What role does pain management have in managed care and how does this differ from its role in traditional fee-for-service reimbursement? At first glance, it looks as if pain (our patients' pain, that is) is a long conceptual distance from managed care. But think about it. Incidentally, the terms "managed care" and "health maintenance organizations" are often used interchangeably in these editorials; there are other forms of managed care, but so far HMOs are the most evolved and appear to be the direction managed care is headed.
First, one might say that pain control will be less important in an HMO because the patient and family are locked in to a contract. Pleasing them will be less important because they must go to the physicians in their HMO That isn't really true. However, in the long run. Patients usually choose from a menu of types of insurance, and they can change their primary care physician or their plan at specified times (eg, annually). Currently, families are placing a lot of emphasis on out-of-pocket costs, but as they become experienced with managed care, other qualities probably will gain in importance: compassion of the caregiveii comfort for their child, and quality of care will be considerations when they select their plan and gatekeeper.
Can effective pain management reduce cost? As a general rule, anything that saves money while maintaining or improving quality of care should eventually be a winner in managed care. It doesn't take much to see how pain management fits this. The most basic way to reduce cost is to reduce hospitalization. Think about the times you had to admit a child who wasn't physically sick enough to need inpatient care. This happens most often when the child's condition (and discomfort) is not under control at home because we have been unable to solve the problem during outpatient visits or because the family cannot cope. Actually, both of these two problems usually work synergistically to put children in the hospital. The physician who controls the acute pain of otitis, pharyngitis, or pyelonephritis (see Schechter NL. "Common Pain Problems in the General Pediatrie Setting," pages 139-146 in this issue) will reduce the occasional admission for one of these conditions. Have you ever hospitalized a child with herpes stomatitis because parent coping was running on empty?
The physician who can successfully manage chronic pain without treatable organic causes also will be a winner (see Shapiro BS. "Treatment of Chronic Pain in Children and Adolescents," pages 148-156). Migraines and other headaches, chronic abdominal pain, and chronic chest and musculoskeletal pain are common examples. We have all seen children with chronic abdominal pain who have bounced from physician to physician, had multiple procedures (some procedures multiple times), and occasionally surgical interventions, but the problem continues. It often takes a physician's physician (an artist of medicine) to bring this problem under control. Again, the gate opener (does anyone like the term gatekeeper?) must know when to hold and when to fold the cards dealt to him or her. This means you must know your consultants, what they can do, and when to refer. The pediatrician of the future will need to be more knowledgeable and shrewder to get what is needed for his or her patients. Referral of the child with chronic abdominal pain to someone who can solve this problem, instead of doing endoscopy for the third time, is the way to go.
Now let's address reimbursement for pain management in managed care. Dr Richard Patt addresses this problem in his overview. Pain control programs, like many other treatment modalities, are not widely accepted as mainstream pediatrie care (tike they should be). The value, use, and reimbursement of pain control will differ depending on the HMO. The following two examples of extremes illustrate this and provide an opportunity to look inside basic HMO structures.
The first example is the large corporate HMO operating on a for-profit basis. These organizations are gathering strength rapidly in mature managed care markets. The reason is. profit. Where there is a surplus of physicians and hospital beds, this HMO can squeeze down on what it pays for services. Some of you probably have had one of these HMOs offering you a fee-farservice at their price for what they want from you: "Take it or leave it. We will go down the street to your competitor if you won't sign." How does this fit with serving the patient, offering compassionate care, and working together to solve problems and reduce costs? Not well. It seems unlikely that this HMO will value or reimburse special programs such as pain control.
On the other hand, some of you are part of a physician hospital organization or otherwise have financial or emotional "ownership" in a managed care plan. You can be on a team with primary care physicians, subspecialists, hospitals, and sometimes insurance carriers to plan and implement your own managed care system. You can bring your expertise in caring for and about patients to setting goals, negotiating priorities, and compromising to get the best possible combination of compassion, quality care, and cost effectiveness. This kind of HMO is more likely to value pain control.
These two extremes and everything in between are battling it out now, and it remains to be seen which type will be favored: market forces will select the winners. The large corporate HMOs have some advantages at this point. They have been raised in a tradition that uses control, planning, organization, and productivity to make money. They also understand the connection between taking financial risks and making a profit. We physicians, on the other hand, have been raised in a tradition that prized independence, self-reliance, and overcoming obstructions to get the best care for our patients. This can make it difficult to be an integral part of a large, coordinated health-care team and to take businesstype financial risks. In the first example of the corporate HMO (above), your short-term financial risk is minimal. If you have a reasonable estimate of the patient volume you will receive and what your fixed costs of practice are, your chances of losing significant money are remote. But neither can you make much money, and the fees you get are likely to be stable or decrease over the years. In contrast, if the corporation can reduce physician, hospital, and other costs below the HMO income, the difference is profit, and this goes to the company and its shareholders. So at a time when the total amount spent on medicine is being restricted by competition for managed care contracts, an increasing portion of this total can be drawn away from patient care to corporate profits.
If you are in the second type of HMO that negotiates its structure internally, you can choose to take at least pan of the financial risks. For example, you might design a globally capitated HMO whereby the primary care physicians, subspecialists, and the hospitals work together to establish their own three individual capitation rates. The insurance carrier may do your marketing, accounting, and perhaps provide information systems but you get the profits (or losses) if HMO costs for care are less (or more) than income. You also can choose to reinvest these profits back into patient care by expanding your primary care network or other services.
Anyway, if you have a chance for "ownership" in an HMO, think about this before turning down the opportunity. If your heart will allow you to be part of the "business of medicine" and you can accept mutual ownership and risk, take control and help design a managed care system that will work for your patients and yourself If successful, this type of HMO could offer greater value, and in the long run, patients will recognize and seek this. Physician "owner operator" HMOs can give corporate for-profit managed care a good fight for patients in the managed care market.
Incidentally, two readers have made important points about recent issues of Pediatrie Annals. The "mad hatter" disease mentioned in a previous editorial is considered due to mercury instead of lead poisoning. Also, the cover of the December 1994 issue on "Community Pediatrics" pictures a child with a pacifier tied around her neck by a heavy shoestring. This is an example of an opportunity for prevention. This mom needs to hear that her child is at risk for asphyxiation by hanging if the child falls and the pacifier becomes caught on something.