Laxmaiah Manchikanti - Academia.edu (original) (raw)

Papers by Laxmaiah Manchikanti

Pain Physician, Jul 14, 2015

Letters to the Editor of patients have shown improvement in all the trials by Manchikanti et al i... more Letters to the Editor of patients have shown improvement in all the trials by Manchikanti et al in practical settings, it will be difficult to improve on the results but it is definitely feasible to replicate the results not only of Manchikanti et al but also of Candido et al and others.

Pain Physician, 2009

Background: In recent years, a number of minimally invasive nuclear decompression techniques for ... more Background: In recent years, a number of minimally invasive nuclear decompression techniques for lumbar disc prolapse, protrusion, and/or herniation have been introduced, including the Dekompressor® a device utilizing an Archimedes screw. The primary goal of the surgical treatment of nerve root compression from a disc protrusion continues to be the relief of compression by removing the herniated nuclear material with open discectomy. However, poor results have been reported for contained disc herniations with open surgical interventions. The results with several alternative techniques including the Dekompressor, automated percutaneous discectomy, and laser discectomy have been described, but are not convincing. There is a paucity of evidence for all decompression techniques. Study Design: A systematic review of the mechanical disc decompression with Dekompressor literature. Objective: The objective of this systematic review is to evaluate the clinical effectiveness of the Dekompress...

Pain Physician, 2010

While the United States leads the world in many measures of health care innovation, it has been s... more While the United States leads the world in many measures of health care innovation, it has been suggested that it lags behind many developed nations in a variety of health outcomes. It has also been stated that the United States continues to outspend all other Organisation for Economic Co-operation and Development (OECD) countries by a wide margin. Spending on health goods and services per person in the United States, in 2007, increased to 7,290–almost2½timestheaverageofallOECDcountries.RisinghealthcarecostsintheUnitedStateshavebeenestimatedtoincreaseto19.17,290 – almost 2½ times the average of all OECD countries. Rising health care costs in the United States have been estimated to increase to 19.1% of gross domestic product (GDP) or 7,290–almost2½timestheaverageofallOECDcountries.RisinghealthcarecostsintheUnitedStateshavebeenestimatedtoincreaseto19.14.4 trillion by 2018. The increases are illustrated in both public and private sectors. Higher health care costs in the United States are implied from the variations in the medical care from area to area around the country, with almost 50% of medical care being not evidence-based, and finally as much as 30% of spending reflecting medical care of uncertain or questiona...

Pain Physician, 2015

Background: The sacroiliac joint is well known as a cause of low back and lower extremity pain. P... more Background: The sacroiliac joint is well known as a cause of low back and lower extremity pain. Prevalence estimates are 10% to 25% in patients with persistent axial low back pain without disc herniation, discogenic pain, or radiculitis based on multiple diagnostic studies and systematic reviews. However, at present there are no definitive management options for treating sacroiliac joint pain. Objective: To evaluate the diagnostic accuracy and therapeutic effectiveness of sacroiliac joint interventions. Study Design: A systematic review of the diagnostic accuracy and therapeutic effectiveness of sacroiliac joint interventions. Methods: The available literature on diagnostic and therapeutic sacroiliac joint interventions was reviewed. The quality assessment criteria utilized were the Quality Appraisal of Reliability Studies (QAREL) checklist for diagnostic accuracy studies, Cochrane review criteria to assess sources of risk of bias, and Interventional Pain Management Techniques – Qua...

Pain Physician, 2016

Since October 1, 2015, the International Classification of Diseases, 10th Revision, Clinical Modi... more Since October 1, 2015, the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) was integrated into U.S. medical practices. This monumental transition seemingly occurred rather unceremoniously, despite significant opposition and reservations having been expressed by the provider community. In prior publications, we have described various survival strategies for interventional pain physicians. The regulators and beneficiaries of system – CMS, consultants, and health information technology industry are congratulating themselves for a job well done. Nonetheless, this transition comes at an immeasurable financial and psychological drain on providers. However, a rude awakening may be making its way with expiration of initial concessions from government and private payers. This manuscript provides a template for interventional pain management professionals with multiple steps for seamless navigation, including descriptions of the most commonly used co...

