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Fiscal Analysis of Emergency Admissions for Chronic Back Pain: A Pilot Study from a Maine Hospital

Douglas J. Jorgensen DO, CPC
DOI: http://dx.doi.org/10.1111/j.1526-4637.2007.00309.x 354-358 First published online: 1 May 2007

ABSTRACT

Objective. Our study was designed to document fiscal data for emergency department admissions for acute exacerbation of chronic back pain.

Design. This was a 12-month retrospective, descriptive study.

Setting. The two emergency facilities operated by the Maine General Medical Center in central Maine provided the study data.

Patients. We collected fiscal data for patients with emergency admissions for acute exacerbation of chronic nonmalignant back pain (International Classification of Disease code 724.1). Data were limited to patients with the top three of five Current Procedural Terminology (CPT) codes visits (99283–99285) for emergency department, indicating problems of moderate to high complexity. Records with event codes (E codes) for trauma and/or malignant disease were excluded.

Outcome Measures. We totaled charges for physician and provider services, laboratory tests, imaging studies, medications, and other billable items.

Results. Of 1,397 emergency department visits for acute exacerbation of chronic back pain logged over the 12-month study for all five CPT codes, 1,039 visits were tagged with the three highest codes; 30% were multiple visits. Mean charges per visit ranged from $399 for CPT code 99283 to $1,943 for code 99285. While only 3% of the patients (N = 46) were seen three or more times, they accounted for 12.4% of the total charges.

Conclusions. Emergency department care may be a costly venue for the management of chronic back pain. Because most patients obtain only short-term relief, they are likely to continue seeking urgent care intermittently until effective long-term pain management is widely available and reimbursable on an outpatient basis.

  • Chronic Back Pain
  • Treatment Cost
  • Pain Management
  • Health Care Policy
  • Reimbursement
  • Emergency Department

Introduction

Most emergency department physicians are familiar with patients who arrive in the middle of the night for relief of acute exacerbation of chronic back pain, often after repeated visits. The emergency department's mandate is immediate symptom relief, not follow-up care and coordination of health care resources [1,2]. Many consider it a costly venue for ongoing management of chronic pain [3]. Habitués of emergency facilities tend to have laboratory tests and imaging studies duplicated when they are admitted at successive visits [4]. A recent report of data from a hospital in Baltimore has indicated that repeat emergency department admissions are common, and most patients have never been seen in a pain clinic [3]. Moreover, most emergency department staff lack the time and training to address underlying issues that contribute to the experience of chronic pain and influence functional recovery [2,5].

Chronic nonmalignant back pain is an excellent model for studying the cost-effectiveness of long-term pain management. The condition is common, easily defined, and a potentially rich source of fiscal data. Unfortunately, the problem has received limited attention in the peer-reviewed literature [6]. While economic models of cancer pain have been studied [7], chronic back pain has been largely unexamined, and one cannot generalize findings from cancer patients to those with chronic back pain. Because the treatment of cancer pain is, by definition, palliative and self-limited, payers are more willing to accommodate these patients. Also, ethical and legal pressures make it difficult to deny cancer patients coverage for pain management. Reimbursement for the coordinated treatment of chronic nonmalignant pain is another story.

Fiscal data from emergency departments provide a good entry point for evaluating the economic burden associated with chronic back pain. Hypothesizing that the treatment of chronic back pain by emergency personnel is a costly approach to management of these patients, we designed a pilot study of fiscal data for urgent-care visits at the Maine General Medical Center, which has emergency facilities on two campuses in central Maine: one in Augusta and the other 25 miles away in Waterville. Our purpose was to collect and analyze enough preliminary data to determine whether more in-depth analyses were justified, for which Institutional Review Board (IRB) approval would be required.

Methods

Our retrospective descriptive study was based on fiscal data from the records of all patients who received emergency care for acute exacerbation of chronic back pain at the Maine General Medical Center over a 12-month period beginning March 1, 2004. The staff of the medical records department extracted from the records of patients over the age of 18 years who had no evidence of acute trauma and no history of malignant disease. This was conducted by removing records with an external cause-of-event (E) code or any International Classification of Disease (ICD) code for cancer. ICD codes were taken from ICD-9-Cm version of the international ICD-9 system, modified for use in the United States. We had access only to data for patients with thoracic spine pain (ICD code 724.1). Severity was indicated by the level of intervention required, as determined by Current Procedural Terminology (CPT) codes for emergency departments. Of the five available codes (99281–99285), we selected only the top three for study (99283, 99284, 99285) to exclude back problems of limited complexity and those associated with relatively mild pain. Fiscal data included charges for physician and provider services, laboratory tests, imaging studies, medications, and other billable items.

