Chronic Pain Fact Sheet

ASA strongly opposes the Centers for Medicare & Medicaid Services’ (CMS) proposal to create a new national policy to pay for chronic pain service delivered by providers who have no formal education or training in this specialized area of medicine. ASA’s achievements and ongoing commitment to quality and patient safety have made it an important voice in American Medicine and the foremost advocate for all patients who require anesthesia or relief from pain.

Chronic pain management is the practice of medicine, and properly trained physicians provide essentially all interventional pain services in the United States, including in rural areas. CMS’s proposal to use scarce Medicare dollars to expand coverage of nurse anesthetists’ services is fraught with risk to patients with no identifiable benefit to the Medicare program or to the patients served by the program. The proposal should be rejected.

• Nurse anesthetists have neither the education nor the training to perform chronic pain services. Two major Medicare contractors, Noridian Administrative Services and Wisconsin Physician Services (WPS), contractors that serve 19 states, declined to use Medicare funds to pay for nurse anesthetists providing chronic pain services. The carriers concluded that the assessment skills required for the evaluation of chronic pain and development of a plan of care were "not part of the CRNA training curricula."

The contractor’s position is consistent with a recent Louisiana court decision that examined whether nurse anesthetists had sufficient education and training in chronic pain management. As part of the litigation, then President-Elect of the American Association of Nurse Anesthetists (AANA), Jackie Rowles, CRNA, "acknowledged that there are no guidelines for assessing the competency, skill set, abilities or training needed for CRNAs to begin performing interventional pain management procedures."

The AANA’s own “Standards for Accreditation of Nurse Anesthesia Education Programs,” specifically cite that no clinical experience with “Pain management (acute/chronic)” is required as part of nurse anesthesia training (click here to review the full standards).

• Current restrictions on nurse anesthetists providing chronic pain services are appropriate and necessary. Even in the hands of specially trained physicians, chronic pain procedures are inherently dangerous due to the anatomy and delicate structure of the spine and nerves upon which chronic pain interventions are performed. Specifically, many chronic pain procedures are administered in and near the spinal column and thus pose significant risks to patients. Potential complications include allergic reactions, infections, bleeding, nerve damage, spinal cord injuries (e.g., paralysis), and brain stem tissue damage - all of which can require extensive and costly medical interventions to address. Additionally, chronic pain services include complex prescription medication regimens involving opioids – where specialized physician training is necessary to prevent potentially lethal side effects.
• Physicians provide chronic pain services. A variety of physicians with specialty training in chronic pain management – anesthesiologists, physiatrists, surgeons and other medical specialists - appropriately deliver chronic pain services throughout the country. Adopting a national policy to include nurse anesthetists is unnecessary, unwise and will not improve access. Medicare’s own data shows that nurse anesthetists provide few, if any chronic pain services likely due to lack of education and training, and, in particular, do not provide these services in rural areas. In fact, Medicare’s data shows that physicians are the overwhelming providers of pain services, even in underserved areas, delivering over 99.8 percent of all services.

A review of national Medicare claims data from 2010 shows that of the nearly 2.4 million Medicare claims for the most commonly billed chronic pain procedures only 4000 – less than one-quarter of 1 percent (0.17 percent) - were billed by nurse anesthetists.

Similarly, in looking at data associated with rural and underserved areas, the 2010 Medicare claims data from Health Professional Shortage Areas (HPSAs) for all procedures for acute and chronic pain showed only 27 (0.02 percent) claims from nurse anesthetists. The same data shows that physicians billed for approximately 120,361 procedures in HPSAs during that same period of time. This bears repeating – only 1 in 400 patients in underserved areas receiving a chronic pain treatment received care from a nurse anesthetist. The CMS proposal will NOT improve access.

• The CMS proposal carries significant risk of abuse. Even CMS appears to acknowledge the potential for this new policy to be misused. As part of the proposal, CMS states, “Simply because the State allows a certain type of health care professional to furnish certain services does not mean that all members of that profession are adequately trained to provide the service. In the case of chronic pain management, the IOM report specifically noted that many practitioners lack the skills needed to help patients with the day-to-day self management that is required to properly serve individuals with chronic pain.” Yet, by advancing a new national payment policy, CMS is granting broad endorsement to an entire class of providers with no education or training in chronic pain management to engage in this medical practice.
  
  To that point, litigation is currently pending in Iowa that illustrates the risks of CMS’s broad new payment policy. In a case that has drawn national attention, patients in Fayette County, Iowa have alleged abuse and fraud by nurse anesthetists providing chronic pain services. In particular, court filings contend that pain treatments were provided “beyond the expertise” of the defendant nurse anesthetists.