Journal of NeuroInterventional Surgery, 2015

Peer review of scientific articles submitted for publication has been such an integral component ... more Peer review of scientific articles submitted for publication has been such an integral component of innovation in science and medicine that participants (be they readers, reviewers, or editors) seldom consider its complexity. Not surprisingly, much has been written about scientific peer review. The aim of this report is to share some of the elements of that discourse with readers of the Journal of NeuroInterventional Surgery (JNIS).

Anesthesiology and Pain Medicine, 2012

Anesthesia & Analgesia, 1984

Regurgitation and subsequent aspiration of gastric contents remains a major cause of morbidity an... more Regurgitation and subsequent aspiration of gastric contents remains a major cause of morbidity and mortality in clinical anesthesia (1,2). According to most authors, a pH less than 2.5 and volume of gastric aspirate more than 20-25 ml are generally considered critical factors in the development of acid pneumonitis in adults (3-6). Another critical factor less often appreciated is the tone of the lower esophageal sphincter, which acts as the major barrier in prevention of regurgitation of gastric contents (7). Numerous anal

Journal of neurosurgery. Spine, 2016

Pain Physician

In the face of the progressive implementation of the Affordable Care Act (ACA), a significant reg... more In the face of the progressive implementation of the Affordable Care Act (ACA), a significant regulatory regime, and the Merit-Based Incentive Payment System (MIPS), the Centers for Medicare and Medicaid Services (CMS) released its proposed 2017 hospital outpatient department (HOPD) and ambulatory surgery center (ASC) payment rules on July 14, 2016, and the physician payment schedule was released July 15, 2016. U.S. health care costs continue to increase, occupying 17.5% of the gross domestic product (GDP) in 2014 and surpassing $3 trillion in overall health care expenditure. Solo and independent practices face unique challenges and many are being acquired by hospitals or larger groups. This transfer of services to hospital settings is indisputably leading to an increase in the net cost to the system. Comparison of facility payments for interventional techniques in HOPD, ASC, and in-office settings shows wide variation for multiple interventional techniques. Major discrepancies in p...

Pain Physician

The Centers for Medicare and Medicaid Services (CMS) released the proposed 2017 Medicare physicia... more The Centers for Medicare and Medicaid Services (CMS) released the proposed 2017 Medicare physician fee schedule on July 7, 2016, addressing Medicare payments for physicians providing services either in an office or facility setting, which also includes payments for office expenses and quality provisions for physicians. This proposed rule occurs in the context of numerous policy changes, most notably related to the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) and its Merit-Based Incentive Payment System (MIPS). The proposed rule affects interventional pain management specialists in reimbursement for evaluation and management services, as well as procedures performed in a facility or in-office setting. Changes in the proposed fee schedule impacting interventional pain management practices include adjustments to the meaningful use (MU) program, care management in patientcentered services, identification and review of potentially misvalued services, evaluation of moderate ...

Pain Physician

The Office of Inspector General (OIG), Department of Health and Human Services (HHS), in a 2009 r... more The Office of Inspector General (OIG), Department of Health and Human Services (HHS), in a 2009 report, showed that unqualified nonphysicians performed 21% of the services. These nonphysicians did not possess the necessary licenses, certifications, credentials, or training to perform the services. Since the time the medical profession was founded, advances in treatments and technology, as well as educational and training standards, have promoted a desire to go beyond the basic scope of practice. Many have sought to broaden the scope of practice through legislative efforts and proclamation rather than education and training. In 2001, President Clinton signed into law a rule that permitted states to “opt out” of the Centers for Medicare and Medicaid Services’ (CMS) requirement for nurse anesthetists to be supervised by any physician. Since then, 17 states have adopted this rule. While it was originally intended to help rural areas improve access to care, the opt out rule essentially s...

