LAS VEGAS—As medical technology has improved treatment and life expectancy has climbed, and as patient populations age and drive up chronic disease rates, the cost of healthcare is increasing sharply—and providers play an important role in helping to curb unnecessary costs.
Pain medicine providers need to become “talented amateurs” when it comes to medical economics. “Day in, day out, we focus on care of patients more than the cost of that care,” said Darren McCoy, FNP-BC, CPE to attendees at PAINWeek 2014.
A 2013 study published in JAMA showed that only about a third of clinicians believe they bear a “major responsibility” for controlling health care costs, McCoy noted. But “we who put pen to paper and write the orders for tests, treatments, durable medical equipment, and prescriptions have the most control of who gets what, when, and how often.”
“We may not have control over what a particular drug costs,” he explained. “We may not have control over what an MRI costs. But we do have control over which patient gets which medication. We do have control over whether or not an MRI is even needed.” Some costly procedures and exams are not always medically justified.
Diagnostic pain imaging can be misleading, for example. “The majority of people with no back pain had one or more levels of ‘degenerative disc disease’” in a classic 1994 New England Journal of Medicine study, he noted; 64% of asymptomatic people had one disc bulge and 38% had at least two.
Avoid unnecessary imaging, McCoy advised. The American College of Radiology has issued evidence-based appropriateness criteria for imaging decisions, he noted. “MRI only if a patient would be a candidate for ESI for radiculopathy, or surgery,” he said. And even if a patient is a surgical candidate, consider alternatives, he was quick to add. Patients who participate in physical therapy and receive medication with behavioral therapy for lumbar fusion, appear to enjoy outcomes comparable to those who undergo surgery, he noted—at 42% lower costs.
If MRI is actually indicated, let patients know that they can shop around for a better price, McCoy advised. “Prices vary greatly; a patient may be better off negotiating a ‘cash pay’ price than to get it done under a high-deductible insurance plan.” Private organizations can help negotiate with imaging centers for flat-rate MRIs, he added.
Instead of ordering new liver and kidney function lab tests when prescribing potentially hepatotoxic or nephrotoxic medications, request recent labs from the primary care provider or ask the patient to bring copies, McCoy suggested.
Using risk evaluation and stratification, and patient education to reduce illicit behaviors can reduce drug testing costs, he added. “There’s no need to test every patient every time,” he said.
Despite recent “buzz” about genetic testing to determine if a patient can metabolize a medication, these tests should only be ordered if the provider plans to “do something with the results, not simply to ‘explain why’ patients’ complaints of pain are refractory to various opioids,” McCoy said. “No matter what medication a patient may metabolize most effectively, insurance coverage may limit options.”