" The Voice Of Interventional Pain Management "

celebrating our 10th anniversary

February 12, 2014



  1. Do Epidural Injections Provide Short and Long-term Relief for Lumbar Disc Herniation?
  2. Saga of Draconian Cuts Continues--ASIPP Member Update on 2014 Cuts
  3. Finally reasonable LCDs being proposed
  4. Five Days Left to Get YOUR Abstract Submitted for Consideration: Abstract Deadline Feb. 17
  5. Attend ASIPP Annual Meeting--Special Ultrasound Workshop Planned for Saturday - Just a Few Spots Available
  6. February 18 Documentation, Billing, and Coding Webinar Rescheduled for March
  7. ASIPP Member Update on 2014 Cuts
  8. Permanent Fix for Medicare Fees Seen
  9. Payroll Data Shows a Lag in Wages, Not Just Hiring
  10. Is Obamacare Unraveling?
  11. More Men in Prime Working Ages Don't Have Jobs
  12. Insurers Face New Pressure Over Limited Doctor Choice
  13. New drug treatment reduces chronic pain following shingles
  14. Obamacare tweaked again: Medium-sized businesses given more time
  15. Millions Trapped in Health-Law Coverage Gap
  16. The Economist Who Exposed ObamaCare
  17. Physician outcry on EHR functionality, cost will shake the health information technology sector
  18. FDA Panels to Consider NSAID Label Changes
  19. SAMSHA Reports Increase in Fentanyl Deaths
  20. State Society News
  21. Physician Wanted

epiduralDo Epidural Injections Provide Short and Long-term Relief for Lumbar Disc Herniation?


Do Epidural Injections Provide Short and Long-term Relief for Lumbar Disc Herniation? In a systematic review to be published in Clinical Orthopedics and Related Research, Manchikanti, Benyamin, Falco, Kaye, and Hirsch publish the most up to date, critically performed systematic reviews showing strong evidence for short-term efficacy from multiple high quality trials and moderate evidence for long-term efficacy from at least one high quality trial, that fluoroscopic caudal, lumbar interlaminar, and transforaminal epidural injections to be efficacious at managing lumbar disc herniation in terms of pain relief and functional improvement.


The primary author, Laxmaiah Manchikanti, MD, Medical Director of Pain Management Center of Paducah and Associate Professor of Anesthesiology and Perioperative Medicine at the University of Louisville stated that this is the most rigorous review conducted thus far utilizing highest methodologic quality and clinical application without usual bias, defining short-term as less than 6 months and long-term as greater than 6 months. In this study, we looked at 66 studies utilizing Cochrane review criteria. Following this, 39 studies were excluded, leaving 23 RCTs of high and moderate methodologic quality for analysis. The outcome measures we utilized were also robust with at least 50% improvement in pain or 3 point improvement in pain scores in at least 50% of the patients to be termed successful. We also utilized functional status improvement as an outcome with 50% reduction in disability or 30% reduction in the disability scores.


Alan Kaye, Professor and Chairman of the Department of Anesthesiology at Louisiana State University School of Medicine, one of the co-authors stated that this is probably the most accurate review performed thus far in reference to lumbar epidural injections in lumbar disc herniation. It provides fair and unbiased review of the subject.


Ramsin Benyamin Medical Director of Millennium Pain Center and Clinical Assistant Professor of Surgery at University of Illinois stated that clinically this is the most appropriate review applying rigorous methodologic assessment quality.


Frank J.E. Falco, Medical Director of Mid Atlantic Spine & Pain Physicians and Director of Pain Medicine Fellowship Program at Temple University Hospital, and Adjunct Associate Professor, Department of PM&R, Temple University Medical School stated there has not been any such review performed in the past. This review illustrates that metaanalysis is not easily performed. We were unable to find 2 clinically homogenous studies in any group.


Joshua Hirsch, Vice Chief of Interventional Care, Chief of Minimally Invasive Spine Surgery, Service Line Chief of Interventional Radiology, Director of Endovascular Neurosurgery and Neuroendovascular Program, Massachusetts General Hospital; and Associate Professor, Harvard Medical School, the senior author of the manuscript stated that this review shows the rigorous standards applied both methodologically and clinically. We believe that this may be the best of the reviews performed on this subject yet.





