC

Discography

• HOPD

• office

• ASC

Facet joint blocks

• HOPD

• office

• ASC

Implantable drug delivery systems

• HOPD

• office

Intercostal nerve blocks/neurolysis

• HOPD

• office

• ASC

Spinal cord stimulation

• HOPD

• office

• ASC

Spinal puncture

• HOPD

• office

• ASC

Sympathetic blocks and neurolysis

• HOPD

• office

• ASC

Trigeminal nerve blocks

• HOPD

• office

• ASC

Trigger point injections

• HOPD

• office

Other nerve blocks

• HOPD

• office

• ASC

Other neurolytic injections

• HOPD

• office

• ASC

All other services

• HOPD

• office

• ASC

 12.7% 13.0%

 87.3 86.6

 0 <1.0

 51.6 52.3

 46.5 43.1

 1.9 4.7

 22.9 64.7

 72.1 23.4

 5.0 11.9

 0 <1.0

100 99.8

 12.3 8.1

 83.7 91.4

4.0 <1.0

 80.1 97.5

19.9 0

 0 2.5

 68.5 76.1

 31.5 23.6

 0 <1.0

 5.5 15.7

 81.1 81.2

 13.4 3.1

 26.8 33.8

 73.2 61.1

 0 5.5

 1.6 1.3

 98.4 98.7

 7.8 3.7

 91.6 95.7

<1.0 <1.0

 23.5 24.5

 72.9 74.5

 3.5 1.0

 24.8 21.3

 71.9 75.9

 3.4 2.7

Share of physicians’ expenditures

Note: HOPD (hospital outpatient department), ASC (ambulatory surgical center). Groups of interventional pain procedures accounting for less than $1 per

$1,000 in physician spending are not shown.

Source: MedPAC analysis of Medicare Part B 5 percent physician/supplier file.

 ....................................................................................................................................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................................................................

Paying for Interventional Pain Services in Ambulatory Settings • December 2001 7

The Secretary should evaluate payment rates for ambulatory surgical centers (ASCs)

using recent charge and cost data from a sample of ASCs. He also should update the list

of procedures that are covered when performed in ASCs.

CMS should proceed with its 1998 proposal to conduct a new rate survey, and, in accordance with the

BIPA, should collect data from 1999 or later. CMS is statutorily required to conduct a rate survey

every 5 years. Past surveys have collected data from a sample of ASCs about charges for individual

procedures and total costs and charges.

In addition, CMS should proceed with its 1998 proposal to update the list of procedures that are

covered when performed in ASCs. The agency is required by statute to review the list at least every

two years. CMS also should revisit its 1998 proposal to modify the methods used to approve

procedures, including using site-of-service volumes as one of the factors (but not the main factor) in its

approval process.

Improving payment policies for physician services

Generally, the practice expense allocation for interventional pain services performed in physician offices

is lower than the amounts paid for the same services under the HOPD prospective payment system and

the ASC fee schedule. It is unclear, however, whether practice expense allocations are adequate,

because data on the costs of providing these services in office settings are lacking. Beneficiaries’ access

to high-quality care in office settings could be adversely affected if payment amounts are not adequate.

The practice expense allocation for interventional pain services is a function of the mix of specialty

groups who perform these services and their hourly practice expenses.2 CMS calculates the practice

expense allocations for each procedure by weighting the average of the direct and indirect costs of the

specialties performing the service by the frequency with which each specialty performs the procedure.

The agency calculates practice expense allocations separately for care delivered in facility and nonfacility (office) settings. CMS estimates practice expenses for each physician specialty by using data

obtained from the American Medical Association’s Socioeconomic Monitoring System (SMS) survey.

Because some specialties are not adequately represented in the SMS data, CMS allows specialty

groups to submit their own cost data.

Current mean practice expenses differ substantially among the specialty groups recognized by Medicare

that perform interventional pain procedures, ranging from $27 per hour for anesthesiology, to $59 for

neurology and $88 for physical medicine (HCFA 1998a). The average practice expense allocation for

a given procedure will decrease the extent to which a greater number of physicians with lower practice

expenses perform the procedure.

RECOMMENDATION 2

2 Medicare requires physicians participating in Medicare to describe the kind of medicine they practice by designating one primary and one

secondary medical specialty.

......................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................

8 Paying for Interventional Pain Services in Ambulatory Settings • December 2001

The Secretary should recalculate the practice expense payments for interventional pain

procedures when data become available on the practice expenses of physicians

specializing in pain management.