Pain Physician

The present evidence illustrates that the placebo effect depends on a variety of neurochemical an... more The present evidence illustrates that the placebo effect depends on a variety of neurochemical and neurophysiological mechanisms, which are measurable and modifiable. However, the placebo response is inexorably tied to the treatment context. All medical treatments take place in a particular context; this context includes the therapist’s attitudes, psychosocial factors affecting the therapeutic relationship, and the patient’s mindset. Therapeutic efficacy at least in part is attributable to the concordance between the proposed treatment and the patient’s belief system. It is this fraction of the therapeutic response that is commonly called the placebo effect. More formally, the placebo effect is defined as that part of the therapeutic response that is not attributable to the properties of active ingredients. A proposed model of the placebo effect includes a complex reaction with induction, psychophysiological mediators, neurobiological mediators, and actualization of effects. Similar...

Pain Physician

The Affordable Care Act (ACA), signature legislation of President Obama, was arguably the most co... more The Affordable Care Act (ACA), signature legislation of President Obama, was arguably the most consequential and comprehensive health care reform since Medicare was introduced as part of President Lyndon B. Johnson’s great society. It has been claimed that many of the law’s reforms are now so integrated in the health system that full repeal would be impractical, while others including President Elect Trump have rejected that idea and called for full repeal and replacement claiming ACA law cannot be fixed. A tsunami of increasing regulatory burden over the past 8 years, the current health care milieu has moved independent practitioners towards hospital employment in great numbers. In addition, public opinion has been slowly climbing against ObamaCare with 54% of Americans now opposing the law. President Obama has indicated that the law has accomplished many of its goals, including increasing accessibility, affordability, and quality of health care. However, others have contradicted t...

Pain Physician

The prevalence, costs, and disability associated with chronic pain continue to escalate. So too, ... more The prevalence, costs, and disability associated with chronic pain continue to escalate. So too, the numerous modalities of treatments applied in managing these patients continue to increase as well. In the period from 2000 to 2011 interventional techniques increased 228%. In addition, analysis of utilization trends and expenditures for spinal interventional techniques alone from 2000 to 2008 illustrated an increase in Medicare fee-for-service expenditures of 240% in terms of dollars spent in the United States. The Office of Inspector General (OIG) of the Department of Health and Human Services showed an increase in facet joint and transforaminal epidural injections, with a significant proportion of these services did not meet the medical necessity criteria. The increasing utilization of interventional techniques is also associated with significant variations among specialty groups and regional variations among states. Overall procedures have increased by 173%, with rate of 130% per...

