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New care measures and their impact on pain medicine: One pain specialist’s perspective Joseph V Pergolizzi Jr

abc

a 1

Department of Medicine, Johns Hopkins, University School of Medicine, Baltimore, MD, USA b 2

Temple University School of Pharmacy, Philadelphia, PA, USA

c 3

Naples Anesthesia and Pain Associates, Naples, FL, USA Published online: 02 Jun 2015.

Click for updates To cite this article: Joseph V Pergolizzi Jr (2015) New care measures and their impact on pain medicine: One pain specialist’s perspective, Postgraduate Medicine, 127:6, 616-622, DOI: 10.1080/00325481.2015.1054616 To link to this article: http://dx.doi.org/10.1080/00325481.2015.1054616

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http://informahealthcare.com/pgm ISSN: 0032-5481 (print), 1941-9260 (electronic) Postgrad Med, 2015; 127(6): 616–622 DOI: 10.1080/00325481.2015.1054616

CLINICAL FEATURE REVIEW

New care measures and their impact on pain medicine: One pain specialist’s perspective Joseph V. Pergolizzi Jr1,2,3

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1

Department of Medicine, Johns Hopkins, University School of Medicine, Baltimore, MD, USA, 2Temple University School of Pharmacy, Philadelphia, PA, USA, and 3Naples Anesthesia and Pain Associates, Naples, FL, USA

Abstract

Keywords:

Value-based purchasing (VBP) goes into effect this year and it links the quality of care to payments for care. Starting in fiscal year 2013, the Centers for Medicare and Medicaid Services reduces all inpatient prospective payment system reimbursements by 1%. This money then can be returned to hospitals in the form of a bonus through VBP. Value-based purchasing holds hospitals accountable for both cost and quality. With VBP, hospitals get a score that is based on the process of care, the outcomes, and patient-centeredness. This means that reimbursements in health care, which keep hospitals in business, are transitioning from “volume of services” to VBP. Although VBP sounds like a great idea, particularly to politicians in Washington tasked with managing out-of-control health care expenditures, there is very little high-quality evidence that VBP will actually improve care. Nevertheless, this is the way we are going to be moving forward. The perception of pain is a highly personalized phenomenon, and chronic pain affects every aspect of a patient’s life. The biopsychosocial model and the concept of utilizing an interdisciplinary team approach in the management of chronic pain make sense, but there are concerns that it could result in higher overall costs and no measurable improvements in the patient’s perception of care. Both results. could have a negative impact on pain specialists.

Value-based purchasing, chronic pain, affordable care act, accountable health plans, multidisciplinary pain treatment

Introduction No physician has ever been president of the United States, perhaps because those called to political life view issues in terms of the greater good of a community, whereas clinicians treat individuals. A physician, for example, may treat 2 individuals with the same condition quite differently and yet still be practicing medicine appropriately, whereas a politician who treats 2 individuals with the same problem differently might be accused of favoritism or worse. Medicine is not just an art and a science, but it is also subject to marketplace conditions. Thus, the government seeks to regulate our health care system as if it is a business. The flaw in this thinking is that American medicine is not a business in the same way that Apple, Coca-Cola, or Ford Motors are businesses. The American health care system is a complex (and sometimes dysfunctional) network of businesses and business-like entities aimed at providing highly individualized services to every citizen in the country. It is no surprise that in most developed countries, health care–related expenditures compose a major portion of the national budget. The United States takes the lead here, spending more on health care per capita than any other nation [1,2]. Increased spending does not necessarily correlate with

