Infusion center, pain care deserts cause challenges for pain management
By Calli Barker Schmidt
When Nathan Neufeld, DO, was 17 years old, he watched his mother die after a long battle with breast cancer. His presence during her death with his father and two younger brothers was a major factor in his decision to study medicine and to specialize in pain management.
He’s now a pain management and palliative care specialist at the City of Hope, a comprehensive cancer care center in Atlanta, and has seen major advances in breast cancer treatment during the last 20 years.
Neufeld doesn’t know if his mother would have had a longer life had she been a patient today. But what he does know is that her death could have been different. “She could have been more awake and alert,” and perhaps had more meaningful conversations with her family before she slipped away, he shares.
But at the time, the Neufelds lived in rural North Dakota, nowhere near the practice of a physician specializing in pain management for individuals with cancer. People in sparsely populated rural areas who experience pain—from cancer, a chronic illness, or for other reasons—can have a vastly different experience from those who live in towns and cities that are home to specialists who understand pain management, as well as the pain clinics and infusion centers where these illnesses are treated.
“If [my mother] could have met a doctor like me, a lot more could have been done,” Neufeld says.
His mother’s experience is, unfortunately, not uncommon. The issue of health care deserts, a term used to describe a geographic area that lacks the specialists and appropriate care its residents need, is a thorny one for providers, their patients, and the insurance companies whose business is to keep costs down.
When people in these health care deserts do find a specialist elsewhere, there are logistics to consider. Even if their medical insurance covers the cost of the treatment itself, how will they get there? The specialist may be hours or even days away—do they have a care partner to drive them? And where will they stay? Insurance rarely pays for any of the costs associated with access to treatment.
Infusion access a major example of care deserts
Infusion treatments are one category of pain management widely affected by lack of access, creating health care deserts that hurt patients.
“It comes down to the economics of a health care business,” says Brian Nyquist, president and chief executive officer of the National Infusion Center Association. Infusion centers, staffed with health care professionals who understand how to administer the drugs used to manage many chronic illnesses, often find it hard to remain financially viable in small towns.
“It’s just like any other business. If you are out in a rural market, you may not have sufficient volume to offset the costs,” he says. “Because of that, we generally see health care providers hyper-localized in major metropolitan markets.”
And that creates “an accessibility and disparity issue,” Nyquist says. When it’s difficult to access treatment because it’s too far away, chances are greater that a patient will skip a treatment because they can’t get a ride, take time off work, or afford a hotel. “That can have dire repercussions,” Nyquist says. “Rather than managing and maintaining their health, that individual now has to manage the fallout of not getting the appropriate care in a timely fashion, which often requires more—and more expensive—care.”
He adds, “It’s a reactionary paradigm, leading to more pain, a lack of productivity, and often a stay in the emergency room, which adds costs, wastes money, and exacerbates all the problems the patient is struggling to manage.”
Pop-ups, big-box stores, public awareness, and other solutions
Individuals living with chronic illnesses who need regular infusions to manage their pain can sometimes get their infusions at a local hospital that typically treats oncology patients. However, this isn’t a perfect solution, says Alicia Barron, executive director of the Infusion Access Foundation. Individuals being treated for cancer often have compromised immune systems. Sharing space with people who need infusions can open these patients up to more infections.
Ambulatory infusion centers have been proposed as one way to bring care to health care deserts. Much like volunteers who give blood at a mobile blood bank that travels to community centers or workplaces, patients could coordinate with their health care providers to get their infusions on the days that the vans are scheduled to be posted nearby. But that is not always ideal either, Barron says: “Phlebotomists can draw blood, but infusion medicine requires trained nurses. They’re not the same people,” and
employment costs are higher.
“Again, in rural areas, it’s just not economically viable where there are fewer people,” she says. Another option, Barron notes, is to piggyback on the businesses that have already figured out how to thrive in sparsely populated areas. Hy-Vee, a chain of about 300 grocery stores in the Midwest, and Walmart, with more than 10,000 stores internationally, are already exploring the idea of expanding their health care services to include infusion centers. A big-box store that already has a pharmacy and the infrastructure to pass the charges on to the customer’s insurance company can take the risks that a mom-and-pop store or smaller infusion center cannot, Barron says.
In all cases, public awareness of the issue is key. That can lead to pressure on insurance companies to expand their coverage, including subsidizing the costs that patients incur to access care. “Insurance companies have focused on diagnosis and treatment, but they need to look at whole-person care,” Neufeld says.
State and federal officials can play a role as well. Budget-conscious politicians should consider that when people can’t access timely treatment for chronic pain, they end up in the emergency room, costing the government more in the long run.
“There is no silver bullet, no one approach or strategy, but a government-subsidized care model is part of that solution, as well as more robust training around chronic pain management,” says Nyquist.
He adds, “What we are all looking for—the solution—is the right medication at the right time in a cost-effective setting.”
THE REALITY OF HEALTH CARE DESERTS
Infusion access: The map above displays 12,000 infusion centers across all 50 states, Washington D.C., and Puerto Rico (centers in Canada and Mexico are not displayed). Red areas depict a high saturation of infusion centers. Blue areas depict infusion shortage areas. The remainder of the map denotes infusion deserts, with shortage areas and deserts often appearing in rural communities, and major metropolitan markets generally including infusion centers near well-insured populations.
Pain care access: A total of 51.6 million American adults live with chronic pain. For every 10,000 people living with severe pain, there is only one board-certified pain specialist. In fact, veterinary students spend five times more education hours focused on pain management than medical students.