1. 2025;28;377-396Physician Payment Reform in Interventional Pain Management: Balancing Cost, Quality, Access, and Survival of Independent Practices
   Health Policy Perspective
   Laxmaiah Manchikanti, MD, Mahendra Sanapati, MD, Vidyasagar Pampati, MSc, Paul J. Hubbell, III, MD, Ann Conn, MD, Ramarao Pasupuleti, MD, Mayank Gupta, MD, Alan D. Kaye, MD, PhD, Alaa Abd-Elsayed, MD, Annu Navani, MD, Miles Day, MD, Devi Nampiaparampil, MD, Christopher G. Gharibo, MD, and Joshua A. Hirsch, MD.

On July 14, 2025, the Centers for Medicare and Medicaid Services (CMS) released the 2026 Physician Proposed Payment Rule aimed at reducing wasteful spending, enhancing quality measures, improving chronic disease management, and protecting independent practices from systemic financial pressures that have favored large healthcare systems and plagued independent practices. The goals are admirable, but the proposed measures with uniform reductions of 2.5% in physician payments based on efficiency adjustments apply across the board to all physicians. Further, practice expense (PE) reductions of 4% to 6%, meant to apply for hospital-based physicians will inadvertently apply to independent physicians constituting 43% of the physician workforce providing services in ambulatory surgery centers (ASCs), as well as hospitals. Thus, reductions of work relative value unit (wRVU) based on efficiency adjustment of 2.5% and PE reductions of 4% to 6%, with total reductions of 7% to 9%, compromise and limit patient care by putting additional pressure on independent physicians. Further, CMS’ proposal to start Ambulatory Specialty Model (ASM) for low back pain with specialties of interventional pain management (IPM) and pain management involved. These specialties have no control over costs incurred as an overwhelming majority of patients are chronic pain patients and managed by family physicians, chiropractors, physical therapists, neurosurgeons, and others, resulting in 9% reductions, or increase in reimbursement over a period of 3 years with recurring changes of 3% each year.
The proposal includes a 3.8% conversion factor (CF) payment update and increased reimbursement for office-based services, including evaluation, management, and procedures. The changes will increase reimbursement by 8% to 10% for office-based services, but they also decrease reimbursement for all procedures performed outside offices by 7% to 9%. 
These proposals arrive at a time when non-physician health care providers are striking for wage increase tied to inflation, and ironically, physicians have experienced repeated cuts in reimbursement with occasional stagnation, leading to 33% reduction from 2001 to 2025 in general, and 41% reductions in reimbursement for interventional pain physicians. In addition, there is an additional 2% sequester cut each year from 2011 to last until 2031, and there is a potential for 4% PAYGO cuts starting next year. Further, supply costs have increased 56% to 80% during these years. Further, despite technological advancements such as EMRs and AI, administrative burdens have intensified rather than improved. Independent physicians contend with complex prior authorizations, evolving Medicare coverage policies, growing audit risk with increased documentation and compliance demands from all payers’ sources, 30% of interventional pain physicians under audit at any time. Our data on interventional pain physicians and published data on other physicians shows that efficiency has decreased and PEs have been skyrocketing.
Ironically, CMS has proposed on January 10, 2025, a 4.3% payment increase to Medicare Advantage Plans, amounting to $21 billion in 2026. To add fuel to the fire, CMS on April 7, 2025, issued a final rule of increasing on average by 5.06% from 2025 to 2026. These proposals come amid growing concerns about Medicare Advantage over payments, including $44 billion due to favorable selection, $40 billion from risk adjustment discrepancies, and $15 billion for duplicative coverage of veterans who already receive benefits through the Veterans Administration (VA). In addition, according to the Medicare Payment Advisory Commission (MedPAC), traditional Medicare beneficiaries also face higher costs, contributing an additional $198 annually, totaling roughly $13 billion per year. All of these added together, CMS is spending on Medicare Advantage over $110 billion a year.
Thus, as independent practice continues to come under assault, the American Society of Interventional Pain Physicians (ASIPP) and other societies urge CMS to create a separate identifier for independent pain physicians to distinguish them from hospital-based physicians and prevent these cuts from harming independent practices. This separate but equal treatment of independent physician practices ultimately interferes with patient care.

KEY WORDS: Physician payment policy, physician fee schedule, independent physicians, Medicare, interventional pain management