Clinical Orthopedics and Related Research


updateSaga of Draconian Cuts Continues--ASIPP Member Update on 2014 Cuts


We have entered the final phase of the first round. We have received some replies for early letters for Senators Blumenthal and Murphy. As usual, CMS and Obama administration is practicing sophistry which means that they provide reasoning that appears sound, but it is misleading or fallacious. They have not bothered to answer any of the questions. They sent a routine letter to democratic senators. We are expecting more letters.

Meanwhile, we are entering a second phase directing negotiations. Congressman Ed Whitfield has a phone call set up with CMS this week. Further, Chairman Upton and many others including senators are asking for meetings and talking to them. That will be the second phase.


If the second phase also fails we will be entering into a third phase. That will be a legislative fix. Overall, don't be discouraged yet. We will continue to fight. As of the close of the comment period on January 27, 2014, there were over 12,500 letters sent to CMS and more than 62,000 total letters to multiple members of the Congress through ASIPP. Hundreds more were sent by various other methods based on members' reports.


We were able to gain the support of almost 40 Members of Congress with a total of the 14 letters to CMS. Senators John Boozman, Mark Pryor, Rand Paul Richard Blumenthal, Christopher Murphy, Mary Landrieu, David Vitter, Roy Blunt, and Republican Leader Mitch McConnell. Representatives Ed Whitfield, Pete Olson, Renee Ellmers, Rodney Davis, and Brett Guthrie. Also we received a Dr. Caucus letter signed by 9 members of the House and an additional letter signed by 20 members of the House.



Keep fighting and keep talking to your members of congress. Don't let them forget this issue and don't let your patients forget this issue.

lcdsFinally reasonable LCDs being proposed


NGS has released its LCD which is more comprehensive including all epidural injections, facet joint interventions, and sacroiliac joint injections. This is very similar to the comprehensive and the best LCD ever which was followed by multiple other carriers. Now they have made changes to incorporate recommendations from Multi-Specialty Pain Workgroup (MPW) as well as ASIPP, however, only one thing missing is they do not cover discogenic pain for epidurals. Otherwise, it is pretty much the same policy.


We are quite certain there may be some who disagree with it, but the changes are not that monumental like was proposed by Noridian and Multi-Specialty Pain Workgroup (MPW). There are some cautionary comments in reference to cervical and thoracic transforaminal epidural injections; however, to control the abuse and improve the access, cut down the costs and not facing the same situation with draconian cuts we have to balance some certain aspects and this is one of them. However, this is still in comment period. The states which are involved still can comment. ASIPP will be contacting all the CAC members and the state presidents soon on this issue.


NGS is one of the largest Medicare carriers covering Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont, and Wisconsin. We will still be commenting and we are in close touch with Executive Medicare Director of NGS. SEE NGS PROPOSED POLICY


Non-covered Services LCD

webinarFebruary 18 Documentation, Billing, and Coding Webinar Rescheduled for March
The webinar is being rescheduled to March and will be in the evening to better accommodate viewing by physicians. If you have already registered, you will receive information on the rescheduled webinar. More information for the medical community will be emailed to you and also posted to asipp.org in the next few days.

Dr. Laxmaiah Manchikanti will now present this webinar in March (Dates and times to be announced)


Cost for the webinar is $175. Participants may receive 1.5 Credit Hours.
The incorporation of documentation measures into a physician practice should not be at the expense of patient care, but instead should augment the ability of the physician practice to provide quality patient care.
A well-designed documentation program can:
* Speed and optimize proper payment of claims.
* Minimize billing mistakes.
* Reduce the chances that an audit will be conducted by HCFA or the OIG.
* Avoid conflicts with the self-referral and anti-kickback statutes.
* Avoid submitting claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent.

Recently documentation in IPM has been under attack from all carriers as well as recovery contractors, OIG, and others. OIG may seek civil monetary penalties and sometimes exclusion for a wide variety of conduct and is authorized to seek different amounts of penalties and assessments based on the type of violation at issue. Penalties range from $10,000 to $50,000 per violation.

In this innovative and interactive webinar, we will evaluate the rules and regulations of documentation, billing, and coding, along with practical examples and case presentations.
This webinar is intended for interventional pain management specialist, nurses, staff, and other healthcare providers.
Registration information will be sent within the next few days.


permanentPermanent Fix for Medicare Fees Seen


WASHINGTON-An annual push by doctors to delay cuts to Medicare patient fees is afoot, but this time the prognosis is better for a permanent solution to the long-festering problem.