Pain Physician

T he year 2013 was a challenging year for Interventional pain physicians with national coverage d... more T he year 2013 was a challenging year for Interventional pain physicians with national coverage determination threats for facets, epidurals, and spinal cord stimulation (1); certified registered nurse anesthetists (CRNAs) entering the full arena of interventional pain management (2-4); Center for Disease control supported single-dose vial policy being created without products to reasonably support it (5); Food and Drug Administration (FDA) regulating procedural standards of interventional techniques; Noridian led local coverage determinations (LCDs) prepared by Multi-Specialty Pain Workgroup (MPW) (6-8); threatened cuts of cervical epidural injections and facet joint interventions in Tennessee (9,10); empowered insurers limiting interventional pain management (IPM) services (11); usual sustained growth rate (SGR) cut fiasco (12,13); and finally the Thanksgiving gift of draconian cuts for epidural injections amounting to 33% for cervical epidural when in a facility and 56% when performed in a physicians office, and 19% for lumbar interlaminar epidural injection in a facility setting for physician fee and 49% when performed in a physicians office (14). Thus, CMS determined the work value of highly trained and skilled IPM physicians to be a whopping 42toassessapatientpreoperatively,toperformahighriskprocedureofcervicalepiduralinjection,andfollowpost−operativelyfornext24hours.Thereweresuccessestomatchthesechallenges.Facetjointsarenotonanationalcoveragedetermination(NCD)list.WeprovidedouropinionstotheFDAandtheyareconsideringthemonperformanceofinterventionalprocedures;theGovernmentAccountabilityOffice(GAO)hasstartedastudytoassessif,infact,CRNAsarequalifiedtoperforminterventionaltechniques(15,16);creationofagrouppurchasingorganization(GPO)withHenrySchein(17);publishedevidence−basedguidelinesforinterventionaltechniqueslistedonAgencyforHealthcareResearchandQuality′s(AHRQ)NationalGuidelineClearinghouse(NGC)website(18);reversalofnoncoveragedecisiononcervicalepiduralsandfacetjointinterventionsinTennessee(19,20);continuingnegotiationswithCignawithevidencesubmissionsignedby684physicians(21);progressinnegotiationswithNoridiantoreviseLCDsbasedonevidenceandreasonableandmedicallynecessary;andfinallywitha3monthfixforproposed2442 to assess a patient preoperatively, to perform a high risk procedure of cervical epidural injection, and follow post-operatively for next 24 hours. There were successes to match these challenges. Facet joints are not on a national coverage determination (NCD) list. We provided our opinions to the FDA and they are considering them on performance of interventional procedures; the Government Accountability Office (GAO) has started a study to assess if, in fact, CRNAs are qualified to perform interventional techniques (15,16); creation of a group purchasing organization (GPO) with Henry Schein (17); published evidence-based guidelines for interventional techniques listed on Agency for Healthcare Research and Quality's (AHRQ) National Guideline Clearinghouse (NGC) website (18); reversal of noncoverage decision on cervical epidurals and facet joint interventions in Tennessee (19,20); continuing negotiations with Cigna with evidence submission signed by 684 physicians (21); progress in negotiations with Noridian to revise LCDs based on evidence and reasonable and medically necessary; and finally with a 3 month fix for proposed 24% SGR cut (22). The above referenced challenges have led some to enter 2014 with lackluster enthusiasm, frustration, and dismay. Issues continue, most importantly draconian cuts proposed by the Centers for Medicare and Medicaid Services (CMS) for lumbar and cervical interlaminar epidural injections CPT 62310 and CPT 62311 with a physician payment of 42toassessapatientpreoperatively,toperformahighriskprocedureofcervicalepiduralinjection,andfollowpost−operativelyfornext24hours.Thereweresuccessestomatchthesechallenges.Facetjointsarenotonanationalcoveragedetermination(NCD)list.WeprovidedouropinionstotheFDAandtheyareconsideringthemonperformanceofinterventionalprocedures;theGovernmentAccountabilityOffice(GAO)hasstartedastudytoassessif,infact,CRNAsarequalifiedtoperforminterventionaltechniques(15,16);creationofagrouppurchasingorganization(GPO)withHenrySchein(17);publishedevidence−basedguidelinesforinterventionaltechniqueslistedonAgencyforHealthcareResearchandQuality′s(AHRQ)NationalGuidelineClearinghouse(NGC)website(18);reversalofnoncoveragedecisiononcervicalepiduralsandfacetjointinterventionsinTennessee(19,20);continuingnegotiationswithCignawithevidencesubmissionsignedby684physicians(21);progressinnegotiationswithNoridiantoreviseLCDsbasedonevidenceandreasonableandmedicallynecessary;andfinallywitha3monthfixforproposed2442 for preoperative assessment, performance of the procedure intraoperatively, and post operative management.

Pain Physician

The Merit-based Incentive Payment System (MIPS) was created by the Medicare Access and CHIP Reaut... more The Merit-based Incentive Payment System (MIPS) was created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to improve the health of all Americans by providing incentives and policies to improve patient health outcomes. MIPS combines 3 existing programs, Meaningful Use (MU), now called Advancing Care Information (ACI), contributing 25% of the composite score; Physician Quality Reporting System (PQRS), changed to Quality, contributing 50% of the composite score; and Value-based Payment (VBP) system to Resource Use or cost, contributing 10% of the composite score. Additionally, Clinical Practice Improvement Activities (CPIA), contributing 15% of the composite score, create multiple strategic goals to design incentives that drive movement toward delivery system reform principles with inclusion of Advanced Alternative Payment Models (APMs). Under the present proposal, the Centers for Medicare and Medicaid Services (CMS) has estimated approximately 30,000 to 90,000 pr...

