Image by Yoon Kwon Yi from PixabayChronic pain procedures are increasingly being performed in ambulatory surgery centers (ASCs), offering patients quicker access, lower costs and reduced infection risks compared to traditional hospital settings, especially benefiting older adults on Medicare.
However, challenges remain in maintaining effective pain management and navigating regulatory and reimbursement hurdles.
“Reimbursement is always a challenge,” Jennifer Hodge, COO of Palmetto Pain Management, told ASC News. “Some insurance carriers look for reasons not to pay, so we need to be proactive.”
For pain clinicians, ASCs often seem like a natural extension of their practice.
Interventional pain procedures are usually minimally invasive and often completed in a single day, making them well-suited for ASC care. Patients benefit from shorter preparation and recovery times, allowing clinicians to manage workflows more efficiently with quicker turnaround.
Palmetto Pain Management, based in Columbia, South Carolina, offers various pain management procedures, including spinal cord stimulation trials and implants.
Previously, patients needing implants had to visit the hospital; now, these procedures are performed in an ASC. This setting provides several advantages for patients, according Hodge, who is also a member of the Ambulatory Surgery Center Association’s (ASCA) Education and Programs Committee.
“You do everything here, including facet joint injections, radiofrequency ablations — pretty much anything we do in our surgery center,” Hodge said. “We’ve expanded our providers and added more procedure rooms to handle growth.”
Most of Palmetto’s patient population is aged 65 and over, on Medicare and on fixed incomes, which makes pain management in an ASC ideal for them.
“It’s much more cost-effective and reduces the risk of infection,” Hodge said. “Patients are in and out quickly instead of spending extended time in a hospital.
Access to care is another benefit, as minimally invasive pain procedures that used to be delayed in hospitals — sometimes by months — are now more readily available in ASCs.
“I believe the difference is that we could provide the procedure for a patient tomorrow, if necessary,” Hodge added. “Quick access to care improves outcomes.”
For older patients, hospitals can be overwhelming. They may be unsure where to park or where to find departments once they arrive. ASCs, with their smaller size, allow caregivers to come and go easily, and parking is often closer, making access more convenient.
A key challenge
ASCs face unique challenges in delivering pain management, especially given their focus on same-day discharges and limited resources.
A key challenge involves balancing effective pain control to keep patients comfortable and avoid readmissions with the need for safe, timely discharges, according to researchers at Yale University School of Medicine.
Many patients, particularly those who undergo more complex procedures, may experience severe pain in the 24 to 48 hours after discharge. Unlike in a hospital, they must manage their pain at home.
Without clear, simple discharge instructions, patients might struggle with complicated medication schedules, increasing the risk of poorly controlled pain or dosing errors.
When pain or postoperative nausea and vomiting are not managed properly, it can lead to hospital readmission or delayed discharge.
The increasing number of patients with chronic pain or a history of opioid use also presents a significant and complex challenge for ASCs. Stricter regulations on prescribing pain medications have forced these centers to implement more rigorous protocols.
Although designed for efficiency, the ASC model often lacks the specialized staffing and resources found in hospitals, which can complicate care for complex pain cases, according to Yale researchers.
“I think the biggest thing is qualified staffing, recruitment, retention and securing the appropriate anesthesia services,” Hodge said. “Anesthesia services are challenging across the country right now.”
Reimbursement is also a hurdle, as insurance providers frequently hesitate to pay — requiring careful pre-procedure verification and detailed documentation, especially for procedures like injections.
“We aim to be proactive upfront by obtaining prior authorization and making sure all our actions meet the criteria for medical necessity,” Hodge explained. “These procedures are more cost-effective for insurance companies when performed in a surgery center. Our fees are lower than hospital rates. Most of our patients are over 65, on Medicare and have fixed incomes. The ASC setting is much better for their out-of-pocket costs.”
Additionally, ASC administrators must navigate regulatory hurdles.
Federal regulations, such as the No Surprises Act, which requires accurate cost estimates and disclosures, and the Anti-Kickback Statute, which governs ownership and referral arrangements, can pose challenges.
The Centers for Medicare & Medicaid Services (CMS) has specific guidelines for pain management, including requiring documentation of medical necessity for procedures and limiting repeat trigger-point injections to a maximum of three without clear evidence of improvement.
Accrediting organizations like The Joint Commission also enforce detailed standards related to patient assessment and safe medication management.
Dr. Jerry J. Markar, an anesthesiologist at UCLA Health in North Hollywood, California, noted that each year, regulations around which procedures can be performed and their sedation levels become more restrictive.
In some cases, ASCs are being asked to perform less sedation and restrict the types of cases they handle, he said.
“The majority of chronic pain procedures can be performed safely in an ASC,” Markar told ASC News. “Sometimes there are patient-specific factors that require a higher level of care; the physician should know if the patient is contraindicated due to some type of chronic medical condition that makes it unsafe for them.”
Although challenges such as regulatory obstacles, reimbursements and staffing shortages persist, ongoing innovations and adjustments are helping ASCs better serve patients with chronic pain.
As health care continues to evolve, these centers are poised to play a key role in delivering efficient, effective pain care nationwide.
