Even pain specialists can be misled. They may read the latest articles published in pain medicine journals, but most of this material covers basic science and does not offer practical guidance for day-today practice. This means that even pain specialists get most of their practical information about pills, injections, implants, and surgeries at sponsored events and medical conventions, where they are inundated with information presented by the firms that make the medicines and the spinal fusion hardware. Although the speakers at these conferences are experts in the field, there is an excellent chance they are being sponsored by (and therefore influenced by) a Wall Street-driven pharmaceutical or medical technology company with a large wallet.
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A diligent doctor might try to dig out the latest information on his own by searching the scientific literature, but she would run into the problem of “disappearing studies.” Many studies are sponsored by pharmaceutical or bioengineering companies. A fair number of these studies are never published or discussed at medical conventions, quite possibly because their results indicate that the medicine or spinal fusion hardware is either not useful or not safe. If the results are not what they hoped for, these companies simply act as if these studies never existed, and most doctors don’t know the difference. Thus, a doctor searching through the medical literature might see lots of positive studies about a certain medication or type of spinal fusion hardware, but no negative studies, because those have been “buried.”
Surprisingly, even insurance companies pressure doctors to prescribe pills and injections—not directly, but indirectly—by making doctors jump through a lot of hoops to get approval for other forms of treatment, like the comprehensive pain-control program we run at my center. Programs like these are not covered by most private insurance companies or by Medicare.
This makes it very difficult to get approval from an insurance company for anything other than standard treatments like medicines, tests, injections, implants, surgeries, and physical therapy. The doctor who wants to do something different must write a letter to the company, call various people, send in copies of reports, answer objections, and more. All of this is incredibly time-consuming and frustrating. Some doctors will jump through one hoop afer another, determined to offer the best-possible care to their patients. But others are not so resolute. And often, no matter how much of a fight you put up, the insurance company will simply say “no,” and that’s it. Insurance companies feel they already spend too much on pain patients; to them, pain treatment is a black hole of expense. They feel there is a good chance the pain patient will move on to a different insurance program in the near future, so there’s no need for them to solve long-term problems, no matter how powerful the impact on society. If the lack of proper care means a person can’t return to work and must go on disability, that’s fine with an insurance company: the cost and responsibility then shifts to the disability system and becomes the taxpayers’ problem and expense.
Many insurance companies, health plans, and state workers’ compensation departments have hired outside “review physicians” to evaluate what the doctor has done or recommends, specifically looking for reasons to deny treatment. These review physicians, who are not pain specialists, get paid by the companies to meet a “quota of no” by denying claim afer claim Other insurance companies take a different approach, developing multiple layers of administration that doctors must work through to get approval. But the process is so difficult and time-consuming, with the insurance companies putting up so many roadblocks, that most doctors follow the path of least resistance and go back to the pills and injections, or anything else that will be covered.
This might be all right if the covered therapies truly helped. But if they did, would 100 million Americans still be suffering from pain and all of its associated ills? Our health system is supposed to be driven by science, but there are no scientific studies showing, for example, that long-term use of opioids is an effective treatment for chronic pain. I would argue that prescribing pain pills, now a common treatment strategy, took hold through clever marketing and sales work.
Patients have long been kept in the dark as to the effectiveness and the dangers of certain pain relief strategies. For example, studies have shown that the sleeping pills commonly prescribed for insomnia can be seriously dangerous over the long run. Yet how often are patients informed that the use of sleeping pills, even intermittently, is associated with a lower life expectancy? Cognitive-behavioral therapy has been shown to be more effective and much safer than sleeping medications, yet insurance companies rarely cover it. In short, our healthcare system is geared toward quick fixes for pain, so we rely primarily on prescriptions and injections, even though they may not be the best solutions.
Today’s pain specialists provide their patients with a lot of interventional or invasive procedures. And that’s because insurance pays doctors more when they do some sort of procedure, as opposed to simply educating their patients. A procedure, then, is more profitable than a simple office visit/consultation. Some pain specialists have found they can optimize their cash flow by setting up their own procedure room or surgery center. Then, when they perform a procedure, they get two fees: the professional fee for the procedure, and the facility fee. Meanwhile, many hospitals court doctors who do a lot of procedures, offering them financially advantageous terms if they will move to the hospital and bring their patients with them While all of this may be legal, the point is financial incentives may not always coincide with the areas where we get the best results.
Here’s another fact not known by most patients: Many spinal fusion hardware makers have set up special deals with doctors, allowing them to buy hardware from the company at a discount, then sell it to the hospital where they will be performing the surgery at full price (of course). During the surgery, the doctor will insert the same hardware into the patient that he just made a profit on. Thus, he is paid twice: for performing the surgery and for selling the hardware to the hospital. And, if he happens to have a financial interest in the hospital, he will make even more money.
Whenever extra payments are involved, you have to wonder if the incentive for profit might be clouding the doctor’s judgment.