Pain Specialists: Urged to Resist Profiteering

SAN DIEGO – Challenges such as declining reimbursements and limitations on payor approval of prescribed therapies are creating fertile ground for conflict of interest and profiteering by physicians, Dr. Jerome Schofferman said at the annual meeting of the American Academy of Pain Medicine.

Those involved in interventional pain management are especially vulnerable. “Some physicians–particularly interventional pain specialists–limit their practices to the most profitable patients: those needing injections, neuromodulation, and other interventions,” he told the audience. “They may say, 'well, it's what I do best, it's what I was trained to do, and it's what I like, and I've got a lot of overhead and I have to make a living.' There are a lot of rationalizations for limiting our practices to the most financially [rewarding] patients.”

That often leaves patients who require chronic medical management and rehabilitation out in the cold, according to Dr. Schofferman, who is in private practice in Daly City, Calif. “We've developed a system where some interventionalists are just doing injections all day long and don't follow up on patients to see how they're doing, and they use new technologies before there's adequate validation of their efficacy,” he said.

“I see patients all the time who, instead of having a single, well-done fluoroscopic-guided epidural, get three epidurals 10 days apart. There is no medical evidence justifying the automatic use of three epidurals,” he said.

Dr. Schofferman noted that his remarks were not intended as an indictment of profit. There's fair profit and then there is profit that is unfair and unethical, he said, citing the example of physicians who increase the numbers of patients they see and give less attention and thought–but perhaps more drugs–to each. “And those doctors may lower their threshold for interventional procedures, particularly those reimbursed at a higher level.”

Poor clinical management decisions are the bedfellows of conflict of interest, which Dr. Schofferman said elicits righteous indignation when mentioned in the same breath with health care. Conflict of interest is not as simple as accepting a laser pointer from a particular drug company and as a result deciding to prescribe their drug instead of comparable agents made by other companies. Few physicians would do that.

“But it doesn't work that way. Conflict of interest is much more subtle and unconscious. Conflict of interest is sort of like pornography–everybody knows it when they see it, but it's hard to define. Let's call it a situation where your professional judgment regarding a patient is unduly influenced by secondary interests.” Those secondary interests, he explained, can include power, one's position in the community, career advancement, biases, and financial gain. “Conflict of interest leads to bias and bias influences clinical decision making.”

One part of the solution is to practice evidence-based medicine, which Dr. Schofferman said would automatically minimize the effects of these secondary influences and reduce clinical practice patterns that are not in the best interests of patients.

“Evidence-based medicine, according to Dr. David L. Sackett [of Oxford University in England], is the integration of the best research evidence, clinical expertise, and patient values. Dr. Bradley Weiner [an orthopedic surgeon from Akron, Ohio] said that when equal alternatives exist, you provide a treatment that affords the least risk. If the treatments and risks are equal, provide the treatment with the lowest cost; then your practice can be ethical without being an ethicist, and you don't even have to know anything about ethics,” Dr. Schofferman said. “We have to critically analyze our practice outcomes. This requires integrity … this requires acceptance of a reasonable profit, not a greedy profit.”

SAN DIEGO – Challenges such as declining reimbursements and limitations on payor approval of prescribed therapies are creating fertile ground for conflict of interest and profiteering by physicians, Dr. Jerome Schofferman said at the annual meeting of the American Academy of Pain Medicine.

Those involved in interventional pain management are especially vulnerable. “Some physicians–particularly interventional pain specialists–limit their practices to the most profitable patients: those needing injections, neuromodulation, and other interventions,” he told the audience. “They may say, 'well, it's what I do best, it's what I was trained to do, and it's what I like, and I've got a lot of overhead and I have to make a living.' There are a lot of rationalizations for limiting our practices to the most financially [rewarding] patients.”

That often leaves patients who require chronic medical management and rehabilitation out in the cold, according to Dr. Schofferman, who is in private practice in Daly City, Calif. “We've developed a system where some interventionalists are just doing injections all day long and don't follow up on patients to see how they're doing, and they use new technologies before there's adequate validation of their efficacy,” he said.

“I see patients all the time who, instead of having a single, well-done fluoroscopic-guided epidural, get three epidurals 10 days apart. There is no medical evidence justifying the automatic use of three epidurals,” he said.

Dr. Schofferman noted that his remarks were not intended as an indictment of profit. There's fair profit and then there is profit that is unfair and unethical, he said, citing the example of physicians who increase the numbers of patients they see and give less attention and thought–but perhaps more drugs–to each. “And those doctors may lower their threshold for interventional procedures, particularly those reimbursed at a higher level.”

