" The Voice Of Interventional Pain Management "

celebrating our 10th anniversary

August 8, 2012







crnaCMS Proposes IPM Privileges for CRNAs: Time to Act Now or Never



 ASIPP is working diligently to try to get the CRNA Scope of Practice ruling resolved.


The Federal Registry published on July 30 proposes interventional pain management reimbursement regulations for CRNAs.


1. The Social Security Act clearly states "anesthesia services and related care." It will be a major stretch to include chronic pain management as related care. Chronic pain management is not just an epidural injection. It requires skills beyond anesthesia, physical medicine, rehabilitation, and neurology. That is the reason why physicians have fellowship training.



2 Apart from the issues mentioned in both documents, CMS has failed to perform cost analysis yet states that there is no change in the cost and they also state that it would improve access, based only on the statement from AANA, which is quite inappropriate for a governmental agency.



3. In early years, pain management was performed by anesthesiologists utilizing blind spinal injections. However, since then, much has changed. The surveys from OIG of CMS have shown

fraud and abuse issues related to interventional pain management, which mainly comes from untrained physicians and other health practitioners, including nurse anesthetists.



4. The opioid epidemic is becoming more and more common. The evaluations show that prescriptions written by nurse practitioners, PAs, and nurse anesthetists are increasing. Consequently, for all purposes, multiple states have inactive pill mill legislations. Education and certification are not present. There are no outcomes in reference to CRNAs performing these procedures. While many argue that IPM procedures should not even be performed by well-trained physicians due to alleged lack of effectiveness (Chou and Huffman, Carragee). Based on this proposed rule, CMS is telling us to do these procedures inappropriately and improperly. There is no issue with reference to access. Even considering ASIPP members only, which probably constitutes only 60% of qualified interventional pain physicians, there is a physician located at least every 40 to 50 mile.



5. Louisiana State Supreme Court ruled that IPM is a practice of medicine and that CRNAs should not be practicing interventional pain management. Other states have imposed many restrictions. In fact, in Tennessee, no physicians other than anesthesiologists, physiatrists, and neurologists can perform these procedures unless they have fellowship training. They are also not entitled to supervise nurse anesthetists.



Here are links to 3 documents - a letter sent to Kathleen Sebeliuson June 28, 2012, a document prepared by David Vaughn of Vaughn & Associates which illustrates the issues related to this, and an article from Outpatient Surgery.



Please act immediately. It is now or never. These are the comments to CMS. We also need to send letters to members of the Congress asking them to help us.


1. Electronically. You may submit electronic comments on this regulation to

http://www.regulations.gov. Follow the instructions for "submitting a comment."


2. By regular mail. You may mail written comments to the following address ONLY:

Centers for Medicare & Medicaid Services,

Department of Health and Human Services,

Attention: CMS-1590-P,

P.O. Box 8013,

Baltimore, MD 21244-8013.

Please allow sufficient time for mailed comments to be received before the close of the comment



3. By express or overnight mail. You may send written comments to the following address ONLY:

Centers for Medicare & Medicaid Services,

Department of Health and Human Services,

Attention: CMS-1590-P,

Mail Stop C4-26-05,

7500 Security Boulevard,Baltimore, MD 21244-1850



Your colleagues, staff, patients, friends, etc., can also use Capwiz letters to send comments. . If you are not going to prepare your own letter, addressing the various issues, you may want to use a Capwiz letter. However, a large number of letters will have a substantial impact. For example, if you recall, in 1998 when ASIPP was started, ASIPP supports single-handedly, across the country, have sent over 12,000 letters which led to the postponement of the rule and eventually repeal of that rule. As you can see, sending comment letters and Capwiz letters works.


Please use the following link to access the Capwiz letter to let your Congressmen know your position on this:





It is our goal to send approximately 20,000 letters on this issue to CMS as comment letters. However, this is time sensitive. To emphasize the issue, I would like to paraphrase, Dr. Jerry L. Epps, Chairman of the Department of Anesthesiology at the University of Tennessee at Knoxville, who stated in his testimony in front of the Tennessee Senate that while he has trained numerous anesthesiologists and nurse anesthetists, he has never trained a nurse anesthetist in pain management. He would not recommend any anesthesiologist going into interventional pain management without further training. In fact, he added that to have privileges to perform interventional pain management procedures at UT Medical Center, even though he is the Chariman of the Department.