History Published online

improved outcomes; indeed, in nonmedical business models, rising costs may indicate declining quality. Yet American health care is very good and in some ways superior to that of other nations; for example, no other country has a better 5-year survival rate for breast cancer [2], and medical innovation and health care in the United States is among the best in the world for many types of cancer, other diseases, and trauma. Many of the world’s leading hospitals, clinics, physicians, specialty societies, journals, device manufacturers, and pharmaceutical companies are based in the United States. It is difficult to think of a medical specialty that does not have thought leaders and innovative manufacturers based here. But American health care is also characterized by a large population of uninsured or underinsured individuals who face high out-of-pocket expenditures related to their health, which may in turn result in them not seeking treatment for certain conditions. Thus, the paradox of American health care is that it is both world class and dysfunctional. Upward-spiraling health care costs, patient safety concerns, growing numbers of uninsured patients, and access to care have led to political interventions in the form of new laws, regulations, initiatives, and programs to improve the system. All of these efforts—some laudable, others less so—have demanded much of the clinical community.

Correspondence: Joseph V. Pergolizzi Jr, MD, Naples Anesthesia and Pain Associates, 840 111th Ave N, #9, Naples, FL 34108, USA. Tel: +1 239 597 3564. E-mail: [email protected]
2015 Informa UK Ltd.

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DOI: 10.1080/00325481.2015.1054616

These initiatives and programs often require clinicians and health care providers to modify their existing systems or set up new ones, maintain more or different types of records, and risk economic and legal consequences for breaking new rules. There is a palpable frustration in the medical community related to our inability to keep up—not with new science or medical breakthroughs, but with laws, codes, and paperwork. Health care reform may be exhilarating to those who hope it will vastly improve medicine and make care more accessible to more people in the future, but it is disheartening to many of us on the front lines, who wonder if we are plunging head-first into new systems that may not work at all. Health care reform has changed more than just regulations; it has changed how physicians view medicine. Today, 60% of American physicians would not recommend their profession as a career, and about a third have a negative outlook for their own careers [3]. Fifty-three percent of primary care physicians aged > 50 years and 30% of those aged between 35 and 49 years may leave their practice in the next 5 years for a variety of reasons, including, but not limited to, changes in the health care system [4]. Private practice and small-group practices—once the pillars of the American health care system—are shutting down in unprecedented numbers [5]. After health care has been reformed, it is not clear how care will be delivered—and by whom—in this new model. So how did we get here? What changes are occurring? Specifically, what does it mean for pain specialists? The 2010 Patient Protection and Affordable Care Act (ACA) required the US Department of Health and Human Services (DHHS) to enlist the Institute of Medicine in examining pain as a public health problem. Chronic pain affects approximately 100 million American adults—more than the total affected by heart disease, cancer, and diabetes combined. Pain also costs the nation as much as $635 billion each year in medical treatment and lost productivity [6]. Chronic pain affects all aspects of a patient’s life and requires a biopsychosocial management approach, which is best directed by an interdisciplinary team; this is especially true for complex patients. Treatments received at interdisciplinary pain centers are costly and time consuming yet result in enhanced clinical effectiveness, improved outcomes, and overall cost saving [7,8]. But what about patient satisfaction? As we increasingly consider patients as consumers, patient satisfaction will take on an even greater role, and improved outcomes do not always translate into higher patient satisfaction. Trentman et al. [9] showed that exam thoroughness, listening, punctuality, and clear instructions were the 4 key drivers that move patient ratings of overall quality of care from “very good” to “excellent” in a pain center setting. With increased pressures to enhance patient throughput and optimism, practice efficiencies achieving a perfect balance of improved outcomes and excellent patient satisfaction will be challenging.

A short history of modern American health care The Centers for Medicare and Medicaid Services is a part of the DHHS and administers Medicare; the agency was established by the US government in 1965 primarily to meet the health care needs of America’s aging population [10]. In the