Pain Physician, Jul 14, 2015

Letters to the Editor of patients have shown improvement in all the trials by Manchikanti et al i... more Letters to the Editor of patients have shown improvement in all the trials by Manchikanti et al in practical settings, it will be difficult to improve on the results but it is definitely feasible to replicate the results not only of Manchikanti et al but also of Candido et al and others.

Pain Physician, 2009

Background: In recent years, a number of minimally invasive nuclear decompression techniques for ... more Background: In recent years, a number of minimally invasive nuclear decompression techniques for lumbar disc prolapse, protrusion, and/or herniation have been introduced, including the Dekompressor® a device utilizing an Archimedes screw. The primary goal of the surgical treatment of nerve root compression from a disc protrusion continues to be the relief of compression by removing the herniated nuclear material with open discectomy. However, poor results have been reported for contained disc herniations with open surgical interventions. The results with several alternative techniques including the Dekompressor, automated percutaneous discectomy, and laser discectomy have been described, but are not convincing. There is a paucity of evidence for all decompression techniques. Study Design: A systematic review of the mechanical disc decompression with Dekompressor literature. Objective: The objective of this systematic review is to evaluate the clinical effectiveness of the Dekompress...

Pain Physician, 2010

While the United States leads the world in many measures of health care innovation, it has been s... more While the United States leads the world in many measures of health care innovation, it has been suggested that it lags behind many developed nations in a variety of health outcomes. It has also been stated that the United States continues to outspend all other Organisation for Economic Co-operation and Development (OECD) countries by a wide margin. Spending on health goods and services per person in the United States, in 2007, increased to 7,290–almost2½timestheaverageofallOECDcountries.RisinghealthcarecostsintheUnitedStateshavebeenestimatedtoincreaseto19.17,290 – almost 2½ times the average of all OECD countries. Rising health care costs in the United States have been estimated to increase to 19.1% of gross domestic product (GDP) or 7,290–almost2½timestheaverageofallOECDcountries.RisinghealthcarecostsintheUnitedStateshavebeenestimatedtoincreaseto19.14.4 trillion by 2018. The increases are illustrated in both public and private sectors. Higher health care costs in the United States are implied from the variations in the medical care from area to area around the country, with almost 50% of medical care being not evidence-based, and finally as much as 30% of spending reflecting medical care of uncertain or questiona...

Pain Physician, 2015

Background: The sacroiliac joint is well known as a cause of low back and lower extremity pain. P... more Background: The sacroiliac joint is well known as a cause of low back and lower extremity pain. Prevalence estimates are 10% to 25% in patients with persistent axial low back pain without disc herniation, discogenic pain, or radiculitis based on multiple diagnostic studies and systematic reviews. However, at present there are no definitive management options for treating sacroiliac joint pain. Objective: To evaluate the diagnostic accuracy and therapeutic effectiveness of sacroiliac joint interventions. Study Design: A systematic review of the diagnostic accuracy and therapeutic effectiveness of sacroiliac joint interventions. Methods: The available literature on diagnostic and therapeutic sacroiliac joint interventions was reviewed. The quality assessment criteria utilized were the Quality Appraisal of Reliability Studies (QAREL) checklist for diagnostic accuracy studies, Cochrane review criteria to assess sources of risk of bias, and Interventional Pain Management Techniques – Qua...

Pain Physician, 2016

Since October 1, 2015, the International Classification of Diseases, 10th Revision, Clinical Modi... more Since October 1, 2015, the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) was integrated into U.S. medical practices. This monumental transition seemingly occurred rather unceremoniously, despite significant opposition and reservations having been expressed by the provider community. In prior publications, we have described various survival strategies for interventional pain physicians. The regulators and beneficiaries of system – CMS, consultants, and health information technology industry are congratulating themselves for a job well done. Nonetheless, this transition comes at an immeasurable financial and psychological drain on providers. However, a rude awakening may be making its way with expiration of initial concessions from government and private payers. This manuscript provides a template for interventional pain management professionals with multiple steps for seamless navigation, including descriptions of the most commonly used co...