Click HERE to read the Federal Registry.



coloradoColorado Court Rules Nurse Anesthetists Don't Need Physician Supervision


Certified registered nurse anesthetists may administer anesthesia to patients without physician supervision, a Colorado appeals court has ruled.


It's the second such ruling in recent months. In June, the Supreme Court of California refused to block a lower court's ruling allowing CRNAs to deliver anesthesia independently.


Doctors say the two rulings are harmful to patient care.


"This is first - and last - a patient safety issue," said Randall Clark, MD, a Colorado anesthesiologist and regional director of the Colorado Society of Anesthesiologists, a plaintiff in the Colorado lawsuit. He also is a member of the American Society of Anesthesiologists board of directors. "Does this improve the quality of care that a patient receives, or does it diminish it? Any reasonable person would agree that it diminishes it. It removes physician oversight from the delivery of a very complex aspect of medical care."



AMA news



ksippRegister Today to Attend KSIPP's Controlled Substance Management Conference




The Kentucky Society of Interventional Pain Physicians will host a conference titled: Evolution of Responsible Opioid Prescribing: Good, Bad, and Ugly on Aug. 18 and 19 at the MG Banquet Hall, 81 Lakeview Drive, Paducah.


Keynote speaker will be Joseph T. Rannazzisi, Deputy Assistant Adminstrator, Office of Diversion Control, Drug Enforcement Agency. The seminar will provide a concise and comprehensive review of controlled substance management for primary care physicians and specialists. Attendees can ear up to 10 hours of AMA PRA category 1 credits.


The conference is hosted for physicians, nurses, medical personnel and law enforcement and is designed for those who desire more information on KASPER, the Pill Mill law, pain management facilities, controlled substance guidance, adherence monitoring, and documentation.


Speakers will present information from 9 am to 5 pm on Saturday and 8 am to 12:30 on Sunday.


To register, go to http://form.jotformpro.com/form/22056746426960




asippASIPP Plans Comprehensive Review Course and Cadaver Workshop and Vertebroplasty Course


    The Comprehensive Review Course and Cadaver Workshop - Basic, Intermediate, and ABIPP Preparation will be held Sept. 14-16 at the Hilton Memphis in Memphis, TN and the MERI Center.


Click here to register: https://secure.jotformpro.com/form/12975431212


The Vertebroplasty Comprehensive Review Course and Cadaver Workshop will be Sept. 15-16 at the Hilton Memphis and MERI Center.





Early registration is available until Aug. 21.


Click HERE for Hilton hotel reservations.




surveyPhysicians Needed to Take Physician Survey


We invite additional physicians to complete a survey to help us understand physician's attitudes about patients who were terminated from their pain management practice. The survey should take no more than 10 minutes to complete. The results will be used to help physicians identify difficult patients and more effectively tailor treatment and communication strategies. Your participation is important because a greater number of responses results in a stronger understanding.


Your decision to be in this research is voluntary. If you have any questions, please contact Alan D. Kaye, MD, PhD, Chair, Department of Anesthesia, Louisiana State University, New Orleans (akaye@lsuhsc.edu) or Gaurav Jain, MD, Southern Illinois University School of Medicine, Springfield, IL (gjain@siumed.edu). Thank you for your time and response.


Please click the following link to complete the survey:





rulingRuling on Contributory Liability Defense Could Expose Physicians to More Lawsuits


A legal challenge before Maryland's high court could be the end of a decades-old doctrine that bars plaintiffs from recovering damages if they contributed to their injury. The state's contributory liability clause says parties who are partly responsible for being harmed may collect no damages from another culpable party.


Physicians say uprooting the law would mean patients could recover damages in medical liability suits, even when a patient's lack of compliance aided to their outcome. The handful of states that allow such legal defenses would be negatively impacted by the Maryland ruling, medical and legal experts say.


AMA news



cboCBO: Delays in SGR Cuts to Cost $271 Billion


WASHINGTON -- The Congressional Budget Office (CBO) has released updated figures on the cost of repealing -- or continuing to override -- the cuts doctors are scheduled to receive under Medicare's Sustainable Growth Rate (SGR) reimbursement formula.


