Is Chronic Pain Management Right for Your ASC?

Staffing Pain Management Industry Trends Financial Management

By: Jared Bilski | Managing Editor

Published: 3/16/2022

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Understand the procedural trends, staffing needs and complex reimbursement landscape before adding this surging specialty.


Running a successful chronic pain management program demands striking a delicate balance between efficiency and efficacy. Much like other programs that specialize in high-volume procedures — such as colonoscopies and cataracts — a pain service line often centers around the breakneck pace of maximum throughput. In fact, a busy pain physician could easily perform 25 to 30 15-minute procedures in a day, according to Edgar L. Ross, MD, director of Brigham and Women’s Pain Management Center in Chestnut Hill, Mass. “That’s the kind of volume you need to make this service line worthwhile,” says Dr. Ross, who is also an associate professor at Harvard Medical School in Cambridge. 

However, unlike the largely predictive results of high-volume surgeries, treating pain is rarely a one-dimensional proposition. It’s a misconception that does a great disservice to pain physicians who are sarcastically referred to as “needle jockeys” because of the number of injections they perform and the patients who greatly benefit from diverse chronic pain programs. “The comprehensive treatment of pain needs to involve physical therapy, sometimes psychological therapy and, with increasing numbers of patients, interventional procedures and medication management,” says Dr. Ross. Running a successful chronic pain service line is a complex, nuanced endeavor that requires plenty of due diligence on the part of facility leaders. Here’s an overview of the key considerations.

• Clear expectations. Surgery centers are adding chronic pain management programs with increasing regularity due to heightened demand for the services — Dr. Ross estimates he’s seen a 20% bump in the types of pain procedures his facility is performing. Much like the understanding of pain itself, chronic pain management is a service line that is constantly evolving. If you can’t keep pace with the changing trends, you’re liable to be left behind.

“Facilities that are building programs for the present focus on injection-based work,” says Sayed E. Wahezi, MD, pain medicine specialist and program director of the pain medicine fellowship at Montefiore Medical Center in the Bronx, N.Y. “If facilities are building for the long-term, they need to look beyond injections and treat a chronic pain management program as a minimally invasive surgery line from every point of view.”

Indeed, Dr. Wahezi believes a fundamental change in how chronic pain programs are being conducted is occurring right now. “Practices are shifting their models to include interventional pain management,” he says. “They’re performing more percutaneous surgeries.”

These specialized, interventional chronic pain treatments target the root cause of pain instead of the symptoms, according to Puja Shah, MD, a double board-certified anesthesiologist and interventional pain management specialist at DISC Sports & Spine Center in Newport Beach, Calif. Most chronic pain management programs center around back pain, and the most common interventions involve epidural steroid, facet joint and trigger point injections — bread-and-butter procedures for many pain programs. “Often, I will do a trial of injections for patients before they undergo surgery,” says Dr. Shah. “Some of the patients can then avoid surgery if the pain from say, their sciatica, goes down significantly after three epidurals.”

As a level up from injections, facilities are performing radiofrequency lesioning (also known as radiofrequency ablation) and placing implants such as spinal cord stimulators. While facility leaders need to stay abreast of the big-picture trends in chronic pain, such as the move toward interventional therapies, it’s just as important to understand these trends at the micro level.

DOUBLE THREAT Dedicated physicians like Puja Shah, MD, a double board-certified anesthesiologist and interventional pain management specialist, are transforming chronic pain management programs.  |  DISC Sports & Spine Center

There are an increasing number of new procedures that show promise in treating chronic pain. For instance, Dr. Ross was involved in the clinical trial of a procedure that just received FDA approval. The trial involved a stimulator implanted in the multifidus muscles to treat debilitating chronic back pain in younger patients who haven’t responded to epidurals, trigger point injections and rehab. The stimulator works to rehab core muscles of the back and has been labeled as a restorative therapy because it reverses muscle atrophy and works to help the patient become much closer to where they should be functionally, according to Dr. Ross. “It has FDA approval, so the agency thought it was very helpful,” he says. “If it does pan out in the long term, this would be a new treatment for back pain that could easily be done in an ASC setting.”