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nearly half-century that Medicare has been in place, social and public health changes in the country have created economic problems for the system: people are living longer and surviving once-deadly and debilitating diseases; medical care is becoming simultaneously more technologically driven and more expensive; and degenerative diseases, comorbid conditions, chronic pain, and obesity are reaching epidemic proportions. In short, more people need more costly care for longer periods of time. In 2003, the Medicare Modernization Act added prescription drug coverage to Medicare and sought to improve the system by attaching incentives for health care providers to specific quality goals [11]. The Deficit Reduction Act of 2005 expanded on reporting requirements [12]. The ACA of 2010, sometimes called Obamacare, launched significant changes by instituting comparative effectiveness programs, quantifying quality metrics, and addressing issues of health insurance [13]. It is difficult to talk about the ACA as if it is one law or one program; it can best be described as a large, amorphous series of regulations designed to be enforced through many bureaucratic organizations, some of which will be set up specifically for this purpose [14]. Each of these organizations will be able to enforce its own systems of regulations, reporting requirements, incentives, and penalties. Although the American Medical Association has officially endorsed ACA [15], many physicians are more ambivalent, because the changes proposed by the ACA are both vast and poorly defined. It is tempting to view the ACA the way the media do, primarily as a bill to ensure that large numbers of Americans obtain health care insurance, but that is a skewed viewpoint. For example, the ACA also brings with it such sweeping programs as the Medicare Electronic Health Records Initiative and the Physician Quality Reporting System. The provisions of the ACA are not just unique to medicine; they are also unique in American civil law and, indeed, have already been unsuccessfully challenged in the Supreme Court in June 2012 [16]. At the heart of the matter, the biggest transition in modern American health care has been a change from the old fee-forservice paradigm to a value-based system. With this shift comes a more subtle change in terms of the stakeholders’ identities. Patients are now health care consumers and hospitals and clinics are now health care providers. The physician– patient relationship has morphed into less of a therapeutic and more of a commercial relationship involving the commodity of health. Indeed, our new lingo considers health care in terms of resources and allocation. In this new health care system, consumers shop for services, which ideally should be covered by insurance. Among these services are likely to be pain control. Hospitals and other health care–providing organizations may seek services from pain specialists to improve their overall offerings to patients. The biggest and most immediate change facing pain specialists is likely to be the same change that will face other specialists and the entire health care system: a sudden influx of newly insured patients.

The newly insured patients Under the ACA, previously uninsured individuals will be able to purchase health insurance from 1 of 2 different

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types of health insurance exchanges to be set up by states. The details of these exchanges are not entirely worked out to date in all states. At first, these exchanges are meant to handle the uninsured and small businesses, but they may expand in the future; in 2017, the exchanges can start enrolling employees from larger companies [17]. The result is projected to be 10 million newly insured patients in the first year [18]. The projected cost of expanding insurance coverage in this way has been estimated to be $1.1 trillion for the period from 2011 to 2022 [19]. By 2021, experts expect that the local, state, and federal government will be paying for approximately half of all health care–related expenditures [20]. Although out-of-control costs have long been identified as a major problem for American health care, the ACA is not a direct cost-controlling measure. The effect of this large number of new patients on the health care system in general and on pain medicine in particular can only be conjectured. Many existing health care organizations have expressed uncertainty about their longterm viability with these changes [21]. One report [22] speculates that these newly insured patients will divert spending away from so-called safety net institutions, which are mandated to care for the uninsured in favor of outpatient care centers. Because adding such a large group of patients to insurance roles at one time is unprecedented, there are no historical metrics to help us understand what types of services or providers newly insured patients will seek out. In an investigation, newly insured patients were found to be less likely than Medicaid patients to be obese, sedentary, or to have physical, mental, or emotional impairment. However, newly insured patients with chronic conditions were less likely than Medicaid patients to know they had these conditions and, even if they were aware of chronic conditions, the newly insured patients were less likely to be taking steps to control them [23]. This demographic could shift, as newly insured patients will quickly have the means to treat their chronic conditions, including chronic pain syndromes. It may be anticipated that this new wave of patients will create greater demand for pharmaceutical products, preventive services, communitybased care, home health care, and general practice. But the impact on pain medicine may not be as pronounced. Although every pain specialist knows that pain is prevalent, Western health care systems have long exhibited “treatment inertia” with respect to the management of chronic pain [24-27]. Pain often goes untreated or undertreated, even for patients under medical care [28]. However, as medicine transitions to a more consumer-based model, pain control may become an increasingly important service demanded by patients rather than dispensed by providers. Indeed, it is possible that the very image of pain medicine will change from a somewhat rare specialty to a more integral part of a multidisciplinary health care model. Despite the media’s suspicions about lucrative pain clinics, or pill mills, the real work of most pain specialists involves time-intensive, long-term relationships with chronic pain patients for relatively low reimbursements. Chronic pain patients can be extremely challenging to treat, in that chronic pain often involves mental health comorbidities [29], a profound sense of personal loss and frustration [30,31], reduced coping skills

