Pain management is the hidden gem of our 9-month-old surgery center, a lucrative in-and-out specialty that doesn't require much in the way of space, equipment, staff and supplies. Come see for yourself.

Profitable, quick and easy to add
If there's such a thing as an easy-to-add specialty, pain management just may qualify.

• Pain is profitable. Here at the Madison Surgery Center, our average cost per pain procedure is $710. This includes disposables, overhead, anesthesia supplies and payroll, and is based on a review of a month's worth of procedures by one of our pain physicians. The average reimbursement is $800 per procedure, meaning the average profit per procedure is $90. We do about 100 pain procedures per month in a dedicated pain room (and another 700 multispecialty cases per month in four ORs and five GI rooms). That represents $9,000 per month and $108,000 per year in pure profit.
• Pain is quick. Our four pain-certified docs (they're among our 33 owners) can do three procedures an hour, sometimes four. We do everything up and down the spine: cervical, lumbar and caudal, and select nerve root blocks. Turnover is consistently less than five minutes. We can easily do 10 pain patients in the morning and 10 more in the afternoon; one pain doc has an a.m. block, another a p.m. block three or four days a week. We schedule procedures in 15-minute intervals.
• Pain is relatively easy to add. Whether you're managing a surgery center or a hospital, the capital equipment you'll need for pain procedures is pretty simple: a C-arm and a fluoroscopy table. You should plan as we did to spend a little more than $150,000 for both. We purchased a new C-arm and a refurbished table.

Our physicians requested a digital C-arm. We found that top-of-the-line digital technology runs from $120,000 to $150,000. We paid $123,000 for ours. But for spinal procedures - especially cervical epidural steroid injections - the more detailed, sharper image you'll get from a digital C-arm is well worth the price. Another advantage to a digital C-arm is that you can download the pictures to a hard drive and to the physician report. The main reason we purchased new? It's very difficult to find a refurbished digital C-arm.

We paid $17,500 for our refurbished pain management table, which has everything we need and nothing we don't. It has a 400-pound weight limit and unobstructed floor clearance. Whether you're doing cervical or caudal procedures, good floor clearance between your C-arm and table is a critical consideration. Two other neat features: Our table has an X-ray barrier and lateral tilt if we need assistance transferring a patient.

We also have an anesthesia machine in our pain management room should a patient need emergency mechanical ventilation. The machine is an adjunct to our room should the pain management physician determine from patient assessment that there's a need for more involved anesthesia care. And don't forget supplying each staff member in the procedure room with radiation safety supplies, including lead aprons, thyroid collars and lead glasses. The glasses run about $180 per pair.

Streamlining disposables
Being a new facility, we've had to use trial and error to streamline our pain procedure process. We surveyed our physicians, and the consensus was to use one single-shot disposable epidural tray and one spinal tray from a single vendor, which lets us standardize supplies. Each tray contains our prep, lidocaine, drape, and needle and syringe. To accommodate all physicians, we customize the trays to their needs by adding different size needles and catheters to our trays. We've made a physician preference card for each pain doc so any staff that works the room knows what the physician uses for his procedures.

We've done what we could to streamline medications as well. We use depomedrol for all injections. Our contracted price for this steroid that gives long-term relief is $7.40 per 40mg vial and $12.85 per 80mg vial. We also use marcaine and lidocaine, which give immediate relief, and occasionally fentanyl, a narcotic that gives about four-hour relief.

Four procedures per hour
Turnover is a real key to running a profitable pain service. We average 15-minute to 20-minute procedure times with turnover times of less than five minutes. If everything goes well in pre-op and labs are OK, we can do four procedures an hour. Among the pain procedures we do are select nerve root blocks, cervical epidural steroid injections, thoracic epidural steroid injections, lumbar epidural steroid injections, facets, discograms, trigger points and sacral-iliac joint injections.

We staff our pain room with five people: the physician, a C-arm tech, a nurse, a surgery tech and either an anesthesia assistant or a CRNA. Two tips to keep your schedule moving: While one procedure is in process, a transport person should pick up the next patient; cross-train all pain staff to assist, run the C-arm and transport.

Don't ignore the pre-op process, which is where efficiency starts. Our comprehensive pre-op screening involves attempting to contact every patient by phone before his appointment to collect histories, and to do pre- and post-op teaching. Upon arrival, patients register and sign a facility consent. We then take them to pre-op, where they sign a consent for the pain procedure. An RN starts an IV, and the anesthesiologist evaluates the patient.

Anesthesia sedates all patients in our facility - and that alone is huge when you're talking efficient turnover. Our CRNAs and AAs use propofol and Versed, and patients are literally awake within five minutes post-op. For the most part, they're ready to be discharged within 30 minutes.

Another word on reimbursement
The confluence of three factors makes pain a lucrative specialty: Reimbursement is surprisingly good, more chronic pain patients are turning to injections for relief and you'll typically do several (separately billable) injections in a single visit.

Alabama Blue Cross/Blue Shield, for example, reimburses ASCs 100 percent for the first injection and 50 percent for the second. Medicare reimburses 100 percent for the first, 50 percent for the second and 25 percent for each additional injection. Private payers typically pay a portion of all charges according to the contract you've negotiated.

So there you have it, a quick rundown of a profitable, quick and easy-to-add specialty. And pain patients are unlike surgical patients in one very important regard: They're eager to make return visits to ease their chronic pain.