This type of procedure has tremendous potential to help chronic pain patients younger than 65 who are traditionally treated with radiofrequency lesioning, a treatment that can have long-term consequences. “Radiofrequency lesioning in a younger person will actually denervate the multifidus muscle, so it may provide some benefit in the short term, but in the long term it can harm the patient,” says Dr. Ross.

• Appropriate staffing. Effective chronic pain management programs rely on multidisciplinary communication among diverse clinicians, and it all starts with having multiple dedicated pain specialists on staff. “Ideally you should have at least two pain specialists, so that when one goes on vacation, you don’t need to stop scheduling procedures,” says Dr. Ross. 

There are an increasing number of specialists board-certified in pain and another specialty, such as anesthesiology, who bring a well-rounded perspective to chronic pain management programs. All pain physicians must have strong skillsets in assessing a patient’s health history, understanding intricate anatomy and reading complex imaging, according to Dr. Wahezi.

Chronic pain programs need a deep and diverse staff of clinicians to thrive. “Facilities should have a psychologist or psychiatrist, a behavioral therapist, a dedicated nurse or physician assistant to facilitate case volumes, and a robust specially trained nursing staff,” says Dr. Wahezi. He also points to the importance of having an airway management expert on staff to maintain patient safety.

Dr. Ross also touts the importance of education and specialized skillsets in chronic pain staffs. “Personnel training is extremely important,” he says. “My nursing staff services pain medicine clinics and procedures, and they all have the ability to handle specific and complex physician preferences.”

• Securing reimbursements. Facility leaders aren’t the only ones who have noticed the surge in chronic pain management programs and procedures. “The dramatic increase in utilization has caught the attention of CMS and many private insurers,” says Dr. Ross. “You can treat patients, but getting reimbursement for implants and procedures is becoming more difficult.”

To avoid unnecessary scrutiny from payers, Dr. Ross suggests facilities keep a close watch on the ratio of pain procedures to follow-up visits. Case volumes that are 80% procedures and 20% follow-up or medication-management visits tend to draw the attention of payers, according to Dr. Ross, who says a credible practice is about a 50/50 or 60/40 mix.

Dr. Wahezi agrees that insurance companies are being a bit more careful about how they reimburse chronic pain management programs and are implementing more stringent checkpoints that facilities must go through to secure payments. “Insurance companies want these procedures to have patient satisfaction metrics and objective measurements to back them,” he says. Dr. Wahezi says the benefits of a procedure can be measured with a scoring system called Global Impressions of Change, which involves patients self-reporting on the effectiveness of treatments by rating how the interventions impacted their activity level, symptoms, emotions and overall quality of life. While patient satisfaction is subjective, objective measures of a procedure’s impact include assessments of post-treatment functionality such as how long patients can stand, walk, sit or work and whether treatments decrease their opioid usage. 

CMS is looking at the metrics it uses to determine the efficacy of various pain procedures and rethinking how the research that provides such metrics is conducted. Case in point: Four years ago, Dr. Wahezi was involved in a Coverage with Evidence Development (CED) study for a vendor that was looking to gain a CPT code from Medicare for its procedure and product. 

Even though a CPT code wasn’t awarded for the procedure, a national coverage determination was provided, and the procedure is currently reimbursed well by payers. “The results overshot even Medicare’s expectations,” says Dr. Wahezi. As pain procedures continue to evolve, he says, you may see more of these Medicare-funded studies in the future.

If facilities are building for the long term, they need to treat a chronic pain management program as a minimally invasive surgery line from every point of view.
— Sayed E. Wahezi, MD

Challenge creates opportunity

The global response to the opioid epidemic reflects the medical community’s about-face regarding these addictive painkillers. In the past, says Dr. Ross, chronic pain was treated at the frontlines by primary care physicians who found an easy solution in narcotics. “That approach had disastrous consequences,” he says. “Now, pain specialists, of whom there are far too few, are being asked to find solutions and different ways of treating chronic pain.”

Dr. Wahezi says the opioid crisis, which is responsible for 80,000 nationwide deaths per year, is still driving the push for alternate treatments of pain that are being conducted at outpatient centers across the country. The silver lining, of course, is that the opioid crisis has directly led to innovative non-narcotic interventions. Chronic pain management programs are developing and delivering — a trend that will only expand moving forward. OSM

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