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[32], deteriorating family and social support [33], and the misuse or abuse of pain killers [34]. Gender and ethnic differences in pain treatment outcomes can be particularly marked and have only recently been investigated [35]. Complicating the picture are federal regulations, heightened scrutiny on prescription pain relievers, and requirements set forth by the Voluntary Risk Enforcement and Mitigation Strategy, all of which have made it more difficult and time consuming to prescribe opioid pain relievers. Bringing pain care to a multidisciplinary health care model means that larger health care organizations must recognize the complex realities of pain medicine today and navigate a way through them.

Pain specialization in the age of the ACA Pain is the primary complaint for which people seek medical attention [36], and virtually all clinicians treat pain as part of their practice. Although pain specialists have a real and growing role in American health care, the future of the pain clinic is murkier. Most pain specialists can see the value of developing a system to fast-track secondary-care pain referral to pain clinics, but ACA provisions may preempt this development by decreasing the rates of reimbursements and the number of reimbursable procedures. But if these decreases come at a time when pain clinics are treating a higher number of patients and are absorbing higher overhead costs, including the cost of instituting electronic medical records, then these clinics may no longer be financially viable [14]. The unique work of the pain specialist may also be vulnerable to ACA provisions. For example, a pain specialist working long term with a chronic pain patient is in a position to provide both adequate care and safety for the patient by modifying treatment as the patient’s condition changes. If patients with chronic pain become consumers, this jeopardizes the therapeutic relationship by casting the pain specialist not as a trusted physician but as a service provider who sells specific care and prescriptions. Chronic pain consumers can easily move from provider to provider. This could encourage the very anonymity that most pain clinics seek to deter, in that anonymity allows drug abusers to exploit the system by acquiring opioid prescriptions for abuse and diversion, or doctor shopping [37,38]. It may serve medicine and the marketplace well for people to be consumers when it comes time to get a flu shot, in that they can seek out the most costeffective and convenient provider, but it is not difficult to imagine how this consumer mentality could damage the much-needed clinical oversight and medical supervision of a chronic pain patient on long-term opioid therapy. In such an environment, physicians may hesitate to prescribe opioids at all, particularly to new patients with long-standing conditions. To be sure, tightening regulations on opioid analgesics have already made some physicians reluctant to prescribe appropriate opioid therapy. As medicine becomes more of a consumer-centric business, increasing numbers of physicians may avoid prescribing opioid agents altogether, not because it is the correct medical decision for their patients but because it is a better business decision—it subjects them, as providers, to less legal scrutiny and exposes them to less legal liability [39]. This behavior has been called opiophobia.