Journal of NeuroInterventional Surgery, 2015

Peer review of scientific articles submitted for publication has been such an integral component ... more Peer review of scientific articles submitted for publication has been such an integral component of innovation in science and medicine that participants (be they readers, reviewers, or editors) seldom consider its complexity. Not surprisingly, much has been written about scientific peer review. The aim of this report is to share some of the elements of that discourse with readers of the Journal of NeuroInterventional Surgery (JNIS).

Anesthesiology and Pain Medicine, 2012

Anesthesia & Analgesia, 1984

Regurgitation and subsequent aspiration of gastric contents remains a major cause of morbidity an... more Regurgitation and subsequent aspiration of gastric contents remains a major cause of morbidity and mortality in clinical anesthesia (1,2). According to most authors, a pH less than 2.5 and volume of gastric aspirate more than 20-25 ml are generally considered critical factors in the development of acid pneumonitis in adults (3-6). Another critical factor less often appreciated is the tone of the lower esophageal sphincter, which acts as the major barrier in prevention of regurgitation of gastric contents (7). Numerous anal

Journal of neurosurgery. Spine, 2016

Pain Physician

In the face of the progressive implementation of the Affordable Care Act (ACA), a significant reg... more In the face of the progressive implementation of the Affordable Care Act (ACA), a significant regulatory regime, and the Merit-Based Incentive Payment System (MIPS), the Centers for Medicare and Medicaid Services (CMS) released its proposed 2017 hospital outpatient department (HOPD) and ambulatory surgery center (ASC) payment rules on July 14, 2016, and the physician payment schedule was released July 15, 2016. U.S. health care costs continue to increase, occupying 17.5% of the gross domestic product (GDP) in 2014 and surpassing $3 trillion in overall health care expenditure. Solo and independent practices face unique challenges and many are being acquired by hospitals or larger groups. This transfer of services to hospital settings is indisputably leading to an increase in the net cost to the system. Comparison of facility payments for interventional techniques in HOPD, ASC, and in-office settings shows wide variation for multiple interventional techniques. Major discrepancies in p...

Pain Physician

The Centers for Medicare and Medicaid Services (CMS) released the proposed 2017 Medicare physicia... more The Centers for Medicare and Medicaid Services (CMS) released the proposed 2017 Medicare physician fee schedule on July 7, 2016, addressing Medicare payments for physicians providing services either in an office or facility setting, which also includes payments for office expenses and quality provisions for physicians. This proposed rule occurs in the context of numerous policy changes, most notably related to the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) and its Merit-Based Incentive Payment System (MIPS). The proposed rule affects interventional pain management specialists in reimbursement for evaluation and management services, as well as procedures performed in a facility or in-office setting. Changes in the proposed fee schedule impacting interventional pain management practices include adjustments to the meaningful use (MU) program, care management in patientcentered services, identification and review of potentially misvalued services, evaluation of moderate ...

Pain Physician

The Office of Inspector General (OIG), Department of Health and Human Services (HHS), in a 2009 r... more The Office of Inspector General (OIG), Department of Health and Human Services (HHS), in a 2009 report, showed that unqualified nonphysicians performed 21% of the services. These nonphysicians did not possess the necessary licenses, certifications, credentials, or training to perform the services. Since the time the medical profession was founded, advances in treatments and technology, as well as educational and training standards, have promoted a desire to go beyond the basic scope of practice. Many have sought to broaden the scope of practice through legislative efforts and proclamation rather than education and training. In 2001, President Clinton signed into law a rule that permitted states to “opt out” of the Centers for Medicare and Medicaid Services’ (CMS) requirement for nurse anesthetists to be supervised by any physician. Since then, 17 states have adopted this rule. While it was originally intended to help rural areas improve access to care, the opt out rule essentially s...