To preserve patient anonymity, the medical records staff assigned a unique identification number to each patient's codes and fiscal data, then submitted the data to us. The anonymous identification numbers allowed us to track repeat visits and assist in the overall analysis. The institution's IRB Committee reviewed our study protocol, and assured us that IRB approval was not needed.

Results

The data for this study were collected from the records of two emergency facilities operated by the Emergency Department of Maine General Hospital, located in Kennebec County. The county has a population of about 121,000 although the center's catchment area is somewhat larger. Of the 30 towns and cities in the county, 24 have populations under 5,000, and only two (Augusta and Waterville) have populations between 15,000 and 19,000. Most county residents are employed by local or state governments, health care facilities, and retail establishments, and the median incomes are similar [8]. The only comparable urgent-care facility in the state is affiliated with the Central Maine Medical Center in Lewiston, a community in adjacent Androscoggin County. Our emergency department has about 66,000 admissions per year; the Lewiston facility has about 69,000. The Augusta and Waterville emergency facilities have 11 and 12 beds, respectively, and employ 6 and 8 emergency physicians, respectively, about one-fifth of whom are women [9]. The county has only three physicians practicing physical medicine and rehabilitation and one pain specialist (the author).

In the 12-month study period, our emergency department logged a total of 1,397 admissions for patients with acute exacerbation of chronic back pain at all five levels of severity as graded by CPT codes 99281 through 99285. Of these, 1,039 visits represented patients with the three highest CPT codes: 99283, 99284, and 99285 (Table 1). For patients seen only once, 729 visits were associated with the three highest CPT codes (995 visits for all five codes). Patients with the highest CPT codes who were seen twice or more during the study period accounted for 310 visits (402 visits for all five codes). As code levels rose, charges invariably increased, as well.

View this table:
Table 1

Fiscal data for emergency department visits at the Maine General Medical Center for moderate to severe chronic back pain over a 12-month period

CPT CodeVisits (N)Average Cost ($)Total Cost ($)
All visits
99283  834   399332,766
99284  187  1,233230,571
99285   18  1,943 34,974
Total1,039575.85598,311
Single visits*
99283  580    422244,760
99284134  1,334178,756
99285 15  2,005 30,075
Total729622.21453,591
Multiple visits
9928325434687,884
992845397651,728
9928531,6294,887
  Total  310  466.13  144,499
  • Charges were standardized using the federal schedule for work-relative value units. CPT code 99283 = moderately complex medical problem, pain moderately severe; 99284 = moderately complex medical problem, pain highly severe; 99285 = highly complex medical issue, pain highly severe.

  • * Represents patients seen only once in the 12-month study period.

  • Represents patients seen twice or more in the 12-month study period.

  • CPT = Current Procedural Terminology.

Among the 1,397 emergency visits for chronic nonmalignant back pain, more than 74% were assigned one of the top three, most costly CPT codes. Of the 1,039 visits associated with these three codes, 30% represented multiple visits to the emergency department over the 12-month study period. While only 3% of the patients in the study (N = 46) were seen three or more times, they accounted for 12.4% of the total charges ($1,799 per visit).

Discussion

This small pilot study had several limitations. Primarily, the results were not generalizable to other urgent-care centers because no controls were studied and no comparable data were available from similar settings. Also, our results are unlikely to be applicable to those reported from large metropolitan areas. We did find, however, that our frequency of admissions was similar to the national average, at about 80 visits per 100 population [6]. Background information about the nature of patients' individual cases was unavailable because we did not obtain IRB approval for the research; we decided to examine preliminary data before taking this step. A word of explanation is in order for why we used only the top three CPT codes, indicating severity of the presenting complaint. We did this to avoid marginal cases and presenting symptoms of potential diagnostic ambiguity [10,11].

