The Value of Acute Pain Management to the Anesthesia Practice

Summary: As the specialty of anesthesia evolves, new lines of business are explored and employed. Over time, however, what once seemed like a cutting-edge technique or profitable opportunity may ultimately come with certain risks. Acute pain management is a prime example of this reality.

There was a time, not too long ago, when many anesthesia practices did not provide much in the way of nerve blocks for acute pain management. Now, it has become the norm for a wide range of orthopedic patients to get nerve blocks intended to provide extended analgesia post-operatively. Experienced practitioners continue to explore new modes of treatment to enhance the post-operative comfort of their patients. The use of TAP blocks for abdominal surgery is a good example of this.

Rationale for the Rise

A number of factors have encouraged the dramatic rise in the use of nerve blocks for post-operative pain management. The wide-spread availability of ultrasonic guidance (USG) to enhance the accuracy of the blocks, a technology that has allowed most anesthesiologists to become proficient in the administration of targeted nerve blocks, has been particularly significant. Many attribute the growth in acute pain block utilization to the national opioid crisis, which has encouraged all anesthesia providers to find ways to use less narcotics in the administration of their anesthetics. The financial incentive created by fee schedule payments for both the block and the USG per case cannot be discounted.

Ultimately, though, it is no doubt the effectiveness of these blocks that has encouraged more providers to learn how to perform them consistently and successfully. In other words, the ability to provide an effective acute pain management program has become an essential component of today's anesthesia practices.

Ramifications of the Rise

As with many aspects of change in American medicine, any change brings its own set of challenges and problems. There is a standard all anesthesia practices aspire to, but which many fail to achieve. The ideal practice consists of a team of equally qualified providers, all of whom are qualified to perform any of the cases that present. Nowhere is this as apparent as in the domain of acute pain management.

Typically, it is the younger physicians who are fresh out of training programs that emphasized the importance of acute pain management who have the best skill set. Some practices still try to use the skills and enthusiasm of these younger physicians to train and upgrade the skillset of the other physicians. It is an important challenge, especially in the current environment where acute pain management is becoming such an important component of the practice. The problem is compounded by the current manpower shortage and the fact that many physicians are moving from one practice to another. The unfortunate reality is that it is often the best trained providers with the best skillset who have the best options and who move on first.

Risks in the Rise

It is also important to remember that the use of nerve blocks also entails a certain compliance risk. There is a pretty standard list of surgical procedures that are enhanced by the use of nerve blocks. Over the past decade we have seen considerable experimentation with new approaches and techniques to the administration of nerve blocks. These new approaches and techniques are soundly grounded in acceptable principles of pain management. But if the perception is that blocks are being performed simply to enhance the revenue potential of the practice, then this becomes an area of potential vulnerability. This is especially true for practices that routinely perform multiple blocks on their patients, though we have yet to see targeted audits for this. In addition, it should be noted that some of these new block techniques have yet to be recognized by CPT and are therefore billed out with an unlisted procedure code. Here are the four most common such procedures:

• 👉🏿 Cervical Plexus
• 👉🏿 IPack
• 👉🏿 Erector Spinae
• 👉🏿 Quadratus Lumborum

The other potential challenge is financial. We have seen far too many times that, when the volume of a service goes up, its price tends to go down. It used to be that chronic pain physicians would get paid for both the basic nerve block they were performing and the fluoroscopic guidance. Over time, each of the common procedures have had fluoroscopy bundled into the block payment. In many cases, this had the effect of reducing the total payment by as much as 30 percent. We have good reason to believe that the same thing will happen to USG, that payment for it will be bundled into the payment for the block. This is in addition to the global impact of supply and demand: the more nerve blocks that are performed, the less payers will pay per block.

And so it is that often what appears to be a great new line of business with serious clinical and financial potential can well lead to disappointment as market factors change. This is why it is so important to constantly monitor the profitability of each specific line of business to assess its actual value to the practice. If you would like some help assessing the state of acute pain medicine in your practice, feel free to contact your account executive or go to info@anesthesiallc.com.