In his pain practice, Dr. McCarberg can see a patient for 45 minutes to deal with a single problem – but in his primary care practice, a patient typically arrives with a list of problems for a 15-minute visit.
"I get paid according to the hemoglobin A1c – whether or not we’re controlling diabetes. That’s part of where my salary comes from," he said. "If I have blood pressure control," other financial incentives kick in. There are no similar metrics for pain management, he added.
The primary care physicians surveyed said that patients with chronic pain come in with unrealistic expectations, which can lead to an adversarial relationship.
These patients may have behaviors that the primary care physicians don’t understand. If they refer patients to an anesthesiologist for pain management, psychiatric issues may not be addressed. After referrals, patients often return still in pain that may have been lessened somewhat by combinations of drugs that the primary care physicians would rather not manage.
It’s a complicated problem in often complicated patients, Dr. McCarberg said, but the strengths of primary care can meet the challenges. Primary care physicians believe in addressing psychosocial issues, and they have the advantage of longitudinal care of patients. "We’re the only ones who can understand all the dynamics," he said.
Instead of a single 45-minute visit, repeated briefer encounters push patients to take the needed steps in self-management, he said, whether it’s for chronic pain, smoking cessation, diabetes control, or other chronic diseases.
"We’re not threatened by not having a cure for a patient," he added. "When we tell people to stop smoking and lose weight and exercise, we know that they’re not going to do that; but we keep bugging them about it."
That same strategy helps in pain management. A key characteristic of primary care is that "we don’t give up on our patients," he said.
A separate survey of 74 managed care administrators found that two-thirds of the managed care programs did not have pain management programs, and 59% had no specific guidelines in place for handling pain – even though 75% of the administrators said they believed that such programs could reduce costs, Dr. McCarberg said.
Although 60% agreed that there is good evidence to support the effectiveness of pain rehabilitation programs, the administrators acknowledged that they frequently deny payment for such programs.
Interdisciplinary pain management programs are effective but expensive, he said. "I think we’ve got to make the pain doctor the primary care doctor," he said.
Dr. McCarberg reported that he is an advisor for Endo Pharmaceuticals, Forest Laboratories, PriCara, a division of Ortho-McNeil-Janssen Pharmaceuticals, and NeurogesX.