Beginning in January 2002, Medicare will recognize pain management as a specialty group. A

Medicare-recognized specialty of pain management is justified, given the high prevalence of pain among

beneficiaries and the varying techniques used to treat pain. Physicians performing interventional pain

services are trained in a variety of specialties, including anesthesiology, neurology, and physical

medicine. The American Board of Anesthesiology provides a subspecialty board certification in pain

management and approximately 3,000 physicians have achieved this certified status. A pain

management specialty will enable researchers to monitor trends in the use of and payments for pain

management services. In addition, this specialty designation is consistent with the specialty taxonomy

that has been developed under the Health Insurance Portability and Accountability Act.

At issue is whether this new specialty will affect the adequacy of the practice expense allocation for

interventional pain services. We have no way to ascertain how this new specialty designation will affect

payments until data becomes available on: 1) the practice expenses of the physicians who will identify

themselves under the new specialty designation; and 2) the mix of physician specialties that will

ultimately perform these services. It typically takes two to three years for CMS to collect sufficient data

to calculate the practice expense allocation for a new specialty. First, physicians must identify

themselves under a new specialty to their carriers. Then they must bill enough services so that they are

adequately represented in the claims data. Practice expense data may need to be collected from

physicians specializing in pain management to supplement data from the SMS survey. Finally, it takes a

full billing year for claims to be used in CMS’s reevaluation of the practice expense allocation. When

sufficient data do become available, the agency should re-analyze the adequacy of the practice expense

allocation for interventional pain services.

Improving payment policies for services provided

in hospital outpatient departments

Certain aspects of the design of the HOPD prospective payment system may result in inaccurate

payment for interventional pain services. It appears that the method CMS used to establish the relative

values, which measure the expected costliness of a unit in each classification category (APC) compared

with the overall average costliness of all units, may result in inaccurate payments for certain services,

including fluoroscopy. Specifically, CMS used only single-procedure claims to calculate the median cost

for services within an APC, which resulted in 55 percent of the outpatient claims being excluded.3 The

agency excluded multiple-procedure claims to minimize the risk of improperly assigning costs to the

wrong service.

......................................................................................................................................................................................................................................................................................................

3 Single-procedure claims are those for which the procedure code to be grouped to an APC is the only code that appears on the bill, other than

incidental services. Multiple-procedure claims included more than one procedure code that could be mapped to an APC. Multiple-procedure bills

were used in other analyses done by CMS, including the impact analysis (Health Care Financing Administration 1998b).

RECOMMENDATION 3
......................................................................................................................................................................................................................................................................................................

Paying for Interventional Pain Services in Ambulatory Settings • December 2001 9

Unfortunately, the lack of claims data about the experience of hospitals under the new outpatient

payment system to date substantially limits MedPAC’s ability to draw definitive conclusions about the

appropriateness of this system for interventional pain services. Nonetheless, CMS’s recent proposal to

revise the HOPD prospective payment system by adding several new APCs for interventional pain

procedures and by paying for some procedures previously not paid in HOPDs, such as the refilling of

ambulatory pain pump reservoirs, should address some of the concerns raised by interested parties

about the new payment system. These changes are expected to affect the majority of interventional pain

management procedures by creating a wider range of payment amounts and groups that are clinically

coherent.

Improving Medicare’s coverage policies

Inconsistencies in coverage policies occur across localities because Medicare’s contractors who

implement local coverage policies—fiscal intermediaries (FIs) for hospital services, carriers for

outpatient services provided in physicians offices and ASCs, and durable medical equipment regional

carriers (DMERCs) for DME services—each can set policies within a specified geographic area.

Variation occurs despite recent efforts by CMS that require its contractors to: 1) develop evidencebased LMRPs, 2) establish an open and public process for developing LMRPs, 3) share information

among one another, and 4) post all draft and final LMRPs on their websites. CMS requires that its

contractors employ at least one medical director who assists in developing LMRPs and meets with

interested parties about draft LMRPs. Medical directors from the carriers and FIs participate in clinical

work groups, and a committee on chronic pain management was formed in the mid-1990s.4

 In

addition, the agency encourages contractors that operate in two or more states to develop uniform

LMRPs across all jurisdictions to the extent possible. Finally, the four DMERCs are required by

Medicare to develop and use one set of coverage policies.

