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American Pain Society
4700 W Lake Ave
Glenview, IL 60025
Ronald Kulich, PhD, Department Editor
Alfred Taricco, MD FACS
In March 1995, I presented a paper at a pain management symposium that dealt with the difficulties existing between pain centers and payers (i.e., insurance carriers). I made it quite clear that pain centers do not enjoy a satisfactory reputation in the payer industry. Three years have passed, and I have not observed any improvement in attitudes. The fault, however, does not lie entirely with the payers. Pain centers bear some of the blame for a variety of reasons, including fraudulent and abusive activities in some organizations (Taricco, 1995).
As payers strive to modify physicians' behavior, so should physicians and other providers strive to modify the behavior of payers, including managed care organizations and self-insured companies. The targets for this approach are claims adjusters, benefits managers, and medical directors. Despite what payers may say, I am not convinced they are willing to pay for quality care. More to the point, they seem to talk about quality care more than they act to support it. This approach can and must change.
Some years ago, I was a medical director for a major carrier. One of our recurring problems was that some charges anesthesiologists were making did not appear to be justified. Not wanting this situation to continue without explanation, I contacted the American Society of Anesthesiologists (ASA). I made a key contact, and the leaders of the organization came to the home office of the carrier for discussion. Face-to-face communication was the cardinal ingredient in our success. The concerns were put on the table, and the ASA leaders (the president, president-elect, and newly elected financial officer) responded in clear and rational terms. The result was a resolution of the carrier's concerns and an improved reimbursement schedule for ASA members. Communication was paramount in establishing a rapport that could benefit all parties.
After this success, the insurance carrier attempted to establish a channel of communication with the American Society of Plastic and Reconstructive Surgeons. There was no response. Needless to say, such a rejection does not endear anyone to a payer.
Clearly, providers must inform payers what they need to do, why they need to do it, and how they should justify charges. Payers are businesses, and they have no understanding of health care or of why certain treatments are necessary in one case, while in a similar case those treatments need modification. However, they are very good at understanding the bottom line of a financial page. Satisfying both payers and providers requires a commitment from both parties. The initiative rarely comes from the payers, so providers should take the lead in establishing a dialogue and avoiding confrontation. Remember who has the checkbook!
Managed care organizations do not manage care so much as they manage cost. There is nothing wrong with that. However, it is up to the pain professionals to provide information about real quality versus what might be called an aura of quality care, as espoused by managed care organizations. Quality of care is not simply a measure of patient satisfaction or assurance that some level of "pain service" might be covered by the carrier. Unless pain specialists take the lead in demanding that quality care be the standard, payers will continue to manage costs while providers attempt to manage care.
The principle of satisfying all clients (i.e., patients of physicians and shareholders of the payers) means that carriers are looking for outcomes that indicate a profit and that clinicians are looking for outcomes that indicate what works best and fits into a cost-effective approach. Information is necessary to make proper decisions. Interestingly, pain centers do have outcome data, but these data are published in pain journals for the benefit of other physicians.
In today's competitive climate, market share has become part of the medical lexicon. If it is not in yours, start closing your shop, because you won't be around long. It should be clear by now that if you wish to succeed financially as well as professionally, communication with your payers is essential. If you haven't yet developed an outcomes studies program, then get started and get the information to the payers. Make appointments with your payers to discuss what you are doing. Put your charges on the table and be sure you can justify them. Remember, when dealing with money issues, all the parties will try to get the best deal for themselves. Without data, your chances of success are slim.
Payers wince when they hear that a claimant (i.e., a patient) has been referred to a pain clinic. If the referral is to a "doc-in-the-box" pain clinic rather than to a true pain center, that reaction is understandable (Taricco, 1995). Payers are aware that some chronic pain problems involve secondary motives and therefore are suspicious with good reason. The following case studies from my earlier report describe the types of services that have established the poor image of pain clinics (Taricco, 1996).
The first case comes out of the western United States. A neurosurgeon who was treating a woman for chronic low-back pain submitted a bill to the carrier for $18,000, stating that the claimant was 10% better. He went on to request an additional $12,000, for which she could be improved another 10% over the course of 6 more weeks of treatments. It didn't take a rocket scientist to figure out that for $126,000, the patient might recover. The carrier denied the request.
Not surprisingly, the carrier soon received a letter from the doctor stating that the claimant had spontaneously recovered and would need no further treatment.
The second case is from a Southern state. A carrier's medical cost controller, whose office was in another state, became suspicious of a pain clinic and decided to visit it with her supervisor. They found one room, 8 ft by 8 ft, containing a few blocks, dumbbell weights, and a large wooden spool of the type used by electrical contractors. The physician was charging for services rendered at the rate of $4,000 per week. A short time later the physician went out of business.
Your job is to overcome this history and suspicion with good outcomes data and goodwill.
As someone who has been on the payer's side of this issue, I can assure you that attitudes can change. My attitude changed as I gained new knowledge by participating in a program that brought together leaders in the field of pain management. I participated in this program not only because I am a physician but because I am a physician with payer experience. This example suggests that doctors are willing to listen only to other doctors. Perhaps if pain specialists change their attitudes about business and behave more like businesspeople, then businesspeople will listen to them.
Alfred Taricco is president of Casualty Cost Containment in Manchester, CT.
