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Anesthesia practices interested in adding chronic pain management to their services should think carefully about the keys to long-term viability:  clinicians who are fellowship trained; a market with a sufficient number of patients with conditions that would benefit from interventional care; in a crowded market, unique clinical offerings that distinguish the practice; a favorable payer mix; appropriate incentives; and close monitoring of metrics, notably, encounters booked.

January 7, 2019

About 15 percent of ABC’s clients practice in the subspecialty of chronic pain management.  While the scope and types of services provided vary among these practices, many report favorable experiences and positive relationships with their facilities.

In the current environment of constrained clinical opportunities, is chronic pain still a logical option for anesthesia groups interested in expanding their services?  The answer might be yes, but the devil is in the details.

Chronic pain practices and anesthesia practices involve completely different staffing and infrastructure considerations.  Anesthesia practices are essentially captive to a facility’s service requirements.  Chronic pain practices are fundamentally independent entities with greater flexibility and a wider range of opportunities for growth.  The success or failure of these practices hinges largely on the practitioners’ skills and work ethic.

Not every anesthesiologist enjoys chronic pain management work.  However, the right formula and focus among clinicians who derive satisfaction from caring for patients with chronic pain can bring significant value to a group, an institution and the patients it serves. 

What are the ingredients for success?  The first and most critical criterion is clinicians with fellowship training in the subspecialty.  The typical chronic pain patient is a 48-year-old male who has already been to 6.8 providers to resolve his intractable pain condition.  Pain management providers must consistently demonstrate their value as diagnosticians, which takes considerable training and experience.  Most anesthesiologists are skilled in the more common chronic pain modalities, including epidural steroid injections, transforaminal injections and paravertebral facet joint injections.  However, the field of chronic pain management has evolved over the past few decades into a highly specialized diagnostic discipline.  

Other requirements include the three Ps:  patients, procedures and payments.  It is one thing to perform blocks on a limited, as-needed basis; it is another to sustain a full-service pain clinic.

The schedule must be consistently full with patients whose conditions can be appropriately treated with interventional modalities.  A practice heavy in medication management patients will struggle to survive.  In the current environment, physicians with these types of practices also may be at increased risk of exposure to compliance review related to concerns regarding the overutilization of narcotics.

In addition, a practice also needs sufficient numbers of patients with insurance and authorization to receive interventional care.  This also means there must be a demand in the local market.  While 64 million Americans suffer from some form of chronic pain, most of which is inadequately treated, a growing number of physicians are providing basic chronic pain care. 

Many cities already have significant networks of chronic pain management specialists.  In a competitive market, timing is everything.  There is no value in being late to a market already filled with pain specialists, unless the practice brings a service or services to the market that no one else offers and that can meet a significant clinical need.

A key consideration is knowing where the patients are going to come from and the services they need.  Successful pain practices must build symbiotic relationships with networks of referring providers who know the conditions the pain specialists to whom they refer are qualified to treat.  In this sense, they perform an invaluable diagnostic triage.

Some chronic pain practices have a positive payer mix and a busy schedule of patients in need of interventional services.  All practices, however, must pay close attention to their key performance metrics—particularly encounters booked.  Anesthesia practices monitor units billed, and these units are determined largely by payer mix.  An anesthesia unit is an anesthesia unit.  But the scenario for pain practices is more complex and varied.  A pain management encounter can consist of a new patient workup, an interventional procedure or a non-procedural follow-up visit. 

To steer clear of problems, anesthesia groups also must pay careful attention to the potential impact on clinicians of adding a chronic pain management service, and find ways to provide appropriate incentives for both anesthesiologists and pain specialists.

Finding common ground for the two groups can be a major challenge.  In the OR, the primary focus is customer service (the customers being patients, surgeons and the hospital).  In the pain clinic, the emphasis is on throughput and productivity.  Groups with anesthesia-specific compensation systems have seen their pain management specialists become disenchanted and leave to build independent practices.

So when should an anesthesia practice give serious consideration to the creation of a separate chronic pain sub-group?  The short answer is when they are ready to make the necessary investment in people and infrastructure.  Groups already involved in chronic pain management should monitor their results assiduously.  What is not measured cannot be managed.  Appropriate, reliable and timely management metrics are the key to long-term success.

If you are considering adding a chronic pain service to your practice, your ABC account executive will be happy to perform an assessment and provide recommendations.

We want to hear from you.  Do you have a topic you would like to see covered in an ABC eAlert?  Please send your suggestions to info@anesthesiallc.com .

With best wishes,

Tony Mira President and CEO