After headache, back pain is the most common pain condition resulting in loss of productivity in the U.S. workforce [12], with direct diagnostic and treatment costs exceeding $230 billion annually [13]. A recent report from the Centers for Disease Control has shown that diagnostic and screening tests are performed at 90% of all emergency admissions and imaging studies are conducted at 44%[14]. A study of radiograph use in low back pain in emergency departments has indicated that approximately 18% of patients received unnecessary radiographs [15]. Patients over the age of 40 years with private insurance, seen by a resident, were particularly likely to have imaging studies ordered. In a study of 200 patients with back problems seen in an emergency department, 143 had radiographs, of whom only six showed X-ray abnormalities mandating treatment. Of the 57 patients who had no imaging studies, 63% showed significant improvement at 2-month follow-up; the remaining patients had radiographs in the interim, and no abnormalities were found requiring treatment. Comparisons with data from the early 1990s suggest that use of emergency department visits has become more expensive in recent years with the increased use of diagnostic and imaging studies [16].

Only limited information is available in the literature about the cost of emergency care for chronic pain. Probably the emergency management of back pain is only one example of the fragmented care received by patients with this difficult problem. Data are not readily available for the health resources that these patients consume in primary care settings, physical medicine, and rehabilitation facilities, and the offices of neuromuscular, orthopedic, and neurosurgical specialists, not to mention the services that they receive from physical therapists, occupational therapists, chiropractors, acupuncturists, massage therapists, and other health care workers. A recently published analysis of health care expenditures in the United States indicated that patients with back pain have overall charges about 60% higher than patients with medical conditions not involving back pain, and their emergency department visits cost 1.7 times more [6].

In our experience, the scenario of the patient with chronic back pain visiting the emergency room every few weeks is commonplace. The patient has a history of one or two failed back surgeries and takes opioid medications several times a day without relief. Once a productive member of society, the patient is now unable to work. The staff may have come to label the patient a drug seeker, driving him to other facilities in the area—a phenomenon documented by community studies of hospital emergency admissions [17]. Thus, the patient undergoes redundant testing and examinations, and the costs of his care escalate. If the patient's use of pain medications becomes excessive, he may develop liver or kidney problems from filtering too many drugs over too long a period. Pharmacokinetic studies of pain medication suggest that chronically ill patients are susceptible to independent physiologic alterations that put them at risk for adverse outcomes due to the overuse of drugs with long half-lives [18]. Older patients are doubly susceptible because the aging process affects opioid pharmacokinetics via altered body composition (distribution volumes), liver metabolism, and renal function [19].

Continued access to services for pain management is difficult for many patients. Elderly or indigent patients may encounter regulatory barriers in the Medicare and Medicaid systems [20]. Patients with health insurance often find that their coverage for pain management comes to a halt [7]. Most insurance plans have no distinct policies regarding outpatient management, as they do for inpatients, and claims are generally handled on an individual basis [20], making it difficult for subscribers to know when reimbursement will end. Surveys and interviews of health insurance policymakers indicate that they often suspect chronic pain patients of overusing resources and believe that pain centers dispense services too freely and tend to bill inappropriately [21]. (Even government agencies have challenged the cost-effectiveness of multidisciplinary pain centers [22].) The problem is often worsened by cultural bias on the part of health care professionals and insurers who hold the belief that opioid therapy should be limited to cases of acute pain and terminal illness. When a patient's health insurance withdraws coverage, the economic burden is shifted to taxpayers [21].

What is the answer? While studies for patients with recurrent cancer pain have demonstrated fewer emergency department visits and hospitalizations when appropriate pain management is available [23,24], economic studies of chronic nonmalignant pain are in short supply [2]. And before insurers and regulators will change their policies about coverage and reimbursement of services, they are likely to require hard data showing that the results of treatment are commensurate with its cost. Better education and training of primary caregivers is needed, too [25]. Survey data have indicated that many physicians lack confidence in their ability to manage chronic and have limited knowledge of treatment options [26].

To those of us who treat patients with chronic pain on a daily basis, the economic benefits of coordinated pain management are obvious. The cost of emergency intervention for one-time relief of symptoms in our study was probably much higher than outpatient intervention would have been, ranging from $399 to $1,943 per admission for chronic to severe back pain. Overall charges for repeat users of the emergency department in our setting were particularly high; the 3% of the patients seen three or more times accounted for 12.4% of the total charges ($1,799 per visit).

Pain specialists and other health professionals who treat chronic pain on a regular basis need to document the cost-effectiveness of care in various settings, including emergency departments, and communicate this information to third-party payers and regulatory bodies, in order to assure patients' access to medically necessary and appropriate pain management services.

References

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