The Senate Finance Committee is scheduled to vote Thursday on "doc fix" legislation that would permanently change how Medicare providers are paid by the government for their services. Similar legislation was unanimously passed by the House Energy and Commerce Committee in July.


Lawmakers and analysts say fatigue over dealing with the "doc fix" nearly every year for the past decade is driving the current bipartisan effort to resolve the issue.



Wall Street Journal


Access to this article may be limited.

payrollPayroll Data Shows a Lag in Wages, Not Just Hiring


For the more than 10 million Americans who are out of work, finding a job is hard. For the 145 million or so who are employed, getting a raise is even harder.


The government said on Friday that employers added 113,000 jobs in January, the second straight month of anemic growth, despite some signs of strength in the broader economy. The unemployment rate inched down in January to 6.6 percent, the lowest level since October 2008, from 6.7 percent in December.


New York Times


unravelIs Obamacare Unraveling?


Rumors have been circulating in the marketplace all week that the administration was thinking of extending the individual health insurance policies that Obamacare was supposed to have cancelled for as much as three more years.

Those rumors have now come out into the open with Tom Murphy's AP story that began running today.

That the administration might extend these polices shouldn't come as a shock. My sense has always been that at least 80% of the pre-Obamacare policies would ultimately have to be canceled because of the administration's stringent grandfathering rules that forced almost all of the old individual market into the new Obamacare risk pool.


Health Policy and Market

primeMore Men in Prime Working Ages Don't Have Jobs


Mark Riley, who is out of work, gives away free food as a volunteer on Tuesdays in Little Rock, Ark. Wesley Hitt for The Wall Street Journal


Mark Riley was 53 years old when he lost a job as a grant writer for an Arkansas community college. "I was stunned," he said. "It happened on my daughter's 11th birthday." His boss blamed state budget cuts.


That was almost three years ago and he still hasn't found steady work. Mr. Riley, whose unemployment benefits ran out 14 months ago, says his long and fruitless search is proof employers won't hire men out of work too long.



Wall Street Journal


Access to this article may be limited.

faceInsurers Face New Pressure Over Limited Doctor Choice

Insurers are facing pressure from regulators and lawmakers about plans that offer limited choices of doctors and hospitals, a tactic the industry said is vital to keep down coverage prices in the new health law's marketplaces.

This week, federal regulators proposed a tougher review process for the doctors and hospitals in plans to be sold next year through HealthCare.gov, a shift that could force insurers to expand those networks.


Meantime, regulators in states including Washington and New Hampshire are ramping up their own scrutiny, and lawmakers in Mississippi and Pennsylvania, among others, are weighing bills that could force plans to add more hospitals and doctors.



Wall Street Journal


Access to this article may be limited.

treatmentNew drug treatment reduces chronic pain following shingles


A new drug treatment has been found to be effective against chronic pain caused by nerve damage, also known as neuropathic pain, in patients who have had shingles.


The researchers hope that the drug might also be effective against other causes of chronic neuropathic pain, such as diabetes, HIV, nerve injury and cancerchemotherapy, as it targets a mechanism that is not targeted by any existing therapies and has fewer side effects.





tweakObamacare tweaked again: Medium-sized businesses given more time


Medium-sized businesses - those with from 50 to 99 full-time employees - will have an extra year to provide health coverage for their employees, in the latest change by the Obama administration to the Affordable Care Act (ACA).


Such businesses will still have to report on how many of their workers have coverage, but won't have to provide the coverage themselves until 2016 or pay a penalty.


Larger businesses - those with 100 or more full-time employees - also got a break in the new regulations issued Monday by the Treasury Department. Starting Jan. 1, 2015, larger businesses must cover only 70 percent of their employees, and have until 2016 to cover 95 percent, or face penalties. Originally, larger businesses had to cover 95 percent of employees in 2015.


Christian Science Monitor

millionsMillions Trapped in Health-Law Coverage Gap


BIRMINGHAM, Ala.-Ernest Maiden was dumbfounded to learn that he falls through the cracks of the health-care law because in a typical week he earns about $200 from the Happiness and Hair Beauty and Barber Salon.


Like millions of other Americans caught in a mismatch of state and federal rules, the 57-year-old hair stylist doesn't make enough money to qualify for federal subsidies to buy health insurance. If he earned another $1,300 a year, the government would pay the full cost. Instead, coverage would cost about what he earns.


"It's a Catch-22," said Mr. Maiden, an uninsured diabetic. Without help, he said, he must "choose between paying the bills and buying medicine."



