Oberursel, January 4, 2016. Local pain management services remain a pious hope in Germany. At the "National Pain Management Forum" on November 12, 2015, in Berlin, patient representatives, pain experts, and representatives of the German Association of General Practitioners called for a tiered, outpatient, freelance care system with a sufficient number of pain specialists, clearly defined interfaces, and systematic needs assessment.

“For the more than 2.8 million patients suffering from severe pain, the care provided in Germany is completely inadequate. There are countless black holes in countless regions where no adequate care is available,” stated Birgitta Gibson, Vice President of the German Pain League (DSL). Significantly more pain specialists and a better geographical distribution of therapeutic services are needed: “Pain specialists must be accessible close to patients’ homes, not 20 kilometers or more away. Some pain patients are currently expected to travel 200 kilometers. This is unacceptable.”

Organization, coordination, creating structures

The reality shows that we are still far from having a functioning healthcare system, according to Prof. Dr. Bertram Häussler, head of the IGES Institute. This is evidenced by the low referral rates and the large number of untreated patients. "Whether a patient is referred to the right place depends on how well-informed the individual general practitioner or specialist is about pain management services and how seriously they take them." Prof. Dr. Hartmut Göbel, head of the Kiel Pain Clinic, shared this experience: "Under-provision of care doesn't arise from a lack of treatment options. It arises from a lack of coordination and networking of treatment services!" In his view, a local contact point where all information about previous diagnoses and treatments is centrally compiled would be helpful. This point of contact must also coordinate the monitoring of progress and success and tailor treatment to the individual patient. "This interface should be located as close to the patient's home as possible. It should be networked with supraregional centers of excellence. These tasks also require a specialist in pain medicine with highly specialized qualifications."

According to Dr. Silvia Maurer, Vice President of the German Pain Society (DGS), this criticism affects fields like psychotherapy in two ways: “The distinction between psychological and medical psychotherapists is already difficult to understand. Patients often struggle to identify who works with pain patients, as there is no adequate term for it.” The situation is different with psychological psychotherapists who can complete advanced training offered by the German Society for Psychological Pain Therapy and Research (DGPSF). “While patients could find these pain psychologists through the DGPSF, there are only 265 of them in all of Germany. In Rhineland-Palatinate, for example, there are only 26 – and they are only authorized to treat adult patients. That is simply not enough.”

Deficits at all levels of care

Dr. Ingrid Dänschel of the German Association of General Practitioners confirmed many of the problems described by pain societies and patient representatives: “The main problem from a general practitioner's perspective is the interfaces within the care system. When do I refer a patient to whom? The existing care coordination system is not working optimally here. We need a good network of pain specialists. These specialists must also be readily available.” In Dänschel's view, pain-specific selective contracts could be a possible step towards better care. She referred to the “Pain Care Landscape,” developed by her association together with the Professional Association of Physicians and Psychological Psychotherapists in Pain and Palliative Medicine in Germany (BVSD), for which general practitioners and pain specialists have jointly developed structured treatment pathways. “Key aspects of this integrated care concept are the division of tasks and responsibilities, as well as the cooperation of all participating physicians and other disciplines, with the goal of preventing the development of chronic pain at an early stage or ensuring better pain management. Diagnostics, therapy, and cooperation go hand in hand according to a specific algorithm,” explained Prof. Dr. Dr. Joachim Nadstawek, Chairman of the German Association of Pain Specialists (BVSD). At the same time, Nadstawek drew attention to the shortage of young pain specialists: “In the next five years, approximately two-thirds of currently practicing pain specialists will retire, and there are almost no new recruits. Ensuring adequate pain care is therefore acutely threatened.”

Local services

Dr. Johannes Fechner, Deputy Chairman of the Baden-Württemberg Association of Statutory Health Insurance Physicians (KV Baden-Württemberg), stated: “The general practitioner must be the first point of contact and the foundation of pain management care, located close to patients' homes.” He believes that specific succession problems for contracted pain management physicians could be solved locally if the new needs assessment guidelines of the Federal Joint Committee included corresponding opening clauses, allowing for the filling of vacant positions with qualified pain therapists from other specialties. Dr. Gerhard Müller-Schwefe, President of the German Pain Society (DGS), considers this option insufficient: “Filling vacancies with physicians from other specialties is a meager stopgap measure. It offers neither security of care nor comprehensive coverage. At best, it perpetuates the existing shortage of services, as it prevents the creation of additional pain management facilities despite the glaring lack of resources.”

Tiered care with clear responsibilities

For Müller-Schwefe, a tiered healthcare system comprised of independent, outpatient physicians is the only model suitable for ensuring comprehensive pain management. In this model, the first point of contact would be the general practitioner, who should hold a specialist qualification in pain medicine. Specialists with additional qualifications in pain therapy, as well as a specialist in pain medicine as required by the German Pain Society (DSL), the German Pain Society (DGS), and the German Association of Pain Surgeons (BVSD), constitute the next levels of care for Müller-Schwefe.

Pain medicine must be included in needs planning

Such a tiered system of care can only be implemented if the need for pain specialists is systematically determined and met. "Pain medicine must become part of the needs assessment of the statutory health insurance associations," said Müller-Schwefe. Needs assessment and the provision of care are based on specialist qualifications. Since no specialist in pain medicine currently exists, there is no pain medicine needs assessment in any single statutory health insurance association nationwide, and therefore no provision of care. All participants in the forum agreed that the current need for pain specialists is far from being met. It is also not guaranteed that medical practices specializing in pain medicine will retain this focus when the current practice owner retires. The reason: Physician positions may only be filled within the same specialist discipline.

Source:
National Pain Management Forum of the German Society for Pain Medicine (DGS), the Professional Association of Physicians and Psychological Psychotherapists in Pain and Palliative Medicine in Germany (BVSD) and the German Pain League (DSL) “Outpatient and Local Pain Management”, November 12, 2015, Berlin