One reason for the closing of many centers was the pull back by insurance carriers for payments for non-interventional pain treatment services. Doing a procedure seemed to be considered more valid and worthy of payment than a non-invasive service even if it was effective in reducing pain, improving function and lowering future cost of care. Today some of the best pain centers cannot survive by depending on insurance payments and are forced to charge their patients large out of pocket sums in order to remain in operation. Some of these insurance carriers that will not pay for comprehensive pain centers will routinely pay for procedures of questionable effectiveness. Although the number of CARF approved pain centers in the US halved, the number of outpatient pain centers mushroomed. The services provided however focused on two areas:

1. Medication management
2. Nerve blocks and other invasive procedures.

Some patients could be helped with one or both of these approaches, but many patients in need of physical therapy and psychological services that had been integrated in a comprehensive treatment plan, would no longer receive optimal treatment. Reimbursement would be the driver of care rather than the needs of the patient. Centers could not stay in business and provide care that insurance companies would not cover. The shift toward procedures became an accepted standard of care and new organizations of pain physicians were formed whose membership focused predominantly on invasive procedures.

The emphasis on medication management was in part fueled by the belief that most patients with persistent pain could be treated successfully and safely with strong pain medications, such as opioids like morphine and oxycodone. We have a better understanding now of problems encountered when we freely offered potent pain medications to too many patients. Strong pain medications not only treat pain but also affect mood. Many patients with or without pain have anxiety and/or depression. Pain medications can provide emotional relief and patients would take them consciously or inadvertently for psychological rather than pain relief. Prescribed pain medication have become more popular than street drugs such as heroin for people who were drug abusers and some patients feigned pain and sold the prescribed pills for a handsome profit.

The cost of services for the treatment of back and neck pain, now with many less comprehensive multi-disciplinary centers, has nonetheless continued to rise at an alarming rate. Next time let’s look at the phenomenon of unintended consequences.