In turn, the financial incentives of the fee-for-service model can lead to overtreatment. Overtreatment is care that is provided despite a high likelihood that it will be ineffective or unnecessary.
Chronic pain patients are especially prone to overtreatment. Chronic pain can be a highly distressing experience. It can be difficult to accept. As such, patients and their providers can go against all odds to get rid of it. It’s not uncommon to see patients who have had numerous interventions and surgeries, often with the same procedures repeated even when they weren’t initially helpful.
The fee-for-service model of reimbursement reinforces the pattern of pursuing care that has little chance of success. Providers financially benefit from providing care whether or not there is much chance that it will significantly reduce pain or improve function.
This combination of factors – difficulties in accepting the chronicity of pain and the fee-for-service model of reimbursement – is a perfect storm for overtreatment in chronic pain. It leads to providers making recommendations based on the possibility of effectiveness rather than the probability of effectiveness. It’s a certain willingness on the part of patients and their providers to try something to reduce pain, even if it is not very likely to be helpful.
Over the past twenty years, the field of chronic pain management has witnessed exponential growth of the use of spine surgeries, interventional procedures (i.e., epidural steroid injections, nerve blocks, neuroablations, and the like), and opioid medications. The growth rates of this care have occurred despite evidence that they are not particularly effective. During this period of time, there have been record numbers of disability applications for chronic pain (Deyo, Mirza, Turner, & Martin, 2009) and numerous publications of clinical trials, reviews, and meta-analyses that show that these treatments are unlikely to be helpful for most patients (see, for example, Gibson & Waddell, 2007; Martell, et al., 2007; van Tulder, et al., 2006; van Wijk, et al., 2005).
Why, then, do healthcare providers continue to recommend them at such high rates? Patients, of course, might be excused for not knowing that these common therapies are ineffective for most people, but healthcare providers should know about their low level of effectiveness. While they might know of the research, it may be that it doesn’t enter into their decision-making process when making recommendations on a day-to-day basis. Here’s how it might play out.
All these therapies can help some minority of people. That is to say, it’s possible that they are helpful for any given patient. However, it’s not likely that they will be helpful. This distinction can get overlooked in a fee-for-service reimbursement system. Money comes to influence healthcare recommendations because providers, clinics, and hospitals get paid based on quantity of patients seen and procedures provided, not on how healthy patients become or how effective procedures are.
In a fee-for-service reimbursement system, the criteria for whether to pursue a treatment gets lowered to whether it is possible that the procedure could be helpful, and not whether it is likely that it will be helpful. The consequence is overtreatment.
So, what can you, the patient, do about it?
Importance of the therapeutic relationship
As a patient, you can do a number of things to reduce the role that money might play in your care. They all relate to being able to establish and maintain a healthy therapeutic relationship with your chronic pain management provider(s) that allows you to make effective and informed decisions about your care.
What does such a healthy therapeutic relationship look like? It’s a safe, non-judgmental relationship in which you can have mature, adult-to-adult discussions about your concerns and your care. It’s a relationship in which you can take an active role in the decision-making processes of your care. I sometimes tell patients to think of it like a high school or college level seminar in which the things that you are discussing are open to interpretation and respectful debate. There is no absolute, right-or-wrong way of going about managing chronic pain. There is no clearly defined conventional agreement about what treatments to pursue and what not to pursue, even for common conditions, such as chronic low back pain. As such, recommendations for treatment are open to some respectful debate. If you have a safe, non-judgmental relationship with your healthcare provider, you can have an adult-to-adult, respectful debate about what to do.
Appreciate the conflict of interest that your healthcare provider has
In this relationship, you can keep in the back of your mind an appreciation for the inherent tension that occurs in your healthcare provider when practicing in a for-profit healthcare system. On the one hand, as a professional and based on a high level of expertise, your healthcare provider is charged to act in your best interest, making recommendations that are going to work best for you. On the other hand, understand that your healthcare provider is also operating a practice that is essentially a business, one in which your healthcare provider’s recommendations also serve his or her own self-interest. When you appreciate this inherent tension in the relationship that you have with your healthcare provider, you are in a better position to make more informed decisions.
The point, here, is not to accuse providers within a for-profit healthcare system of wrong-doing. They are simply engaging in the practice of healthcare delivery in the manner that is encouraged by their system. Rather, the point, here, is simply to know the lay of the land, as it were. The ground on which you stand when obtaining care from a chronic pain management provider involves an inherent tension between conflicting motivations. The provider, clinic, or hospital that you seek care from is attempting to work in your best interest and their own self-interest at the same time. It’s important that you understand this tension that is inherent in the recommendations that you receive from your chronic pain management providers and take it into account as you decide on which recommendations to pursue and which not to pursue.