The fresh numbers give Washington lawmakers a better idea of the effect of changes they could make later this year to the SGR cuts. Physician reimbursements are scheduled to drop by 27% next year unless Congress acts, the CBO noted in the report. Every year since 2003, Congress has acted to override the SGR cuts by either maintaining or increasing payments when they were scheduled to drop.


The CBO estimates that if cuts are blocked and payments sustained at current rates from now through 2022, it would cost an additional $271 billion from 2013 to 2022. Resetting payments to 2011 levels, only to increase them annually at 2% plus however much the gross domestic product (GDP) grows, would cost an additional $376.6 billion.


MedPage Today



sendASIPP Members: Send in Your Published Article Information



 A new feature of the ASIPP enews will offer ASIPP members the opportunity to send in and have their published works listed.  Please email in notification of any published article that was not published in Pain Physician journal and we will ist in the weekly enews.


This week we will feature article published by Dr. Rinoo Shah and Dr. Laxmaiah Manchikati et al.


 By Dr. Rinoo Shah:


1.Shah RV. Spine Pain Classification: The Problem. Spine (Phila Pa 1976). 2012 Jun 22. [Epub ahead of print]


2. Shah RV. Sacral kyphoplasty for the treatment of painful sacral insufficiency fractures and metastases.

Spine J. 2012 Feb;12(2):113-20.


3. Shah RV. Sternal kyphoplasty for metastatic lung cancer: image-guided palliative care, utilizing fluoroscopy and sonography.


and by Manchikanti et al:


1.Benyamin RM, Manchikanti L, Parr AT, Diwan SA, Singh V, Falco FJE, Datta S, Abdi S, Hirsch JA. The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Physician 2012; 15:E363-E404.

2.Diwan SA, Manchikant L, Benyamin RM, Bryce DA, Geffert S, Hameed H, Sharma ML, Abdi S, Falco FJE. Effectiveness of cervical epidural injections in the management of chronic neck and upper extremity pain. Pain Physician 2012; 15:E405-E434.

3.Manchikanti L, Singh V, Cash KA, Pampati V, Damron KS, Boswell MV. Effect of fluoroscopically guided caudal epidural steroid or local anesthetic injections in the treatment of lumbar disc herniation and radiculitis: A randomized, controlled, double blind trial with a two-year follow-up. Pain Physician 2012; 15:273-286.

4.Manchikanti L, Pampati V, Hirsch JA. Analysis of utilization patterns of vertebroplasty and kyphoplasty in the Medicare population. . J Neurointervent Surg 2012; Published Online July 7, 2012.

5.Manchikanti L, Pampati V, Falco FJE, Hirsch JA. Growth of spinal interventional pain management techniques: Analysis of utilization trends and medicare expenditures 2000 to 2008. Spine (Phila Pa 1976) 2012 July 7 [Epub ahead of print].

6.Manchikanti L, Cash KA, Pampati V, Malla Y. Fluoroscopic cervical epidural injections in chronic axial or disc-related neck pain without disc herniation, facet joint pain, or radiculitis. J Pain Res 2012; 227-236.


 Send in notification of your published works today to Holly Long (hlong@asipp.org)

 Pain Med. 2012 Feb;13(2):198-203.  


ctNew CT Technique Shows Joint Implant Location


A new CT technique promises to produce improved images of joint replacements and may lower dose exposure, according to research presented this week at the annual meeting of the American Association of Physicists in Medicine.


Patients with knee, spine, and hip implants receive CT scans to assess the prostheses, fractures or infections, but the devices can interfere with the scan.


To address these problems, researchers from Johns Hopkins University in Baltimore developed a method called known component reconstruction (KCR) which incorporates a model of the implant's shape and material into the image reconstruction process. Combining iterative reconstruction with prior information about the implants provides location and orientation information, researchers said.


Diagnostic Imaging



theftMedical ID Theft: Double Danger for Doctors


When Anne Peters, MD, a Los Angeles-based internist, started receiving phone calls in 2006 from patients who were not hers about medical procedures she didn't perform or even offer at her practice, she figured out pretty quickly that she had become a victim of medical identity theft.


When Dr. Peters sought advice on how to resolve the situation, she not only came up empty-handed, but she soon started feeling like a criminal herself. She was visited by federal agents, she received notices from the Internal Revenue Service regarding back taxes on $750,000 she never earned, and she was even detained once at the airport for more than an hour when she returned from a trip abroad. Meanwhile, Medicare stopped sending her payments for legitimate claims.



