Proof or Consequences: Who Shall Pay for the Evidence in Pain Medicine?

Interventional pain medicine faces a crisis. In the interests of bringing relief to their patients, pain specialists practice a variety of invasive procedures that interrupt pain pathways in order to stop pain, or modulate physiological processes in order to reduce pain perception. Few of these interventions have been subjected to randomized controlled trials. Meanwhile, in an effort to reign in increasing costs, third-party payors are implementing “evidence-based medicine” (EBM) standards. Unfortunately, the version of EBM that they apply is increasingly demanding multiple, randomized, controlled trials before interventions are recognized and reimbursed. Conversely, when randomized controlled trials are lacking, their absence is becoming accepted as proof of ineffectiveness of a procedure, and reimbursement is being denied. As a result, a conflict has developed. Practitioners unfortunately are faced with patients today whose treatment cannot be ignored while waiting for someone to generate the evidence. Meanwhile, payors cannot afford to recognize and reimburse every intervention when they cannot tell if it amounts to no more than a source of income for practitioners, with no benefit to patients. Preventing resolution of these tensions is an obstacle that has not attracted attention and consideration in debates and treatises on EBM. To test and validate …