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CON: Exclusive Contracts Should Not Include Pain Medicine
Lawrence S. Gorfine, M.D.
Committee on Pain Medicine
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Exclusive hospital contracts should not include pain medicine/management as the
sole domain of hospital-based anesthesiologists. It is illogical and
presumptuous that anesthesiologists are the only practitioners of this branch of
medicine and entitled to an exclusive contract. Pain management is a complex
multispecialty and multidimensional study and practice of medicine. It
encompasses the anatomic, physiologic and psychological study of pain. The
treatment of this complex mix of multisystem components often requires more than
one medical and psychological specialty. Frequently, physical rehabilitation of
some type also is needed. Many of these areas of treatment are not usually part
of the expertise of the pain medicine anesthesiologist. To exclude other
anesthesiologist and nonanesthesiologist pain practitioners from the hospital
denies patients of that community access to a potential mix of physicians with
different experiences and treatment skills.
Anesthesiologists have had a leadership role in the development of pain medicine
as a subspecialty. We should continue in that leadership role by trying to offer
options and choices to our hospitals and communities. Closing a hospital or
medical staff to pain physicians other than those in the contracted
anesthesiology group limits choice and options. It does not promote the growth
of new ideas in pain medicine, and it does not promote the growth of new
treatment modalities or the general promulgation of pain medicine as a
specialty. We need to encourage the growth of different perspectives and
facilitate the availability of physicians with different treatment skills and
experiences. Our reputation as leaders in this field will be lost if we continue
to request exclusivity. We will, instead, be viewed as protectionists who are
not interested in the growth of knowledge and the advancement of patient care.
The practice of anesthesiology is very different than the practice of pain
medicine/management. Though many hospitals and their operating rooms function
more efficiently with a single anesthesia group, no such increased efficiency
occurs as a result of having an exclusive contract in pain medicine. Pain
medicine better resembles a surgical subspecialty than it resembles the practice
of anesthesiology. Pain medicine procedures are often scheduled in an operating
room or special procedure suite similar to the scheduling process utilized by
surgery and endoscopy. In fact, pain medicine physicians often perform surgical
procedures such as pump and stimulator implants requiring anesthesia. After
these procedures, patients are followed up with in an office or outpatient
clinic. Some of these patients need long-term care and medication treatment.
These types of procedures are not hospital-based and work better in an office or
clinic setting. There is, then, no increased efficiency or other benefit if the
pain physician is a member of a hospital-based anesthesia group.
Where the practice of pain medicine is more like a surgical subspecialty
practice, an exclusive contract serves to merely block competition. This
inevitably leads to less availability of treatment options and services.
Typically, each physician group or single practicing physician has an area of
major interest. Some pain physicians prefer treating cancer pain; others treat
back pain or acute postoperative pain. Physicians develop more expertise and
skill in their specific areas of interest. These skills are noted and
appreciated by other physicians in the community, and patients requiring these
skills are naturally directed to these specialist doctors. Other areas of pain
medicine are, then, underserved if other physicians or groups are not present.
Patients requiring medication for neuropathic pain, weaning and narcotic
detoxification, for example, may not have a physician with interest and
expertise available to help.
Although competition is eliminated by an exclusive contract, it does not
necessarily benefit the hospital-based anesthesia group. If more physicians are
available, more services are offered. The availability of more pain
medicine-trained physicians leads to a greater awareness of the benefits pain
medicine has to offer and, as a result, increases the utilization of these
services. Instead of decreasing the amount of work performed by the pain
medicine physician in the anesthesiology group, there is often a greater request
for pain medicine services in general by the physicians and members of the
community. The hospitals and often the anesthesia groups in the hospitals
increase the volume of work relating to pain medicine. The hospital-based
anesthesia group with an exclusive contract in anesthesiology has nothing to
fear by opening the staff to trained pain physicians. The increase in services
offered, increase in awareness of the community and increased options for the
patients ultimately benefit even the hospital-based anesthesia group.
Physicians who are fellowship-trained in pain medicine and who have no desire to
join an anesthesia group to provide anesthesia services should be allowed to
work. Many of the fellowship-trained anesthesiology pain physicians want only to
practice pain medicine. Unfortunately, if they are not on the medical staff of a
hospital, they are not able to work in most areas. In some states, the law
requires that a physician have hospital or surgical center privileges for the
procedures performed in an office. Some states require emergency transfer
agreements to hospitals if procedures are performed in an office setting. Peer
review and quality assurance can only be performed effectively if the physician
is on a hospital or surgical center staff. Most medical insurance companies
require a physician to have hospital privileges before a contract is written to
care for the patients covered under the plan. Therefore, hospital medical staff
privileges are needed to practice medicine today. Exclusive contracts do not
allow trained pain physicians to obtain these necessary hospital privileges. In
many cases, pain physicians are forced to join an anesthesia group and work only
part-time in pain or not work at all. This creates an unjust environment for
pain medicine physicians, which does not exist in other medical specialties.
This unfair treatment of our fellowship-trained pain medicine anesthesiologists
must be changed. Our pain medicine physicians must be allowed the opportunity to
open a medical practice in the area of their choice without being unfairly
blocked by established anesthesiologists.
Restricting pain medicine physicians from a community serves no benefit to that
community, the hospital or the anesthesia group. Exclusive contracts for pain
medicine serve to restrict pain medicine physicians from practicing in their
chosen field of medicine. It further creates division and hostility between pain
anesthesiologists and hospital-based anesthesiologists. This hostility often
extends to encompass all anesthesiologists, who are then perceived by pain
medicine physicians as unfriendly and protectionists. This division in our
specialty and this unjust environment have pushed pain medicine
anesthesiologists to join organizations other than ASA for support and
representation.
Exclusive contracts for pain medicine are wrong, unjust and divisive. It must be
changed on moral and ethical grounds. It must be changed to allow diversity in
treatment options and for improved quality of care. Reasonable anesthesiologists
must speak out against this unjust treatment of a segment of our specialty. We
can expect pain medicine anesthesiologists to return to ASA only if we
demonstrate a real commitment to rectify these injustices and show a true
appreciation of the difficulties exclusive contracts have caused.
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Lawrence S. Gorfine, M.D., is Medical Director, Southern Pain Institute, Lake
Worth, Florida.
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ASA Contents
FEATURES
Writing the Next Chapter in Pain Medicine
Evolution of Pain Medicine Training in the United States
ASA Statement to FDA Committee
Phantom Limb and Causalgia Pain in the Three Great Wars
PRO: Anesthesiology Group Practice Versus Independent Pain Practitioners:
Exclusive Contracts Should Include Pain Medicine
CON: Exclusive Contracts Should Not Include Pain Medicine
ARTICLES
Board of Directors Annual Meeting Summary
New AMA Council Member Beefs Up Anesthesiology's Influence
All in the Family for 31 Years: ASA Executive Director Glenn W. Johnson to
Retire
DEPARTMENTS
Ventilations
Administrative Update
Washington Report
Spotlight On…
Practice Management
State Beat
Residents' Review
What's New In...
Subspecialty News
ASA News
Letters to the Editor
FAER Report
The views expressed herein are those of the authors and do not necessarily
represent or reflect the views, policies or actions of the American Society of
Anesthesiologists.
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