AMA news


employersEmployers Expecting Growth in Healthcare Costs


As employers brace to absorb cost increases in employee health benefits, many are also experimenting with new ways to control these expenses, according to a new survey from the National Business Group on Health, a non-profit association of 342 large employers.


The survey's findings, which were released today, are based on the responses of 82 large employers out of a universe of about 250.


Healthcare Finance News



clinicPain Clinic Owner Sentenced to 15 Years


LEXINGTON, Ky. (AP) - A Louisiana businessman convicted of distributing oxycodone and methadone pills in eastern Kentucky by using clinics to prescribe the drugs to bogus patients was sentenced Thursday to 15 years in federal prison.


U.S. District Judge Gregory Van Tatenhove also ordered 46-year-old Michael Leman of Slidell, La., to pay $1 million in restitution to two Kentucky agencies - one that handles crime victim compensation and the other dealing with substance abuse. Van Tatenhove fined his two pain clinic businesses $50,000. Prosecutors said the businesses are defunct. Assistant U.S. Attorney Roger West said the fines would serve as a "death sentence" for the companies.


San Francisco Chronicle


shortageDoctor Shortage Likely to Worsen With Health Law


Due to a number of factors both political and demographic, demand for health care in the United States is expected to increase dramatically over the next couple of decades. This has policymakers frenzied: while they sought to provide care for tens of millions of uninsured Americans, it now seems that supply may not be able to meet this demand. Specifically, the country is facing a national shortage of doctors, says the New York Times.


Due largely to the gradual retirement of the baby boomers, doctors are unable to serve an excessive flow of patients, many of whom are seniors that require more time and resources. This problem is further exacerbated by the implementation of the Affordable Care Act (ACA), which will further increase this demand and stretch doctors to their limit.

  •  Researchers have estimated that even in the absence of the health care reform law, the shortage of doctors would have exceeded 100,000 by 2025.
  •  When the ACA is included, the Association of American Medical Colleges estimates that in 2015 the country will have 62,900 fewer doctors than needed.
  • This figure is expected to double by 2025 when the retirement of the baby boomers and the implementation of the ACA are in full force.





ipadiPad Can Aid Doctors in Evaluating Spinal Images: Study


The Apple iPad was up to the task of reviewing Magnetic Resonance images of emergency spinal injury cases, a study published in the journal Academic Radiology revealed.


MRIs are used in radiology to examine the ligaments and pathology of the spinal cord.


In the journal's August issue, Jonathan P. McNulty, head of teaching and learning for diagnostic imaging programs at University College Dublin, along with colleagues found that the iPad was equal to a secondary-class LCD in diagnostic accuracy. A secondary-class monitor is used for evaluations other than a primary diagnosis, according to the American Association of Physicists in Medicine (AAPM).


The other authors of the report were Dr. John Ryan, a lecturer in diagnostic imaging at University College Dublin, Dr, Louise Rainford, head of diagnostic imaging in biological imaging research at University College Dublin and Dr. Michael Evanoff of the American Board of Radiology.


For the study, 13-board certified radiologists examined 31 MR images on a ViewSonic VP201m LCD (with an nVidia GeForce 7100 graphics card) and the iPad. On both screens, they found evidence of compression, hemorrhaging or edema (accumulation of fluid in connective tissue) of the spinal cord in 13 instances. Meanwhile, 18 control images came up negative for the conditions.


Health Care IT news


operatingMore Operating Rules Come Online


WASHINGTON - The U.S. Department of Health and Human Services (HHS) on Aug. 7 released an interim final rule for making healthcare claim payments electronically and describing adjustments to claim payments. The department expects this next step in the adoption of operating rules to save up to $9 billion over the next 10 years.


"These new rules will cut red tape, save money and ensure doctors spend more time seeing patients and less time filling out forms," said HHS Secretary Kathleen Sebelius in a press release.


Healthcare Finance News







All contents Copyright © 2009
American Society of Interventional Pain Physicians ®
81 Lakeview Drive, Paducah, KY 42001
Phone 270.554.9412, Fax 270.554.5394
E-mail asipp@asipp.org