Stay grounded when making decisions about your care
It also helps if you can stay grounded when making decisions about your healthcare. While it is understandable that you may become overwhelmed or desperate or angry at times, you likely may not make your best decisions when feeling these ways. It fosters the likelihood that you’ll be willing to ‘take a long shot’ – a treatment that might work, but is unlikely to work. In turn, being willing to try anything, fosters unnecessary care, which may be recommended to you in part because of profit motive. Instead, you will be more successful in managing pain when you make decisions about treatment based on probability of effectiveness, not the possibility of effectiveness. While all things are possibly helpful, only a few things are likely to be helpful. So, when you are ungrounded and apt to want to ‘throw a Hail Mary pass,’ maybe the first thing to do is to get grounded and then have a respectful, adult-to-adult discussion with your healthcare provider about what treatment is most likely to be helpful.
Know which treatments are effective and which are not effective
Related to this point, and in order to have such a grounded discussion that minimizes the role of money in your healthcare, you need to know what is effective and what is not effective in the management of chronic pain. The Institute for Chronic Pain and other organizations (such as Body in Mind) attempt to translate published, clinical research into language that is approachable to patients, their families, primary care providers, and third-party payers. To minimize the role that money plays in your care, it pays to educate yourself about the empirical evidence for the effectiveness of common treatments for chronic pain. By having a command of such knowledge, you will be able to have a more sophisticated discussion with your healthcare providers about the recommendations that you receive.
Seek out second opinions
Another important strategy is to seek out second opinions from providers whose training and practice are different from the provider who made the initial recommendation. By doing so, you allow yourself a greater amount of options from which you can make a more informed decision about your care. As such, it minimizes the risk of acting on recommendations that may in part have been provided based on profit motive.
For example, if you receive a recommendation from a spine surgeon for your chronic low back pain, don’t just seek out a second opinion from another surgeon, who may very likely come up with the same recommendation; rather, seek out a second opinion, say, from a chronic pain rehabilitation provider who will likely conceptualize and treat your chronic low back pain differently.
Understand that there is no conventional agreement as to how to manage common chronic pain disorders. Surgeons, interventional pain providers, and chronic pain rehabilitation providers all treat the same condition differently. Among all the different types of chronic pain management providers, there is considerable debate as to how to conceptualize and treat chronic pain. Some commonly performed procedures have very little empirical support for their effectiveness and still others have been shown to be ineffective. In the on-going debate, it is common to highlight the potential role of the profit motive when discussing why these procedures continue to be performed (see, for instance, Deyo, Nachemson, & Mirza, 2004; Perret & Rosen, 2011; Weiner & Levi, 2004).
When you obtain a second opinion that is outside the field of the initial recommendation, you are more apt to obtain an opinion that reflects another side of the debate that goes on among chronic pain management providers. In doing so, you learn about options that you might not otherwise obtain. Subsequently, you can learn about the relative effectiveness of each option you receive, discuss them with your healthcare providers, and foster an informed decision. Consequently, you minimize the degree to which profit motive influences the recommendations you receive and pursue.
Seek out care from salaried providers or non-profit organizations
Lastly, if you have the option, seek out healthcare providers who work in organizations that pay them on a salary, rather than through a fee-for-service model. When the livelihood of your healthcare providers are not dependent on whether you give consent to the recommendations they provide, you minimize the role that money plays in generating those recommendations. It’s interesting to note that some of the most prestigious healthcare institutions in the U. S. pay their healthcare providers on a salary. Some examples are the Mayo Clinic, the Cleveland Clinic, the VA Medical Centers, Kaiser Permanente, and GroupHealth.
Of course, many patients do not have the option to seek care in one of these organizations. In such circumstances, you might try to obtain care in a non-profit healthcare organization. Non-profit organizations might still pay their providers through a fee-for-service system, but they may also have a mission that tempers the profit motive of their individual providers.
Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62-68. doi: 10.3122/jabfm.2009.01.080102
Deyo, R. A., Nachemson, N., & Mirza, S. K. (2004). Spinal-fusion surgery: The case for restraint. New England Journal of Medicine, 350, 722-726.
Gibson J. N., & Waddell, G. (Updated January 6, 2007). Surgical intervention for lumbar disc prolapse. In Cochrane Database of Systematic Reviews, 2007 (2). Retrieved December 27, 2013, from The Cochrane Library, Wiley Interscience.
Martell, B. A., O’Conner, P. G., Kerns, R. D., Becker, W. C., Morales, K. H., Kosten, T. R., & Fiellin, D. A. (2007). Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Annals of Internal Medicine, 146, 116-127.
Perret, D. & Rosen, C. (2011). A physician-driven solution – The Association for Medical Ethics, the Physician Payment Sunshine Act, and ethical challenges in pain management. Pain Medicine, 12, 1361-1375.
van Tulder, M. W., Koes, B., Seitsalo, S., & Malmivaara, A. (2006). Outcomes of invasive treatment strategies in low back pain and sciatica: An evidence based review. European Spine Journal, 15, S82-S89.
van Wijk, R. M., Geurts, J. W., Wynne, H. J., Hammink, E., Buskens, E., Lousberg, R., Knape, J. T., & Groen, G. J. (2005). Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: A randomized, double-blind, sham lesion-controlled trial. Clinical Journal of Pain, 21, 335-344.
Weiner, B, K. & Levi, B. H. (2004). The profit motive and surgery. Spine, 29, 2588-2591.
Author: Murray J. McAllister, PsyD
Date of last modification: 2-29-2014