Interventional pain management at crossroads: the perfect storm brewing for a new decade of challenges

The health care industry in general and care of chronic pain in particular are described as recession-proof. However, a perfect storm with a confluence of many factors and events -none of which alone is particularly devastating - is brewing and may create a catastrophic force, even in a small specialty such as interventional pain management. Multiple challenges related to interventional pain management in the current decade will include individual and group physicians, office practices, ambulatory surgery centers (ASCs), and hospital outpatient departments (HOPD). Rising health care costs are discussed on a daily basis in the United States. The critics have claimed that health outcomes are the same as or worse than those in other countries, but others have presented the evidence that the United States has the best health care system. All agree it is essential to reduce costs. Numerous factors contribute to increasing health care costs. They include administrative costs, waste, abuse, and fraud. It has been claimed the U.S. health care system wastes up to $800 billion a year. Of this, fraud accounts for approximately $200 billion a year, involving fraudulent Medicare claims, kickbacks for referrals for unnecessary services, and other scams. Administrative inefficiency and redundant paperwork accounts for 18% of health care waste, whereas medical mistakes account for $50 billion to $100 billion in unnecessary spending each year, or 11% of the total. Further, American physicians spend nearly 8 hours per week on paperwork and employ 1.66 clerical workers per doctor, more than any other country. It has been illustrated that it takes $60,000 to $88,000 per physician per year, equal to one-third of a family practitioner's gross income, and $23 to $31 billion each year in total to interact with health insurance plans. The studies have illustrated that an average physician spends $68,274 per year communicating with insurance companies and performing other non-medical functions. For an office-based practice, the overall total in the United States is $38.7 billion, or $85,276 per physician. In the United States there are 2 types of physician payment systems: private health care and Medicare. Medicare has moved away from the Medicare Economic Index (MEI) and introduced the sustainable growth rate (SGR) formula which has led to cuts in physician payments on a yearly basis. In 2010 and beyond into the new decade, interventional pain management will see significant changes in how we practice medicine. There is focus on avoiding waste, abuse, fraud, and also cutting costs. Evidence-based medicine (EBM) and comparative effectiveness research (CER) have been introduced as cost-cutting and rationing measures, however, with biased approaches. This manuscript will analyze various issues related to interventional pain management with a critical analysis of physician payments, office facility payments, and ASC payments by various payor groups.

[Counterfeit medicines: a growing threat]

The medical drug market has undergone considerable transformation in recent years. Like other products, medicines have been affected by globalization. Free trade policies have had a number of negative effects including a reduction in quality control not only for some products but also for raw materials and finished products. The global environment has also created conditions conducive to counterfeit medicines. The term counterfeit medicine is defined differently from one country to another in terms of quality, legality and fraudulent intent. This situation prompted the WHO to propose the following definition: "A counterfeit medicine is one which is deliberately and fraudulently mislabeled with respect to identity and/or source. Counterfeiting can apply to both branded and generic products and counterfeit products may include products with the correct ingredients or with the wrong ingredients, without active ingredients, with insufficient active ingredients or with fake packaging." Weak pharmaceutical regulation often compounded by widespread corruption in developing countries has greatly facilitated the development of this illicit market with harmful and costly effects on public health. Due to the lack of pharmocovigilance accidents involving use of counterfeit drugs go unreported. For this reason it is not possible to measure the economic impact. While counterfeiting has become a major threat in developing countries, it also affects industrialized countries. Fraudulent behavior occurs all over the world.

Fraud and abuse trends for 2006: what's hot for physicians and physician practices

Federal and State Governments will have new tools and new mandates to ferret out fraud and abuse in federal health care programs. This article describes new legislative, regulatory, and investigative trends in the fraud and abuse arena that are likely to affect physicians and physician groups.

Qui tam claims: threat to voluntary compliance programs in health care organizations

The Department of Justice (DOJ) reports that after violent crime, health care fraud is the department's top priority. The number of health care fraud investigations pending at the DOJ increased from 270 cases in 1992 to more than 4,000 in 1997. The DOJ's primary weapon in prosecuting health care fraud is the federal False Claims Act (FCA) of 1863 (31 U.S.C. secs. 3729-3733). Almost unique among federal antifraud provisions, the FCA may also be used by "private prosecutors" to file lawsuits on behalf of the federal government charging organizations with submitting false claims to the government. The FCA rewards such whistle-blowers with a share of any resulting recoveries as a bounty and protects them from discharge for filing false claims lawsuits against their employers. It also requires defendants to pay the costs and attorneys fees of successful claimants. Although the private "bounty hunter" features of the FCA data back to the Civil War, these so-called qui tam claims were nearly dormant until 1986, when Congress amended the FCA to revive their use. Following the 1986 amendments, and paralleling the rapid increase in federal reimbursements for health care costs, private qui tam claims have far expanded beyond their traditional purview of defense contracts into the field of health care. By 1997, health care providers were the targets of 54 percent of the 530 private qui tam lawsuits field that year.

Quackery: the National Council Against Health Fraud perspective

Quackery is the promotion of false and unproven health schemes for a profit. It is rooted in the traditions of marketplace. Scientific thinking and standards of conduct underlie professionalism and consumer protection law. At the present time, commercialism has overwhelmed professionalism in the marketing of alternative remedies. Neither patients nor legitimate businesses that adhere to the standards of science and consumer protection are well served by a double standard.

Chock-full of change. Opportunities, and perils, abound as industry continues to evolve

Tighten your belt and hold onto your wallet: Another year of change looms for healthcare. In a 1999 outlook report, our staff tells all about Medicare cutbacks, managed-care turbulence and a looming crisis in skilled nursing. And everyone is braced for the appearance of that ugly year-2000 computer bug.

Crime and healthcare

When charges were made last summer against 12 men affiliated with a New Jersey-based third-party administrator firm, headlines trumpeted the arrests as the first major case of organized crime infiltrating the healthcare industry. While law enforcement experts don't believe the mob has established a major role in healthcare, they acknowledge the $1 trillion-a-year industry is a lucrative target for illicit activity.