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Value-based purchasing Value-based purchasing (VBP) is the paradigm that is supposed to lead us from the old fee-for-service business model of medicine to a quality-based system. Launched by the Centers for Medicaid and Medicare Services in 2013 as part of the ACA, VBP attempts to link the quality of care to reimbursement. This is done by reducing all inpatient prospective payment system reimbursements by 1%, which can be earned back as a bonus through the VBP system [40]. Of course, linking reimbursement to quality requires a meaningful way of measuring quality. With VBP, hospitals are rated on their processes of care, outcomes, and degree of patient-centeredness, typically measured as patient satisfaction. Value-based purchasing brings with it standardized performance metrics and public reporting of results, which enables patients to make informed choices. Payment reform enters the system through so-called differential reimbursements, the 1% bonus for quality care. Payment reform will not stop with this VBP 1% system; an ongoing series of changes are anticipated, including a larger percentage to be withheld and paid back in the form of quality-tied “bonuses.” In 2014, VBP will double so that it affects 2% of reimbursements. Value-based purchasing will attempt to standardize performance metrics, allow for transparency and public reporting of health care date, guide payment reform through what might be termed differential reimbursement, and facilitate so-called informed choice by patients. But VBP is not itself a costsaving measure; it is budget-neutral. It will transition hospitals from the old Reporting Hospital Quality Data for Annual Payment Update to the Consumer Assessment and Healthcare Providers and Systems and its hospital (H-CAHPS) and ambulatory care counterparts, which are multiple-choice surveys. Value-based purchasing will rely on the H-CAHPS systems for payment calculations. The VBP initiative will provide partial support to an organization called Partnership for Patients, a public–private effort intended to improve the safety, quality, and affordability of, as well as the access to, health care [41]. One of the main goals of Partnership for Patients is to reduce health care costs, although it is not clear how this organization will achieve such savings. Although not often discussed, an important potential benefit of VBP is the aggregation of unprecedented amounts of health care data, which could provide valuable insights into health care choices and outcomes [42]. This is not a matter solely of academic interest. The publication of performance data in and of itself improves outcomes. In 1994, publication of pediatric cardiology data from a clinic in the United Kingdom resulted in a decline of infant mortality rates from 30% in 1994 to 4% by 1996 [43]. It may be that the availability and even publication of data on pain control may increase awareness about pain management and improve analgesia for hospital patients.

The accountable care organization The ACA has encouraged the launch of Accountable Care Organizations (ACOs)—groups of physicians, hospitals, and

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other key stakeholders working together to improve health care for Medicare patients and also trying to reduce spending at the same time. Numerous ACO pilot programs have been initiated since 2012 and more are in the works. Overall, ACOs work by trying to improve coordination of care by setting benchmarks, assessing performance, and administering payments. The ACOs are urged to bring a more prevalent business perspective to health care resource allocation [44]. The paradigm shift here is nuanced but profound: health care is now a resource and subject to allocation rather than medical care to be dispensed to individuals. It is easy to see how these changes may result in a fundamental transition from the long-standing fee-for-service model to a shared-risk model [45]. This highlights the association between cost containment and medical liability. For instance, stringent hospital admission criteria imposed by an ACO may be a valid cost-containment strategy but result in a negative outcome that likely would be adjudicated in a malpractice suit, based on whether the decision was medically appropriate rather than whether or not it was a good business decision [46]. This puts physicians in an untenable position, trying to make business-based decisions that maintain the highest standards of medical ethics. As virtually every clinician knows, sometimes the best medical decision is not a good business decision. The transition from one model (medical fee-for-service) to another (business shared-risk) is far from seamless and could have far-reaching implications, of which patients may yet be unaware. Although some advocates applaud the potential of ACOs to improve health care and reduce cost [47], others are already trying to find ways to work around them [48].

Patient satisfaction and the ACA Patient-centeredness, typically measured as patient satisfaction, is an important variable in VBP. Although evidencebased guidelines are a pillar of modern Western medicine, there is no scientific evidence supporting patient satisfaction as a valid measure of outcome or even quality of care [49]. In fact, patient satisfaction is an entirely novel metric and encompasses factors that were rarely considered in health care systems before, such as how easy it is for patients to make an appointment, how long they must wait to see a provider, and how convenient it is to contact the clinic by phone [50]. Although such considerations may be important to patients, the question is whether they are medically relevant and—if so—what exactly they measure. In the future, will clinics be able to offset deficiencies in clinical outcomes by offering high levels of patient amenities? Although H-CAHPS and other surveys are already being used to measure quality, the obvious question is whether patient satisfaction is a realistic metric in health care. For example, a patient facing catastrophic injury and subsequent disability may not have a good experience, regardless of how well the hospital and clinical team perform. Expert care from a less-than-congenial physician may be downgraded in favor of more mediocre care from a friendlier physician. Although courtesy, respect, and communication are important elements in the physician–patient relationship, physicians may feel that