The disparities among coverage decisions in different geographic areas may be affecting access to

certain interventional pain services. For example, several carriers have issued different LMRPs about

the number of paravertebral facet joint blocks that can be provided during an encounter and the

indications for which this procedure may be performed. MedPAC’s review of the medical literature

suggests that the limited number of randomized controlled studies evaluating interventional pain services

is hindering the ability of Medicare’s contractors to establish policies in this clinical area.

The Secretary should sponsor additional research about the effectiveness of

interventional pain services to strengthen the evidence basis for Medicare’s coverage

decisions.

RECOMMENDATION 4

......................................................................................................................................................................................................................................................................................................

4 Meetings of these clinical work groups are not required to take place in public settings.
.......................................................................................................................................................................................................................................................................................................

10 Paying for Interventional Pain Services in Ambulatory Settings • December 2001

Additional research about the use of interventional pain services will assist Medicare’s contractors

implementing evidence-based LMRPs. Conducting carefully controlled studies is especially important in

the area of pain management, because pain tolerance is highly individualized and may have a

psychological component. Researchers have shown that pain interventions can have a large placebo

effect, further reinforcing the importance of strong study designs. Many of the existing clinical studies

that evaluate interventional pain services are case series without controls. Indeed, the Cochrane

Collaboration recently called for the conduct of larger, better-designed studies to improve understanding

of the effectiveness of injection therapy for subacute and chronic low back pain.5

 Some public-private

initiatives are aiming to fill this informational gap. For example, the National Comprehensive Cancer

Network and the National Cancer Institute have several ongoing studies in cancer pain management.

However, there appear to be fewer research initiatives in the treatment of nonmalignant pain.

Additional research about the use of interventional pain services could address concerns raised by

groups interviewed on behalf of the Commission that some of the current LMRPs do not reflect

conventional pain management practice. Some groups also were concerned that LMRPs were imposed

without consulting with experts in the area of interventional pain medicine, and that physicians

specializing in pain management could not sit on carrier advisory committees (CACs). CMS requires

that carriers establish CACs in each state to make local coverage decisions after reviewing scientific

evidence in a public forum, and that CACs consider evidence obtained from its members as well as

from outside sources. The agency has clarified its policy to its contractors that physicians without a

Medicare-recognized specialty can sit on CACs. Finally, groups may formally request that CMS make

a national coverage decision about services with widely varying local coverage policies. CMS officials

have invited provider groups that offer interventional pain services to submit requests for national

coverage decisions, but none have been submitted.

The Secretary might consider the use of provisional coverage as one way to advance research on

interventional services. Under provisional coverage, investigational procedures may be covered if

beneficiaries receive treatments at facilities that follow a rigorous study protocol to evaluate the

outcomes of care. Final coverage decisions are made once the data are analyzed. The concept of

provisional coverage also could be used to evaluate the effectiveness of procedures that are currently

considered standards of care, but for which limited evidence about effectiveness exists. Such a policy

might need to be introduced at a national level to ensure an adequate sample of beneficiaries and

consistency in the methods used to collect and evaluate data.

CMS could also pursue further research about the effectiveness of interventional pain services by jointly

sponsoring clinical trials with the National Institutes of Health (NIH). Beginning in September 2000,

Medicare began covering the routine costs of qualifying clinical trials, as well as reasonable and

necessary items and services used to diagnose and treat complications arising from participation in

clinical trials. A recent example of such a collaboration by NIH and CMS is their task force to design a

clinical trial to evaluate the efficacy and costs of daily dialysis. As the Medicare population ages, it is

important to better understand what does and does not work in treating and managing pain.

......................................................................................................................................................................................................................................................................................................

5 The Cochrane Collaboration is a non-profit organization based in the United Kingdom that aims to improve health care decisionmaking by

performing systematic reviews of the effects of health care interventions (Nelemans et al. 2000).
......................................................................................................................................................................................................................................................................................................

Paying for Interventional Pain Services in Ambulatory Settings • December 2001 11

In addition to further clinical research on the effectiveness of interventional techniques, MedPAC

believes the development of cross-specialty guidelines in pain management also may make an important

contribution. Many pain specialty groups have developed their own guidelines, but they are not always

in agreement. A consensus development panel that cuts across the various specialty groups involved in

pain management could help move specialty groups toward clinical consistency in areas where

differences exists. Such endeavors could also benefit Medicare contractors as they develop LMRPs.