Pain Physician

The present evidence illustrates that the placebo effect depends on a variety of neurochemical an... more The present evidence illustrates that the placebo effect depends on a variety of neurochemical and neurophysiological mechanisms, which are measurable and modifiable. However, the placebo response is inexorably tied to the treatment context. All medical treatments take place in a particular context; this context includes the therapist’s attitudes, psychosocial factors affecting the therapeutic relationship, and the patient’s mindset. Therapeutic efficacy at least in part is attributable to the concordance between the proposed treatment and the patient’s belief system. It is this fraction of the therapeutic response that is commonly called the placebo effect. More formally, the placebo effect is defined as that part of the therapeutic response that is not attributable to the properties of active ingredients. A proposed model of the placebo effect includes a complex reaction with induction, psychophysiological mediators, neurobiological mediators, and actualization of effects. Similar...

Pain Physician

The Affordable Care Act (ACA), signature legislation of President Obama, was arguably the most co... more The Affordable Care Act (ACA), signature legislation of President Obama, was arguably the most consequential and comprehensive health care reform since Medicare was introduced as part of President Lyndon B. Johnson’s great society. It has been claimed that many of the law’s reforms are now so integrated in the health system that full repeal would be impractical, while others including President Elect Trump have rejected that idea and called for full repeal and replacement claiming ACA law cannot be fixed. A tsunami of increasing regulatory burden over the past 8 years, the current health care milieu has moved independent practitioners towards hospital employment in great numbers. In addition, public opinion has been slowly climbing against ObamaCare with 54% of Americans now opposing the law. President Obama has indicated that the law has accomplished many of its goals, including increasing accessibility, affordability, and quality of health care. However, others have contradicted t...

Pain Physician

The prevalence, costs, and disability associated with chronic pain continue to escalate. So too, ... more The prevalence, costs, and disability associated with chronic pain continue to escalate. So too, the numerous modalities of treatments applied in managing these patients continue to increase as well. In the period from 2000 to 2011 interventional techniques increased 228%. In addition, analysis of utilization trends and expenditures for spinal interventional techniques alone from 2000 to 2008 illustrated an increase in Medicare fee-for-service expenditures of 240% in terms of dollars spent in the United States. The Office of Inspector General (OIG) of the Department of Health and Human Services showed an increase in facet joint and transforaminal epidural injections, with a significant proportion of these services did not meet the medical necessity criteria. The increasing utilization of interventional techniques is also associated with significant variations among specialty groups and regional variations among states. Overall procedures have increased by 173%, with rate of 130% per...

