After a decade at University Hospitals of Cleveland, Jennifer Kriegler, M.D., found that the way to succeed was to get out.
She realized the pain management program she had developed in 1983 would be hindered unless it severed its ties to the large teaching institution.
University Hospitals had moved the program into an adjacent outpatient facility when inpatient reimbursement dried up. But Kriegler strongly believed the program needed to move off the medical center's campus in order to serve patients better.
The suggestion to move the program out of the hospital came from the Commission on Accreditation of Rehabilitation Facilities, which accredits multidisciplinary rehabilitative-model pain centers and clinics.
During the program's accreditation review in April 1994, CARF suggested a major overhaul. "They said, `You really need to take it out of the hospital, put everybody under one umbrella and have your own budget,'*" Kriegler said.
But moving it entirely "was not what (University Hospitals) was willing or able to do at the time," she said.
Last October she and her staff-a dozen pain management professionals in all-picked up and moved across town to Mount Sinai Medical Center. After several months of negotiations, Mount Sinai had agreed to establish its own program and grant Kriegler and her staff the independence they sought.
Since then, the program has been housed at Annie May Myers Wellness Center, an outpatient facility it shares with Mount Sinai's sports medicine program. It's right off the expressway in Beachwood, a suburb of Cleveland, so it's more accessible to patients who live in the suburbs as well as other cities, said Kriegler, who directs the program. Plus, "it is more cost-effective out here," she said.
She and her staff had projected the program would perform better than break-even in its first year at Mount Sinai. A year later, "we're within 2% of our projections," according to Linton Sharpnack, administrator of the Mount Sinai pain management program. Sharpnack also moved to Mount Sinai from University Hospitals.
specialists-such as neurologists, anesthesiologists and psychologists-worked under the dictates of their own departments without formal arrangements to work with the pain program. "All different specialties worked together under goodwill," she said.
In addition, the program did not have its own budget. Nor could the staff control therapists' schedules.
A capital investment of about $120,000 outfitted the pain program's new facility. The center collects about $1.3 million in revenues annually, Sharpnack said. In addition, its patients return to work or school at a rate of 76%, he said.
The Mount Sinai program is thriving in an industry that's still trying to prove itself. Since the first pain programs started up some 25 years ago, the field has experienced problems with inconsistent accreditation, skepticism from organized medicine and scrutiny by third-party payers.
The main issues pain management programs now face are meeting managed-care demands for lower prices, providing efficacy and outcomes data, and dealing with inadequate reimbursement, according to a report by Marketdata Enterprises, a Valley Stream, N.Y.-based market research company.
In 1994 pain programs made up a $4 billion market, Marketdata found. The firm forecasts the field will grow to $4.5 billion this year. By 1998, it will pass $5 billion.
Last year, almost 3 million patients were treated by pain programs in and out of the hospital. An estimated 90 million Americans experience periodic pain as a result of back and neck problems, arthritis, migraine headaches, repetitive stress injuries and several other conditions, according to Marketdata.
Nationwide, there are about 440 accredited pain management clinics, pain centers and individual practitioners, in addition to about 250 unaccredited pain clinics or programs.
Chronic pain patients often experiment with alternative providers. It's impossible to pin down how many psychiatrists, chiropractors, acupuncturists, massage therapists, biofeedback specialists and others are involved in pain management. Altogether, Marketdata estimates there are 3,320 individual and institutional sources of pain treatment.
Although patients tend to enter pain programs once all other routes have failed, providers are realizing they should send chronic pain patients to multidisciplinary pain centers earlier, said Dennis Turk, director of the Pain Evaluation and Treatment Center at the University of Pittsburgh.
Turk recently reviewed the literature on the efficacy of multidisciplinary pain centers and found overwhelming evidence of such programs' success.
They've demonstrated cost savings and may even supersede the need for invasive surgery, Turk said. And because inpatient and outpatient programs are thought to be about equally effective, "it's more cost-effective to do it in an outpatient setting," he said.