Clinical Pain Advisor: What other revenue sources are you investigating in order to offset the drop in reimbursements?
Dr. Barelka: [As] opposed to typical funding sources in the private arena, VA funding comes from advance appropriation requests submitted by the president directly to Congress. Our challenge in this area is to address all patient complaints with available resources, while identifying patients who may benefit from additional available therapies.
Clinical Pain Advisor: How have your opioid prescribing habits changed?
Dr. Barelka: Within our VA system, the initiation and maintenance of chronic opioid therapy is typically undertaken by the primary care provider. [O]ver the past several years, there has been an effective educational campaign to disseminate the currently understood limits of opioid effectiveness in the chronic pain population. To a large [extent], this undertaking has been led by the ambulatory care service and their service chief, John Chardos, MD. Available statistics show that our hospital has seen a 27% decrease in patients on opioid therapy over the last 3 ½ years. The VA nationwide has seen a decrease of 16%. What is more difficult to track is the clinical impact of prescribing fewer opioids. Another challenge going forward will be to make sure [that] patients who are no longer opioid candidates still receive alternative agents or therapies to address their pain complaints.
Clinical Pain Advisor: Do you believe that Medicare and workers’ compensation guidelines are truly in the best interest of the patient?
Dr. Barelka: I believe that there will always be a struggle in formulating any guidelines that address the pathology of the chronic pain patient in a reasonable manner. As we know too well, available therapies are incomplete and thereby leave the door open for more and more things to be done. Often, the other options available are less likely to be effective or even dangerous [to] the patient. The art of saying “no” is sometimes lost on noble clinicians striving to unreasonably address all their patients’ suffering. Confounding this further is the fee-for-service environment and a patient cohort that often seeks complete resolution of their pain. We can be sure that this struggle will continue. I think it reasonable that we continue to direct our attention towards gathering important outcomes data so that we have at least [a] tangible grasp on the effectiveness of available modalities and their shortcomings.