Additional research about the use of interventional pain services also could help address a concern

raised by some clinical experts about the quality of these services when they are performed in

physicians’ offices. Some clinical experts interviewed on behalf of the Commission voiced a concern

that these procedures are being performed in physicians’ offices that lack the necessary sterile

environment or imaging equipment, such as fluoroscopy, required to safely guide some spinal injections

to the proper locations. Although complications are rare, inappropriate needle placement may result in

paralysis or death for some of these procedures. Nonetheless, the Commission could find no evidence

in the medical literature showing that patient outcomes were affected when interventional pain services

were furnished in physician offices compared with other ambulatory settings.

Ultimately, the Commission believes that CMS should move to a standard nationwide system of claims

processing, which would eliminate LMRPs and require that CMS make nationwide decisions about the

coverage of medical services. This conclusion is based on the Commission’s analysis of the complexity

of LMRPs discussed in our December 2001 report on reducing Medicare complexity and regulatory

burden (MedPAC 2001b). Eliminating LMRPs would reduce much of the current complexity,

inconsistency, and uncertainty in the current coverage process program and eliminate the associated

burden on beneficiaries and providers. ■
.......................................................................................................................................................................................................................................................................................................

Paying for Interventional Pain Services in Ambulatory Settings • December 2001

References

American Geriatric Society Panel on Chronic Pain in Older Persons. The management of chronic pain

in older persons. Clinical practice guidelines, Journal of the American Geriatrics Society. May 1998,

Vol. 46, No. 5, p. 635-651.

Health Care Financing Administration, Department of Health and Human Services. Medicare program;

Revisions to payment policies under the physician fee schedule for calendar year 1999; proposed rule,

Federal Register. June 5, 1998a, Vol. 63, No. 108, p. 30830.

Health Care Financing Administration, Department of Health and Human Services. Medicare program

prospective payment system for hospital outpatient services; proposed rule. Federal Register.

September 8, 1998b, Vol. 63, No. 173, p. 47581.

Krames ES. Interventional pain management: appropriate when less invasive therapies fail to provide

adequate analgesia, The Medical Clinics of North America. May 1999, Vol. 83, No. 3, p.787-808.

Magni G, Marchetti M, Moreschi C, et al. Chronic musculoskeletal pain and depressive symptoms in

the National Health and Nutrition Examination. Epidemiological follow-up study, Pain. May 1993, Vol.

53, No. 2, p. 163-168.

Medicare Payment Advisory Commission. Report to the Congress: Medicare payment policy.

Washington (DC), MedPAC. March 2001a.

Medicare Payment Advisory Commission. Report to the Congress: Medicare complexity and

regulatory burden. Washington (DC), MedPAC. December 2001b.

Mobily PR, Herr KA, Clark MK, et al. An epidemiologic analysis of pain in the elderly: The Iowa 65+

rural health study, Journal of Aging and Health. 1994, Vol. 6, No. 2, p. 139-145.

Mohr P, Milet M. Study of potential barriers to accessing interventional pain management procedures in

Medicare. Project HOPE Center for Health Affairs, Bethesda MD. December 2001.

Nelemans PJ, de Bie RA, de Vet HC, Sturmans F. Injection therapy for subacute and chronic benign

low back pain, Cochrane Library Database of Systematic Reviews. 2000, Vol. 2.

12
......................................................................................................................................................................................................................................................................................................

Paying for Interventional Pain Services in Ambulatory Settings • December 2001

Commissioners’ voting on recommendations

13

In the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), the

Congress required MedPAC to call for individual Commissioner votes on each recommendation, and to

document the voting record in its report. The information below satisfies that mandate.

Recommendation 1

The Secretary should evaluate payments for services provided in hospital outpatient departments,

ambulatory surgical centers, and physicians’ offices to ensure that financial incentives do not

inappropriately affect decisions regarding where care is provided.

Yes: Braun, Burke, DeBusk, Feezor, Hackbarth, Loop, Muller, Nelson, Newhouse, Newport,

Raphael, Reischauer, Rosenblatt, Rowe, Stowers

Absent: Smith, Wakefield

Recommendation 2

The Secretary should evaluate payment rates for ambulatory surgical centers (ASCs) using recent

charge and cost data from a sample of ASCs. He also should update the list of procedures that are

covered when performed in ASCs.

Yes: Braun, Burke, DeBusk, Feezor, Hackbarth, Loop, Muller, Nelson, Newhouse, Newport,

Raphael, Reischauer, Rosenblatt, Rowe, Stowers

Absent: Smith, Wakefield

Recommendation 3

The Secretary should recalculate the practice expense payments for interventional pain procedures

when data become available on the practice expenses of physicians specializing in pain management.

