February 12, 2014
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
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
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
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
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
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
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
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.
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
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
18 Documentation, Billing, and Coding Webinar Rescheduled for
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
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
* 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.
|Permanent 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
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.
Access to this article may be
|Payroll 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
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
Health Policy and
More 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.
Access to this article may be
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.
Access to this article may be
New 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
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
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.
in Health-Law Coverage Gap
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."
Access to this article may be
|The Economist Who
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.
Access to this article may be
outcry on EHR functionality, cost will shake the health information technology
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
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
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
Copyright © 2008
American Society of Interventional Pain Physicians ®
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Phone 270.554.9412, Fax 270.554.5394