Pain Physician

T he year 2013 was a challenging year for Interventional pain physicians with national coverage d... more T he year 2013 was a challenging year for Interventional pain physicians with national coverage determination threats for facets, epidurals, and spinal cord stimulation (1); certified registered nurse anesthetists (CRNAs) entering the full arena of interventional pain management (2-4); Center for Disease control supported single-dose vial policy being created without products to reasonably support it (5); Food and Drug Administration (FDA) regulating procedural standards of interventional techniques; Noridian led local coverage determinations (LCDs) prepared by Multi-Specialty Pain Workgroup (MPW) (6-8); threatened cuts of cervical epidural injections and facet joint interventions in Tennessee (9,10); empowered insurers limiting interventional pain management (IPM) services (11); usual sustained growth rate (SGR) cut fiasco (12,13); and finally the Thanksgiving gift of draconian cuts for epidural injections amounting to 33% for cervical epidural when in a facility and 56% when performed in a physicians office, and 19% for lumbar interlaminar epidural injection in a facility setting for physician fee and 49% when performed in a physicians office (14). Thus, CMS determined the work value of highly trained and skilled IPM physicians to be a whopping 42toassessapatientpreoperatively,toperformahighriskprocedureofcervicalepiduralinjection,andfollowpost−operativelyfornext24hours.Thereweresuccessestomatchthesechallenges.Facetjointsarenotonanationalcoveragedetermination(NCD)list.WeprovidedouropinionstotheFDAandtheyareconsideringthemonperformanceofinterventionalprocedures;theGovernmentAccountabilityOffice(GAO)hasstartedastudytoassessif,infact,CRNAsarequalifiedtoperforminterventionaltechniques(15,16);creationofagrouppurchasingorganization(GPO)withHenrySchein(17);publishedevidence−basedguidelinesforinterventionaltechniqueslistedonAgencyforHealthcareResearchandQuality′s(AHRQ)NationalGuidelineClearinghouse(NGC)website(18);reversalofnoncoveragedecisiononcervicalepiduralsandfacetjointinterventionsinTennessee(19,20);continuingnegotiationswithCignawithevidencesubmissionsignedby684physicians(21);progressinnegotiationswithNoridiantoreviseLCDsbasedonevidenceandreasonableandmedicallynecessary;andfinallywitha3monthfixforproposed2442 to assess a patient preoperatively, to perform a high risk procedure of cervical epidural injection, and follow post-operatively for next 24 hours. There were successes to match these challenges. Facet joints are not on a national coverage determination (NCD) list. We provided our opinions to the FDA and they are considering them on performance of interventional procedures; the Government Accountability Office (GAO) has started a study to assess if, in fact, CRNAs are qualified to perform interventional techniques (15,16); creation of a group purchasing organization (GPO) with Henry Schein (17); published evidence-based guidelines for interventional techniques listed on Agency for Healthcare Research and Quality's (AHRQ) National Guideline Clearinghouse (NGC) website (18); reversal of noncoverage decision on cervical epidurals and facet joint interventions in Tennessee (19,20); continuing negotiations with Cigna with evidence submission signed by 684 physicians (21); progress in negotiations with Noridian to revise LCDs based on evidence and reasonable and medically necessary; and finally with a 3 month fix for proposed 24% SGR cut (22). The above referenced challenges have led some to enter 2014 with lackluster enthusiasm, frustration, and dismay. Issues continue, most importantly draconian cuts proposed by the Centers for Medicare and Medicaid Services (CMS) for lumbar and cervical interlaminar epidural injections CPT 62310 and CPT 62311 with a physician payment of 42toassessapatientpreoperatively,toperformahighriskprocedureofcervicalepiduralinjection,andfollowpost−operativelyfornext24hours.Thereweresuccessestomatchthesechallenges.Facetjointsarenotonanationalcoveragedetermination(NCD)list.WeprovidedouropinionstotheFDAandtheyareconsideringthemonperformanceofinterventionalprocedures;theGovernmentAccountabilityOffice(GAO)hasstartedastudytoassessif,infact,CRNAsarequalifiedtoperforminterventionaltechniques(15,16);creationofagrouppurchasingorganization(GPO)withHenrySchein(17);publishedevidence−basedguidelinesforinterventionaltechniqueslistedonAgencyforHealthcareResearchandQuality′s(AHRQ)NationalGuidelineClearinghouse(NGC)website(18);reversalofnoncoveragedecisiononcervicalepiduralsandfacetjointinterventionsinTennessee(19,20);continuingnegotiationswithCignawithevidencesubmissionsignedby684physicians(21);progressinnegotiationswithNoridiantoreviseLCDsbasedonevidenceandreasonableandmedicallynecessary;andfinallywitha3monthfixforproposed2442 for preoperative assessment, performance of the procedure intraoperatively, and post operative management.

Pain Physician

The Merit-based Incentive Payment System (MIPS) was created by the Medicare Access and CHIP Reaut... more The Merit-based Incentive Payment System (MIPS) was created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to improve the health of all Americans by providing incentives and policies to improve patient health outcomes. MIPS combines 3 existing programs, Meaningful Use (MU), now called Advancing Care Information (ACI), contributing 25% of the composite score; Physician Quality Reporting System (PQRS), changed to Quality, contributing 50% of the composite score; and Value-based Payment (VBP) system to Resource Use or cost, contributing 10% of the composite score. Additionally, Clinical Practice Improvement Activities (CPIA), contributing 15% of the composite score, create multiple strategic goals to design incentives that drive movement toward delivery system reform principles with inclusion of Advanced Alternative Payment Models (APMs). Under the present proposal, the Centers for Medicare and Medicaid Services (CMS) has estimated approximately 30,000 to 90,000 pr...