Realistic Levels of Pain Relief

Patients frequently seek medical attention because of pain. Pain relief is a major motivation for the provider visit but getting a diagnosis and some reassurance about the painful condition is the reason for the office visit. Patients tolerate pain and often self-medicate for pain without seeking medical advice. Pain is ubiquitous and is understood by many patients to be a normal part of living.

Any provider who treats chronic pain knows that complete pain relief is rarely achieved. Patients may have surgery for a disc or radiation for a metastatic bone lesion, resulting in miraculous relief, but even when clear structural lesions are repaired, all pain may not stop. When we surveyed a large sample of patients with chronic pain, we were surprised to find that they did not anticipate or expect complete pain relief. When asked how much pain reduction would be acceptable after treatment in a pain clinic, the most common answer was 50% reduction of pain.

We also know that everyone can get 100% pain relief with total anesthesia. However, many patients are not willing to put up with the side effects (unconsciousness) to achieve the pain reduction. Many patients with terminal cancer opt for higher pain levels to be awake and alert during the final stages of life.

This is not to say that a total absence of persistent pain would not be welcome. Most people with pain desire a return to normal life with normal function, including work, hobbies, sexual activity, sleep, and other activities that are taken for granted when accessing quality of life. Those with persistent pain, especially with of time, know what to expect. They have been through failed drug trials, injections, physical therapy, acupuncture, and even surgery without the desired result.

Knowing that complete relief from the pain is rarely possible and understanding that most patients recognize this dilemma, the provider should not promise this outcome. When discussing the continuing treatment of a patient who has been examined, has failed multiple therapies, and returns to the provider with pain levels of 7 or 8 out of 10, the discussion should focus on other aspects of treatment. Statements from a pain provider such as "There is nothing more I can do," "You will need to learn to live with this pain," or "The doctor who deals with this type of pain is a psychiatrist," are all dreaded phrases to the patient with persistent pain. The provider should instead promise continued support and, despite lack of treatment efficacy, should not give up on the patient or stop being creative in providing help. Appropriate statements include "Even though we have not found anything to stop your pain, I am still here for you," and "You and I are going to continue to work on this pain problem to improve your function." For the patient with persistent pain, promise what you can deliver: comfort, compassion, creativity, teamwork, a caring environment, and most of all, yourself.

Patients seek help and wish for a cure but are comforted by our style and manner. We can always deliver compassion and continuity of care, which may not seem like much, but it is greatly valued by our patients.

Special thanks to Bill H. McCarberg, MD

Pay for Performance May Stimulate Practice Changes

California physicians given financial incentives to improve the quality of healthcare have made important changes designed to achieve that goal, according to the results of a RAND Corporation study reported in the March/April issue of Health Affairs.

"Physician groups are responding to pay-for-performance programs by making practice changes and altering how they compensate physicians to reward quality, but health plans and purchasers say that those investments are not yet translating into substantial gains in quality," lead author Cheryl L. Damberg, PhD, a senior policy researcher at RAND in Santa Monica, California, said in a news release. "The true benefits of these programs may take more time to be realized and it is likely that investments in other quality efforts will be needed in addition to performance-based pay."

Although pay-for-performance is already in widespread use and has grown rapidly in recent years, the effects of this incentive system on physician response and healthcare outcomes are still unclear. What types of financial incentive strategies work best is also still undetermined.

This study looked at 7 major California health plans and 225 physician groups enrolled in the California Integrated Healthcare Association's pay-for-performance program, which began in 2003. The 35,000 physicians employed in these groups have a patient base of 6.2 million people enrolled in commercial health maintenance organizations and point-of-service plans.

Between 2003 and 2007, participating health plans paid a total of $203 million in incentives to participating physician groups. In turn, the groups provided some payments of about $1500 to $2000 annually to individual physicians based on quality measures. These included the number of patients with diabetes who receive recommended blood tests, patient experience regarding access to care, and adopting health information technology capabilities.

Surveys revealed that most of the medical groups felt that the financial incentives were too small to stimulate significant change among most physicians and that the payments should be 2 to 5 times higher to achieve quality improvements.

Although most physician organizations reported that they collected more in financial incentives than they had spent to comply with the program, 6 reported that their bonuses barely met their increased costs.

In response to this incentive system, physician-level performance rating, feedback, and accountability increased; information technology such as use of electronic medical records was more rapidly implemented; organizational focus was clarified; and more support was generated for improvement. Twenty of the medical groups surveyed reported positive changes in practice of their individual physicians, such as more-intensive patient outreach.

"However, after three years of investment, these changes had not translated into breakthrough quality improvements," the study authors write. "Continued monitoring is required to determine whether early investments made by physician organizations provide a basis for greater improvements in the future."

Despite the concern that pay for performance could result in physicians dropping patients who did not follow prescribed recommendations, there were few reports of such events. More than two thirds of the medical groups surveyed believed that the pay-for-performance program yielded more benefits than harms.

Limitations of this study include a small, nonrandom sample of systematically identified physician organizations, limiting generalizability; that data were based on subjective self-assessments; weak incentives; and a limited number and scope of measures.

"Physician organizations face a number of challenges that impede their ability to move forward on quality, including difficulties in engaging and changing the behavior of front-line physicians (particularly if an organization doesn't 'own' a substantial fraction of the physician's practice) and lack of knowledge of what specific improvement actions physicians should take," the study authors conclude. "Meanwhile, purchasers and providers are challenged regarding how to gauge the opportunity costs of investing in [pay for performance] versus elsewhere, and how to expand performance accountabilities given limitations of current performance measure sets and the data needed to generate measures."

Special thanks to Laurie Barclay, MD is a freelance reviewer and writer.