Stop the Medicare cuts to senior citizens and the disabled in pain

As a pain physician, I would like to personally explain to President Barack Obama, Kathleen Sebelius, senior citizens and any disabled American suffering in pain, the devastating effects that will result from the drastic Medicare cuts in chronic pain care that are scheduled to take effect January 1, 2014.  These cuts will severely, drastically and unfairly cut access to chronic pain care for senior citizens and other Medicare beneficiaries and at the same time promote the worsening of the prescription drug abuse epidemic.  This is the wrong medicine, at the wrong time.

Now a pain specialist, I started my career as an emergency physician, and for years I took care of thousands of patients suffering from pain, as well as countless patients suffering from the ravages of prescription opiate addictions and overdoses.   After more than a decade in emergency medicine, I rededicated my career to becoming a pain management specialist, by being one of the first emergency physicians to complete an ACGME accredited pain medicine fellowship, and earn ABMS pain medicine board certification.  I did this with the expressed goal of committing my career towards simultaneously easing the suffering of those in chronic pain with keen attention towards non-addictive treatments that would help ease suffering, yet not contribute to the terrible prescription drug overdose epidemic occurring in the United States today.

Tragically, on November 27th, 2013, Medicare published its final payment rule for 2014 that will enact a crushing blow to funding for chronic pain care, particularly non-narcotic, and non-addictive pain procedures and injections provided in doctors’ offices.  Such procedures include epidural steroid injections, nerve blocks, joint injections and pain-relieving spinal cord stimulators among others.  The judicious use of such procedures is a crucial weapon in the battle against chronic pain many senior citizens and other disabled Medicare beneficiaries face, particularly for those physicians who choose to focus on non-narcotic and non-addictive treatment options.

For such procedures performed in a physician’s office, the cuts are drastic and across the board, including cuts up to 58% for epidural steroid injections, and over 75% for in-office spinal cord stimulator trials.  Nearly every other procedure a pain specialist performs will be cut by at least 5 to 25%.  Cutting such treatments will necessarily have the unintended effect of increasing the use of the other main option to treat chronic pain: narcotics.

Such drastic cuts will naturally reduce the most highly-trained pain specialists’ ability to provide quality, safe and non-addictive treatment options to their patients.  For a physician who just started his own practice just over a year ago, these sudden cuts are devastating.  I may not be able to stay in business or provide the quality care my patients need.  The startup and ongoing overhead costs for an interventional pain practice including equipment and staff are in the hundreds of thousands of dollars, not to mention student loans from medical training.

Simultaneously, while cutting physician fees provided in a physician’s office, Medicare has opted to increase funding for the same identical procedures provided in hospitals.  These procedures provided in a hospital already cost 5-6 times more than when provided in a physician’s office, for the identical procedure. Yet, Medicare has opted to increase such already more expensive payments up to 20% while drastically decreasing funding to physicians providing the same care at already much cheaper fees in their offices.

Such cuts by Medicare will deal a crushing blow to senior citizens and disabled Medicare patients in chronic, severe pain, while at the same time reducing the ability of the most highly-trained pain specialists to provide such care.  The result will be to encourage the prescribing of already overprescribed narcotic pain medications that are contributing to the more than 15,000 yearly deaths by prescription pain killers.

Patients will not be able to afford the cost of the best and safest treatments if forced to pay out-of-pocket.  I urge those that suffer with chronic pain, and those with a loved one suffering in pain, to please call or write your US Congressman, the United States Secretary of Health and Human Services Kathleen Sebelius, President Barack Obama, and anyone else who cares about the disabled, and those suffering in chronic pain.  Tell them to stop these harmful cuts now.

Scott Mayhew is a physician specializing in pain management.


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  • whoknows

    This is a very bad sign as most of the large centers have long waiting lists and are usually very dysfunctional. There is already I believe a shortage of pain MD’s. If you have pain, a private MD I think is more desirable such as your practice.

  • Jon French

    EDNC, if that is the purpose then they have failed miserably. Under the 2014 reimbursement, these procedures will increasingly be done in the hospital setting at ~$800 a shot as it will be financially impossible to continue to perform these in the more efficient and affordable office setting where the same procedure will pay $100. If they wanted to rein in abuse they should have required board certification through the ABMS and an ACGME accredited pain fellowship as prerequisites to bill ESI’s under CMS. Instead CMS in their infinite wisdom has decided to open the flood gates of abuse to NPs, CRNAs and PAs and as collateral punish all providers across the board. I believe I provide only necessary and ethical care and it sickens me when these procedures are misused and abused. However, punishing all providers and facilitating the performance of potentially dangerous procedures by untrained mid levels is a travesty to say the least! Your points are heard but your answer is lacking.

  • Jon French

    Scott, your article is excellent. Healthcare costs will only increase under these cuts. In addition, opioid prescriptions will rise as physicians’ armamentarium is limited to medication management. This in turn will lead to undo pain and suffering, misuse and abuse. It’s a very poor solution which will only hurt providers, patients and the general public.

  • Richard Dobson

    Several comments have claimed in effect that ESIs are a valid alternative to opioid medication. Could and would anyone provide peer reviewed studies that support that claim?

  • TheStigg

    I also hear your points about abuse of the system. Any payment system with rules can be gamed, and this happens everywhere, not just in medicine. The majority of doctors are honest professionals trying to do the best for their patients with the resources available. There are unfortunately outliers who abuse the hell out of the system. I was offered an opportunity to take over the practice of a Korean guy in LA who does injections two days per week and basically maxes out what is allowed by Medicare and MediCal on every patient by performing ridiculous multi-level two-sided procedures that no responsible doctor would perform. The recruiter told me he has always been the target of scrutiny as the highest Medicare/MediCal billing pain doc in the city, but never been stopped. Ludicrous.

    There are ways of curbing this abuse without punishing every single doctor in the field and their patients. Require board certification and appropriate subspecialty certification. Place reasonable limits on the number of injections per year per patient, and how much can be done in one session. Require documented benefit to make it easier to investigate outlier physicians and their patients (collusion is a real possibility in these cases).

    The barrier to meaningful reform is, as usual, big money for the big players who can purchase influence, and a president who is hell bent on hurting doctors.