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customer service will emerge as more important that medical expertise. From the health care provider’s point of view, penalizing the hospital when a patient subjectively claims he is not satisfied is not a fair or even useful criterion for evaluating the quality of care the patient received. Moreover, the patient’s age [51,52], ethnicity [53-55], and diagnosis [56] may impact patient satisfaction scores in ways not yet fully elucidated. Thus, patient satisfaction is a subjective metric that varies by patient demographic and measures something we are not sure is connected to the quality of care. On the other hand, the use of these patient satisfaction surveys may have a special relevance for pain medicine, in that pain control is specifically addressed in one question on the H-CAHPS survey, and reduced pain levels have been associated with increased patient satisfaction [57]. Shining a light on pain control as part of the overall hospital experience may encourage hospitals to put increasing emphasis on pain control, which, in turn, will further value pain specialization. By asking patients specifically about pain control, hospitals now have clear financial and medical incentives for offering pain management to patients. This should come in the form of patient education, frequent pain assessments using a validated measure such as the visual analog scale, and adequate pain medications administered in a carefully supervised setting. Although side effects are not specifically addressed in the H-CAHPS survey, patients find opioid-associated side effects such as constipation [58] particularly distressing and uncomfortable. These side effects may result in lower patient satisfaction scores. As a result, opioid-related emesis prophylaxis and bowel regimens for patients on longer-term opioid therapy should be considered. Although the ACA is promoting patient scoring of hospitals and clinics, it is unfair to think that the ACA has encouraged patients to start rating their health care experiences. Consumers of all sorts—including health care consumers— share their marketplace adventures on a variety of interactive websites such as Angie’s List and others. One study found that scores from Yelp.com, a popular consumer website, significantly correlated with H-CAHPS scores (R = 0.49, P < 0.001) and that a high rating on that site overall correlated with lower rates of pneumonia; fewer readmissions for myocardial infarction, heart failure, and pneumonia; and lower rates of myocardial infarction mortality [59]. Thus, whether formalized in the H-CAHPS or not, patients today are sharing information about health care providers and rating health care services already, and it may be that high patient scores do indeed correlate with health care quality. The formula for achieving good patient satisfaction may not be particularly complex. It involves looking at patient goals and expectations and at modifiable versus nonmodifiable factors that influence reaching those objectives [60]. Modifiable factors are under the control of the clinical team, and include pain control, management of adverse events, and communication with the patient. Ideally the patient’s goals and expectations should be managed through patient education and open communication with the clinical team. A patient may be disappointed even with a good outcome if the patient does not get the expected result. For pain specialists, this may mean that some patients view pain control as suboptimal if

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they experience any degree of pain. Most surgical patients must be counseled that pain relief will be substantial but rarely complete; that is, some postoperative pain will be experienced. Without such education, a postsurgical patient may believe that some pain is an indication of poor quality care. Nonmodifiable factors include the patient’s condition, diagnosis, medical history, prognosis, and demographic variables. The patient’s condition must be discussed frankly with the patient and family. When a health care organization embraces patientcenteredness in its approach to health care quality, the value of pain control emerges as a key consideration. Perhaps even more important is the value of communication; the 3 factors most strongly associated with the patient’s perception of quality of care were (1) how thoroughly they were examined and treated, (2) how well the provider listened to the patient, and (3) how much time the provider spent with the patient [9]. Thus, for pain specialists in particular and clinicians in general, conducting a thorough examination, listening carefully to the patient’s expressed concerns, and showing the patient respect, along with the amount of time spent with the patient, may improve patient satisfaction scores. In this connection, it is important to emphasize that pain clinicians should assess pain frequently and ask the patient open-ended questions to elicit more thorough responses. When possible, pain specialists should instruct patients on how to communicate their pain levels, such as using a visual analog scale, and inform patients that pain levels may be taken frequently during their hospital stay as the levels can change abruptly. Patients may come to the hospital with varying concepts of what pain is and how it is to be handled. They must be informed that pain can be safely and effectively controlled and that suffering in silence not only may cause them needless suffering but also may delay ambulation and hinder their participation in rehabilitation and recovery.

