Pain physician
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In the face of the progressive implementation of the Affordable Care Act (ACA), a significant regulatory regime, and the Merit-Based Incentive Payment System (MIPS), the Centers for Medicare and Medicaid Services (CMS) released its proposed 2017 hospital outpatient department (HOPD) and ambulatory surgery center (ASC) payment rules on July 14, 2016, and the physician payment schedule was released July 15, 2016. U.S. health care costs continue to increase, occupying 17.5% of the gross domestic product (GDP) in 2014 and surpassing $3 trillion in overall health care expenditure. Solo and independent practices face unique challenges and many are being acquired by hospitals or larger groups. This transfer of services to hospital settings is indisputably leading to an increase in the net cost to the system. Comparison of facility payments for interventional techniques in HOPD, ASC, and in-office settings shows wide variation for multiple interventional techniques. Major discrepancies in payment schedules are related to higher payments for hospitals than comparable treatments in in-office settings and ASCs. In-office procedures, which have been converted to ASC procedures, are reimbursed at as high as 1,366% higher than ASCs and 2,156% higher than in-office settings. The Medicare Payment Advisory Commission (MedPAC) has made recommendations on avoiding the discrepancies and site-of-service differentials in in-office settings, hospital outpatient settings, and ASCs. These have not been implemented by CMS. In addition, there have been slow reductions in reimbursements over the recent years, which continue to accumulate, leading to significant reductions in paymentsIn conclusion, equalization of site-of-service differentials will simultaneously improve reimbursement patterns for interventional pain management procedures, increase access and quality of care, and finally, reduce costs for CMS, extending Medicare solvency. ⋯ Hospital outpatient departments, ambulatory surgery centers, physician in-office services, interventional pain management, interventional techniques.
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Percutaneous radiofrequency ablation (RFA) of the sphenopalatine ganglion (SPG) has been shown to be an effective modality of treatment for patients with intractable chronic cluster headaches (CHs). While the use of fluoroscopy for RFA of the SPG is common, to our knowledge there are no documented cases of procedures using cone beam computed tomography (CBCT) for image guidance. We present a case report of a patient suffering from chronic intractable CH with complete long-lasting relief after RFA of the SPG using CBCT. The case reaffirms the potential efficacy of RFA of the SPG in a case of chronic cluster headache as well as the use of CBCT as a superior alternative to bi-plane fluoroscopy for image guidance in the management of chronic CH. ⋯ Cone beam computed tomography, sphenopalatine ganglion block, cluster headache, interventional pain, autonomic cephalalgia, radiofrequency ablation.
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Headache (HA) is a significant cause of morbidity globally. Despite many available treatment options, HAs that are refractory to conservative management can be challenging to treat. Third occipital nerve (TON) and greater occipital nerve (GON) irritation are potential etiologic agents of primary and cervicogenic HAs that can be targeted using minimally invasive treatment options such as nerve blocks or radiofrequency ablation. However, a substantial number of patients that undergo radiofrequency ablation do not experience pain relief despite a positive diagnostic medial branch block (MBB). ⋯ Chronic pain, cervicogenic headache, third occipital nerve, greater occipital nerve, injectate spread, radiofrequency ablation.
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Randomized Controlled Trial
Fluoroscopically Guided Thoracic Interlaminar Epidural Injection: A Comparative Epidurography Study Using 2.5 mL and 5 mL of Contrast Dye.
Thoracic epidural anesthesia (TEA) is frequently used to maintain intraoperative analgesia. After injecting the initial bolus dose of epidural local anesthetics (LA), intermittent injection of LA through an epidural catheter is required to maintain the intraoperative analgesia. For intermittent epidural administration, usually 2 - 5 mL of LA has been used. However, no studies have suggested an optimal volume of LA of TEA for intermittent epidural administration of TEA. ⋯ Thoracic epidural anesthesia, intermittent epidural administration, optimal volume, epidurography, cephalad, caudad, analgesic effect.
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The Merit-based Incentive Payment System (MIPS) was created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to improve the health of all Americans by providing incentives and policies to improve patient health outcomes. MIPS combines 3 existing programs, Meaningful Use (MU), now called Advancing Care Information (ACI), contributing 25% of the composite score; Physician Quality Reporting System (PQRS), changed to Quality, contributing 50% of the composite score; and Value-based Payment (VBP) system to Resource Use or cost, contributing 10% of the composite score. Additionally, Clinical Practice Improvement Activities (CPIA), contributing 15% of the composite score, create multiple strategic goals to design incentives that drive movement toward delivery system reform principles with inclusion of Advanced Alternative Payment Models (APMs). Under the present proposal, the Centers for Medicare and Medicaid Services (CMS) has estimated approximately 30,000 to 90,000 providers from a total of over 761,000 providers will be exempt from MIPS. About 87% of solo practitioners and 70% of practitioners in groups of less than 10 will be subjected to negative payments or penalties ranging from 4% to 9%. In addition, MIPS also will affect a provider's reputation by making performance measures accessible to consumers and third-party physician rating Web sites.The MIPS composite performance scoring method, at least in theory, utilizes weights for each performance category, exceptional performance factors to earn bonuses, and incorporates the special circumstances of small practices.In conclusion, MIPS has the potential to affect practitioners negatively. Interventional Pain Medicine practitioners must understand the various MIPS measures and how they might participate in order to secure a brighter future. ⋯ Medicare Access and CHIP Reauthorization Act of 2015, merit-based incentive payment system, quality performance measures, resource use, clinical practice improvement activities, advancing care information performance category.