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10 Articles in Volume 6, Issue #1
Bioethics
Do Topical Herbal Agents Provide Pain Relief?
Infusion Catheter Epidural
New Report of a High-Dose Morphine Metabolite
Pain Education and Pain Educators
Suspecting and Diagnosing Arachnoiditis
Tennant Blood Study — First Update
The Demise of Multidisciplinary Pain Management Clinics?
The Dimensions of Pain
The Role of Psychology in Pain Management

The Demise of Multidisciplinary Pain Management Clinics?

A potential strategy for addressing the conflicting ethos of business-oriented insurance and corporate healthcare versus the ends and means of right and morally sound patient care.
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Unfortunately, these professionals are not the only people involved in the care of the chronic pain patient. Chronic pain management is not solely the domain of the medical community, but is also impacted by the insurance industry, hospital administrations, the legal system, the pharmaceutical and implantable medical device industries, and a number of other entities. Perhaps the groups most likely to impact a patient’s potential admission into an integrated multidisciplinary chronic pain management program are third party payers and hospital administrators. It is a fact that, given the ethical premise and ethos of these enterprises as business-oriented entities, the attendant actions of these actors may not be wholly consistent with the ends and means of right and morally sound patient care.23 Yet these enterprises have established written and meaningful commitments to domains of patient care, albeit within the constraints of a business environment.

Sadly, while chronic pain management practitioners function under ethical codes of conduct which emphasize the primacy of the patient’s well-being, the business ethos and ethics of the healthcare insurance and hospital corporations may not be directly compatible or supportive of such ethically sound medical care of the chronic pain patient. The effects of such a business-oriented ethos have been infused in the healthcare system and have led to an increasing commodification of medical care. This may be partly responsible for financially-driven motives to reduce or eliminate multidisciplinary pain care as “surplus provision” and, in so doing, render numerous patients without access to such empirically effective care.

Business Ethos vs Patient Care

Due to its emphasis on the economic model, insurance carriers are reluctant to fund integrated multidisciplinary chronic pain management services. The explanation for this increasingly frequent refusal is multi-causal, and several speculations can be made. First, as third party payers are often “penny wise and pound foolish”, the “sticker shock” of a 4-6 week intensive treatment program often results in their refusal to recognize the formidable body of research mentioned earlier8-16 supporting not only clinical efficacy but cost-efficiency. Second, third party payers often expect multidisciplinary chronic pain management programs to be successful in every case. Stieg noted, “…there is a tendency of third-party payers to expect pain treatment centers to solve all of their patients’ social problems.”24 It is apparent that health insurance carriers do not recognize that even the best multidisciplinary programs cannot control all patient and social variables, and accordingly cannot control all outcomes. Third, multidisciplinary chronic pain management programs sometimes find themselves in competition with pharmaceutical companies marketing medications including opioids, NSAID’s and anti-convulsants as relatively inexpensive “quick fixes” to third party payers. Health insurance carriers may now be even more likely to see medications as an appealing option given the recent switch to generic status of formerly expensive medications such as time-released oxycodone, transdermal fentanyl, and gabapentin, irrespective of empirical findings that suggest that the integration of pharmacological approaches to multidisciplinary care is superior.13 The pharmaceutical approach, alone, is often insufficient to treat the multiple and compound issues that instigate and perpetuate a particular patient’s pain. Finally, as reimbursement for actually spending time with patients are decreasing while reimbursements for procedures are increasing,25-27 there is a developing disincentive for interventional pain management specialists to refer their refractory patients to multidisciplinary chronic pain management programs. Chapman noted that, “Concurrent with the decline in intensive programs is the rise of procedural interventions and medication, which receive a great deal of support from medical technology and pharmaceutical companies”28 Such interventions, while effective in the short term, may not provide lasting relief from pain, and are very often best employed to interrupt the pain-disability cycle so as to make the patient more amenable and capable for other treatment approaches such as biomechanical retraining, occupational therapy, etc.

“One of the most prominent theories in medical ethics is that of principle-based ethics...which suggests that clinical decisions and acts be guided by the mid-level principles of autonomy, nonmaleficence, beneficence and justice.”

While third party payers have become progressively less amenable to funding multidisciplinary chronic pain management programs, hospitals have chosen to terminate them, resulting in reduced availability.17 These programs, while clinically effective, are quite labor-intensive. Due to the disruption which chronic pain patients experience in so many areas of their lives, a wide variety of professionals is required in order to restore them to functional status. A review of the literature fails to yield any studies of the lack of profitability of multidisciplinary chronic pain management programs. Nevertheless, it is evident that these programs are not “cash cows,” and accordingly hospital administrations do not consider them to be consistent with their goals of cost-containment and profit generation.

Bioethical Theory and Chronic Pain Management

Based upon the information which has been provided in this article up to this point, a strong argument can be made that the dissipating funding and availability of integrated multidisciplinary chronic pain management programs is the result of conflicts in the ethos and ethics of the business enterprise of health insurance carriers and hospital administrations—despite well-documented clinical efficacy and cost-efficiency.8-14 In order to strengthen this argument, this analysis will now turn to an examination of the progressive demise of multidisciplinary chronic pain management programs within the context of two highly regarded theories of bioethics, each of which is intended to serve as a guideline according to which practitioners can treat patients effectively and ethically.

Last updated on: December 28, 2011
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