The pain physician and pain patient today and tomorrow Physicians have always treated pain, but the ACA may change how our health care system treats people with pain. Pain specialists can expect increased efforts by health care systems to control acute and chronic pain, greater awareness of pain syndromes by all stakeholders, and enhanced communication efforts with patients in an effort to both assess and handle their pain. Pain specialists may also find that demand for pain relief increases as growing health care consumerism demands better pain control. In addition, pain specialists will be faced with working within integrated health systems. Hospital/provider establishment of medical and surgical groups has the promise of creating truly integrated health systems where hospital-employed physicians work together with system leaders towards common goals. These groups, however, may potentially redefine the role of the pain specialist. In many of these models, the physician is now an employee and not an employer. This means that there will be a functional change in status and a diminished sense of control because the patients are no longer the “inventory” of the physician practice but rather are within the dominion and control of the

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hospital/health care system. The impact of all of these perceived changes is not known but may drive patients to embrace their new status as health care consumers, creating a push for more thorough and better pain control at all points on the continuum of care. The problem for pain specialists is that pain is not one thing. Acute pain, such as postoperative pain, is both manageable and largely preventable. Health care organizations will likely place more emphasis on safe, effective relief of postoperative pain. Health care consumers may not realize that chronic pain is a different condition and more challenging to treat both for the physician and for the health care system. Patients facing persistent pain should be referred to a pain specialist as quickly as possible; a multidisciplinary approach to pain is often the most effective and cost-effective [61]. Although chronic pain patients are not necessarily hospitalized for chronic pain, they do seek health care services, more typically through clinics and individual providers, as well as emergency departments. Where these patients are treated in the post-ACA health care system remains to be seen. With increasing numbers of insured patients, it may be that chronic pain patients will seek care in pain clinics or get referrals to specialists. Pain specialists must be prepared to educate these patients about the nature and treatment options for chronic pain that may not be as “consumer-friendly” as postoperative analgesia. When pain patients are referred to pain specialists, the role of 3-way communication becomes paramount. Pain specialists must communicate well and promptly to the primary care physician and vice versa, and patients must be kept in the loop. Above all, patients should understand their diagnosis and treatment options. Furthermore, pain care should be individualized based on an understanding of the patient’s daily life and personal goals. More complex multidisciplinary teams may be needed to manage particularly complex cases.

Conclusion Pain specialists face declining reimbursements, heightened scrutiny and regulations, and greater patient volumes in the coming years, thanks in part, but not in whole, to the ACA. The transition from the physician–patient relationship to one of provider–consumer has far-reaching implications, not the least of which is the role of patient satisfaction as an unproven metric in assessing medical quality. Because pain control has been associated with improved patient satisfaction, pain specialists may find themselves in the vanguard of this new age of health care. Moreover, prophylactic care for opioidassociated side effects may improve patient satisfaction with treatment. Those pain specialists who can communicate well with patients about pain and its control may bring an important element to new health care paradigms. It is very likely that pain clinics will change in the future, but the health care system’s new emphasis on pain control has never been stronger.

Declaration of interest Joseph V. Pergolizzi Jr, MD, has served as a consultant for Johnson & Johnson, Purdue Pharma LP, Baxter International

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Inc, Endo Pharmaceuticals Inc, Iroko Pharmaceuticals, and Collegium Pharmaceuticals. Dr Pergolizzi is also a shareholder of Apotek Research, LLC.

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