Financing the treatment of chronic pain: models for risk-sharing among pain medicine physicians, health care payers, and consumers.

Chronic pain patients are among a growing group of medically underserved Americans. Despite increasing public awareness about pain and widespread legislative activity that is focusing on the needs of pain patients, there remain significant roadblocks in bringing the expertise of Pain Medicine specialists to these unfortunate people. This paper explores how the managed care revolution has impacted the practice of Pain Medicine in the United States. The dissolution of many prominent multi-disciplinary pain treatment centers has been paralleled by the evolution of pain management as an area of interest by several competing medical specialty societies. Despite this fragmentation, the American Academy of Pain Medicine continues to grow and to promote the needs of Pain Medicine specialists and their patients. The advantages and disadvantages of various practice patterns for Pain Medicine specialists is explored against a backdrop of discussions about: (1) the problems currently faced by chronic pain patients; (2) the role of organized Pain Medicine in helping patients to access and finance care; and (3) the future of American health care and the new responsibilities that will bring to physicians. Finally, we have some specific recommendations for pain medicine specialists about: (1) sharing risk; (2) exerting individual leadership; and (3) simplifying one's professional life in the new health care environment, that we hope will enable them to continue caring for as many chronic pain patients as possible. It is opined that the development of sophisticated regional specialty networks is the best model to accomplish this task in the future.

Roadblocks to effective pain treatment.

Managed care "backlash" rhetoric to the contrary, roadblocks to effective pain treatment occur both intrinsic and extrinsic to the healthcare system. Pain medicine, an emerging, formally recognized specialty, and the special population of patients which it serves, experience additional discreet barriers. Chief among these is a lack of clear identity and recognition of the specialty and the disenfranchisement of many of the patients it serves in the American healthcare system. Special problems within various healthcare financing environments is discussed.

Measuring outcomes: the key to quality management.

Managed care continues to encroach upon virtually all health care delivery systems. Cost controls within these systems have been governed in the past by selection/deselection procedures and utilization management that are primarily based upon claims cost data. The recent movement toward integration of health care quality measures with financial data offers some hope that quality will not be unduly compromised in the efforts to control health care costs. In this new milieu there are increasing opportunities for health care professionals to participate in the development and refinement of managed care products. A model for a worker's compensation managed care system being developed in Colorado is offered as an example of the movement toward more meaningful partnering between health care payers and providers.

Childhood lightning injuries on the playing field.

Two young boys were struck by lightning during summer outdoor activities. One of them died. A literature review reveals that the most commonly reported locations of childhood lightning injuries are on the playing field, at the swimming pool, and in tents. Knowledge of measures to lower the risks of lightning strikes as well as the use of new lightning detection technology should help to reduce the numbers of these tragic events in the future.

The cost-effectiveness of pain treatment: who cares?

Those in professions treating pain must prepare to justify the cost-effectiveness of the treatments they supply. Attempts have been made to define cost-effectiveness. Is it the lowest possible cost? The return of the patient to work and other daily activities? Pain clinics must develop good working relationships with business providers; establish credibility; plan, communicate, evaluate results scientifically; and educate the public.

Chronic pain in old and young patients: differences appear less important than similarities.

Two studies compared physical and psychosocial characteristics of elderly and younger chronic pain patients. No age differences were found during intake for the number of physical coping strategies. Elderly patients named fewer cognitive strategies. No age differences were detected in the percentage of patients offered treatment, who agreed to enter treatment, or who completed treatment. Although older patients more frequently had abnormal physical findings, there were no significant differences on measures of self-reported activity, pain severity, life interference, emotional or worry reactions in response to pain. Both age groups had comparable scores on measures of social support and perceptions of how others react to their pain. The present research suggests that there are relatively few factors distinguishing pain patients based on age. Moreover, age should not be a significant factor to consider when offering patients multidisciplinary treatment for chronic pain that focuses on psychological as well as physical modalities.