Poor clinical management decisions are the bedfellows of conflict of interest, which Dr. Schofferman said elicits righteous indignation when mentioned in the same breath with health care. Conflict of interest is not as simple as accepting a laser pointer from a particular drug company and as a result deciding to prescribe their drug instead of comparable agents made by other companies. Few physicians would do that.

“But it doesn't work that way. Conflict of interest is much more subtle and unconscious. Conflict of interest is sort of like pornography–everybody knows it when they see it, but it's hard to define. Let's call it a situation where your professional judgment regarding a patient is unduly influenced by secondary interests.” Those secondary interests, he explained, can include power, one's position in the community, career advancement, biases, and financial gain. “Conflict of interest leads to bias and bias influences clinical decision making.”

One part of the solution is to practice evidence-based medicine, which Dr. Schofferman said would automatically minimize the effects of these secondary influences and reduce clinical practice patterns that are not in the best interests of patients.

“Evidence-based medicine, according to Dr. David L. Sackett [of Oxford University in England], is the integration of the best research evidence, clinical expertise, and patient values. Dr. Bradley Weiner [an orthopedic surgeon from Akron, Ohio] said that when equal alternatives exist, you provide a treatment that affords the least risk. If the treatments and risks are equal, provide the treatment with the lowest cost; then your practice can be ethical without being an ethicist, and you don't even have to know anything about ethics,” Dr. Schofferman said. “We have to critically analyze our practice outcomes. This requires integrity … this requires acceptance of a reasonable profit, not a greedy profit.”

SAN DIEGO – Challenges such as declining reimbursements and limitations on payor approval of prescribed therapies are creating fertile ground for conflict of interest and profiteering by physicians, Dr. Jerome Schofferman said at the annual meeting of the American Academy of Pain Medicine.

Those involved in interventional pain management are especially vulnerable. “Some physicians–particularly interventional pain specialists–limit their practices to the most profitable patients: those needing injections, neuromodulation, and other interventions,” he told the audience. “They may say, 'well, it's what I do best, it's what I was trained to do, and it's what I like, and I've got a lot of overhead and I have to make a living.' There are a lot of rationalizations for limiting our practices to the most financially [rewarding] patients.”

That often leaves patients who require chronic medical management and rehabilitation out in the cold, according to Dr. Schofferman, who is in private practice in Daly City, Calif. “We've developed a system where some interventionalists are just doing injections all day long and don't follow up on patients to see how they're doing, and they use new technologies before there's adequate validation of their efficacy,” he said.

“I see patients all the time who, instead of having a single, well-done fluoroscopic-guided epidural, get three epidurals 10 days apart. There is no medical evidence justifying the automatic use of three epidurals,” he said.

Dr. Schofferman noted that his remarks were not intended as an indictment of profit. There's fair profit and then there is profit that is unfair and unethical, he said, citing the example of physicians who increase the numbers of patients they see and give less attention and thought–but perhaps more drugs–to each. “And those doctors may lower their threshold for interventional procedures, particularly those reimbursed at a higher level.”

Poor clinical management decisions are the bedfellows of conflict of interest, which Dr. Schofferman said elicits righteous indignation when mentioned in the same breath with health care. Conflict of interest is not as simple as accepting a laser pointer from a particular drug company and as a result deciding to prescribe their drug instead of comparable agents made by other companies. Few physicians would do that.

“But it doesn't work that way. Conflict of interest is much more subtle and unconscious. Conflict of interest is sort of like pornography–everybody knows it when they see it, but it's hard to define. Let's call it a situation where your professional judgment regarding a patient is unduly influenced by secondary interests.” Those secondary interests, he explained, can include power, one's position in the community, career advancement, biases, and financial gain. “Conflict of interest leads to bias and bias influences clinical decision making.”

One part of the solution is to practice evidence-based medicine, which Dr. Schofferman said would automatically minimize the effects of these secondary influences and reduce clinical practice patterns that are not in the best interests of patients.

“Evidence-based medicine, according to Dr. David L. Sackett [of Oxford University in England], is the integration of the best research evidence, clinical expertise, and patient values. Dr. Bradley Weiner [an orthopedic surgeon from Akron, Ohio] said that when equal alternatives exist, you provide a treatment that affords the least risk. If the treatments and risks are equal, provide the treatment with the lowest cost; then your practice can be ethical without being an ethicist, and you don't even have to know anything about ethics,” Dr. Schofferman said. “We have to critically analyze our practice outcomes. This requires integrity … this requires acceptance of a reasonable profit, not a greedy profit.”