Wall Street Journal


Access to this article may be limited.

economistThe Economist Who Exposed ObamaCare


In September, two weeks before the Affordable Care Act was due to launch, President Obama declared that "there's no serious evidence that the law . . . is holding back economic growth." As for repealing ObamaCare, he added, "That's not an agenda for economic growth. You're not going to meet an economist who says that that's a number-one priority in terms of boosting growth and jobs in this country-at least not a serious economist."


In a way, Mr. Obama had a point: "Never met him," says economist Casey Mulligan. If the unfamiliarity is mutual, the confusion is all presidential. Mr. Mulligan studies how government choices influence the incentives and rewards for work-and many more people may recognize the University of Chicago professor as a serious economist after this week. That's because, more than anyone, Mr. Mulligan is responsible for the still-raging furor over the Congressional Budget Office's conclusion that ObamaCare will, in fact, harm growth and jobs.


Rarely are political tempers so raw over an 11-page appendix to a dense budget projection for the next decade. But then the CBO-Congress's official fiscal scorekeeper, widely revered by Democrats and Republicans alike as the gold standard of economic analysis-reported that by 2024 the equivalent of 2.5 million Americans who were otherwise willing and able to work before ObamaCare will work less or not at all as a result of ObamaCare.


Wall Street Journal


Access to this article may be limited.

EHRPhysician outcry on EHR functionality, cost will shake the health information technology sector


Despite the government's bribe of nearly $27 billion to digitize patient records, nearly 70% of physicians say electronic health record (EHR) systems have not been worth it. It's a sobering statistic backed by newly released data from marketing and research firm MPI Group and Medical Economics that suggest nearly two-thirds of doctors would not purchase their current EHR system again because of poor functionality and high costs.


In a surprise finding, nearly 45% of physicians from the national survey report spending more than $100,000 on an EHR. About 77% of the largest practices spent nearly $200,000 on their systems.


While physicians can receive $44,000 through the Medicare EHR Meaningful Use (MU) incentive program, and $63,750 through Medicaid's MU program, some physicians say it's not nearly enough to cover the increasing costs of implementation, training, annual licensing fees, hardware and associated services. But the most dramatic unanticipated costs were associated with the need to increase staff, coupled with a loss in physician productivity.



Medical Economics


FDAFDA Panels to Consider NSAID Label Changes


Two FDA advisory committees will meet Monday and Tuesday to consider the significance of recent evidence surrounding the cardiovascular risks of nonsteroidal anti-inflammatory drugs (NSAIDs), including studies pointing to lower risks with naproxen.


The FDA put a boxed warning discussing cardiovascular and gastrointestinal risks on all NSAIDs in 2005 after concluding that differences between the drugs could not be discerned. But since then evidence has been accumulating that the risks are not consistent across the class. A key analysis published last year in The Lancet, for example, showed that all NSAIDs carry some degree of cardiovascular risk, but that naproxen appears to be the safest.



MedPage Today


samshaSAMSHA Reports Increase in Fentanyl Deaths


The Substance Abuse and Mental Health Services Administration (SAMHSA) is alerting the treatment community and the general public that since the beginning of the year a marked increase in deaths reportedly linked to the use of heroin contaminated with the drug fentanyl has been noted. Fentanyl is a form of opioid and when used in combination with heroin can rapidly cause severe injury and even death.


There have been more than 17 deaths linked to the possible use of fentanyl-contaminated heroin in the Pittsburgh, Pa. area alone since January 24, 2014. In the first two weeks of January there were 22 such deaths reported in Rhode Island. It has been observed that these trends can expand quickly to include large and more distant geographic areas of the country. As yet the origin of the fentanyl is unknown but additional deaths have been reported from New Jersey and Vermont.


Heroin is always an extremely dangerous drug of abuse because it subjects its users to a wide array of risks such as overdose and increased exposure to Hepatitis C and HIV/AIDS and other infectious diseases. It often contains other ingredients which render it even more potentially harmful or in some deadly.


SAMHSA requests treatment providers to alert their patients and greater community stakeholders to be alert to the increased risk of fatal overdose. SAMHSA released an Opioid Overdose Toolkit late last year. It contains information on recognizing and responding appropriately to overdose. The Toolkit presents information on recognizing and responding to overdose in a manner suitable to a variety of stakeholders. It can be read or downloaded to print and share at: http://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit/SMA13-4742






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American Society of Interventional Pain Physicians ®
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