Yes: Braun, Burke, DeBusk, Feezor, Hackbarth, Loop, Muller, Nelson, Newhouse, Newport,

Raphael, Reischauer, Rosenblatt, Rowe, Stowers

Absent: Smith, Wakefield

Recommendation 4

The Secretary should sponsor additional research about the effectiveness of interventional pain services

to strengthen the evidence basis for Medicare’s coverage decisions.

Yes: Braun, Burke, DeBusk, Feezor, Hackbarth, Loop, Muller, Nelson, Newhouse, Newport,

Raphael, Reischauer, Rosenblatt, Rowe, Stowers

Absent: Smith, Wakefield

..................................................................................................................

More about MedPAC

..................................................................................................................

Term expires April 2004

Sheila P. Burke, M.P.A.,

R.N., F.A.A.N

Smithsonian Institution

Washington, D.C.

Allen Feezor, M.A.

California Public Employees’

Retirement System

Sacramento, CA

Ralph W. Muller

University of Chicago Hospitals

and Health Systems

Chicago, IL

Joseph P. Newhouse, PH.D.

Harvard University

Boston, MA

Alice Rosenblatt, F.S.A.,

M.A.A.A.

WellPoint Health Networks

Thousand Oaks, CA

John W. Rowe, M.D.

Aetna Inc.

Hartford, CT

Term expires April 2002

Beatrice S. Braun, M.D.

AARP Board of Directors

Spring Hill, FL

Floyd D. Loop, M.D.

The Cleveland Clinic Foundation

Cleveland, OH

Janet G. Newport

PacifiCare Health Systems

Santa Ana, CA

Carol Raphael

Visiting Nurse Service of New York

New York, NY

Mary K. Wakefield, Ph.D.,

R.N., F.A.A.N

College of Nursing and Health Science

George Mason University

Fairfax, VA

.....................................................................................................

Commission members

Glenn M. Hackbarth, J.D., chairman

Independent consultant

Bend, OR

Robert D. Reischauer, Ph.D., vice chairman

The Urban Institute

Washington, DC

Term expires April 2003

Autry O.V. “Pete” DeBusk

DeRoyal

Powell, TN

Glenn M. Hackbarth, J.D.

Alan R. Nelson, M.D.

American College of Physicians–

American Society of Internal Medicine

Washington, DC

Robert D. Reischauer, Ph.D.

David A. Smith

AFL-CIO

Washington, DC

Ray E. Stowers, D.O.

Oklahoma State University College of

Osteopathic Medicine

Tulsa, OK

.................................................................................................... .....................................................................................

.......................................................................................................................................................................................................................................................................................................................

Paying for Interventional Pain Services in Ambulatory Settings • December 2001 17

......................................................................................................................................................................................................................................................................................................

Paying for Interventional Pain Services in Ambulatory Settings • December 2001

Administrative support

Reda Broadnax, B.S.

Wylene Carlyle

Diane E. Ellison

Plinie (Ann) Johnson

Cheron McCrae

Cynthia Wilson

Analysts

Sharon L. Bee, M.S.

David V. Glass, M.S.

Timothy F. Greene, M.B.A.

Jesse Patrice Kerns, M.P.P.

Craig K. Lisk, M.S.

Marian Lowe

Mary B. Mazanec, M.D., J.D.

Nancy Ray, M.S.

Susanne Seagrave, Ph.D.

Mae Thamer, Ph.D.

Ariel Winter, M.P.P

Chantal Worzala, Ph.D.

Daniel Zabinski, Ph.D.

Commission staff

Murray N. Ross, Ph.D.

Executive director

Lu Zawistowich, Sc.D.

Deputy director

Jennifer Jenson, M.P.H., M.P.P.

Special assistant to the executive

director

Helaine I. Fingold, J.D.

General counsel

Research directors

Jack Ashby, M.H.A.

Scott Harrison, Ph.D.

Kevin J. Hayes, Ph.D.

Karen Milgate, M.P.P.

Sally Kaplan, Ph.D.

Julian H. Pettengill, M.A.

..................................................................................... .....................................................................................

.....................................................................................

19

1730 K Street, NW • Suite 800 • Washington, DC 20006

(202) 653-7220 • Fax: (202) 653-7238 • www.medpac.gov