Fee-for-Service Healthcare and the Ninth Epidural

Fee-for-service healthcare pays for each procedure, visit and test separately, so it rewards the count, not the result. In chronic pain it builds a calendar. Picture a composite patient who comes in for his ninth epidural in three years at the same level. Nobody has measured his fasting insulin or asked how he sleeps.

A sixty-one-year-old man comes in for his ninth epidural in three years. Same level, same six weeks of relief, same order to come back in twelve weeks. Nobody has measured his fasting insulin or asked how he sleeps. He is a composite, and I have treated him. Fee-for-service healthcare did not invent his back pain. It built the calendar he is living on.

The video above is Chapter 12 of The Pained Brain, written by Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Dr. KrisJay Fucanan, MD. It lays out who is paid for what. This page goes deeper into the studies, including the ones that complicate the story. It ends with questions you can take to your own doctor.

How fee-for-service healthcare shapes a pain plan

Fee-for-service means each procedure, visit and test is paid for separately. That rewards the count, not the result. Some injections buy six weeks so a patient can rehab, sleep and change his terrain. That shot is a bridge, and I will defend it. The ninth shot at the same level, with nothing planned in between, is an assembly line. The difference is not the needle. It is what happens during the weeks the needle buys.

The volume grew faster than the patients. In traditional Medicare, the epidural rate rose 103 percent per 100,000 beneficiaries from 2000 to 2010. The transforaminal type (a shot placed beside the nerve root) rose 579.1 percent. Sacroiliac joint shots rose 281 percent from 2000 to 2022. Over that time the Medicare population grew 63.3 percent. Among 196,332 patients with commercial insurance, the average was 4.46 spinal procedures in the year after the first. The busiest tenth of providers did 36.6 percent of all of them.

Fairness belongs in the same paragraph. A repeat radiofrequency ablation after real relief wears off fits the guidelines. Claims data cannot tell a planned repeat from a failure. Among 44,936 ablation patients, 33.1 percent had a second within six months. And since 2019 the curves have bent. All interventional procedures fell 16.8 percent in traditional Medicare through 2024. Those are counts with no outcome attached. They cannot say whether the man in the chair now has a plan or just fewer shots.

The pay formula and who owns the scanner

Across 31 physician groups in 22 health systems, volume was the base of pay in 83.9 percent of primary-care plans. It was the base in 93.3 percent of specialist plans. Asked how a doctor could raise his income, 70.0 percent of groups gave the same answer: do more.

Ownership sharpens it. When a physician group owned the MRI scanner, low back scans came back normal 86 percent more often. The scan is not harmless. Among patients of orthopedists, getting one raised the chance of back surgery by 34 percentage points. Private equity’s share of pain doctors climbed from 0.4 percent to 8.2 percent in a decade.

The detail that complicates the story comes from the Veterans Health Administration, where doctors draw salaries. There, spinal shots for low back pain were still the single costliest low-value service, at 21.4 percent of low-value spending. Salary did not end the habit. Training, referral patterns and belief carry part of this. Any account that blames only the fee is incomplete.

A drug to treat a drug

Among 1,342 people living with chronic pain, 71.4 percent took five or more medications. And 25.9 percent took ten or more. Among American adults whose pain limits work, each added five medications carried 1.47 times the odds of an ER visit. The cause is often a cascade. Gabapentinoids can cause fluid buildup in the legs. Among 23,544 nursing-home residents starting one, about 1 in 20 got a loop diuretic (a water pill) within three months, at a median of 36 days. A second drug for the first drug’s side effect is the whole model in miniature. The same pattern shows up in the heartburn pill that is hard to quit. One medication list, one person, one fall shows what that costs an older patient. Never stop or change a medication on your own; review the list with the physician who prescribes it.

Devices follow the same logic, with a battery. One study compared claims for 1,260 matched patients given a spinal cord stimulator. 22.1 percent had the device revised or removed within two years. Chronic opioid use was no lower than with standard care by the second year. Pooled across 38 studies, 11.9 percent of stimulators were taken out by three years. And 32.8 percent of those who kept theirs got less than half their pain relieved.

And the cheapest step is often skipped. Take 411 patients who had low back surgery at one center. Only 34.8 percent had a physical therapy plan in the year before. Only 14.6 percent had six or more exercise visits. And 84.4 percent had filled an opioid.

Malpractice fear, or the fee?

Doctors know. In a survey of 2,106 of them, the median guess of needless care was 20.6 percent. 84.7 percent named fear of malpractice as the reason. And 70.8 percent agreed that doctors do more procedures when they profit from them. The malpractice story does not hold up well. In one study, 36 hospitalists rated their own 4,215 orders. 28 percent carried some defensive motive. But fully defensive orders made up only 2.9 percent of cost. The doctors who claimed the most defensive orders spent no more than the rest.

The people inside the system pay too. 39.1 percent of American doctors report high moral distress, at 4.4 times the odds of other workers. I was trained by this system and I bill it. The procedures in this book are its procedures. What I refuse is the procedure as the destination. The reforms aimed at the fee have mostly missed. Choosing Wisely cut low-value back imaging by 4 percent. A value-based payment program left it at 13.8 percent in both arms.

What a lifelong label can hide

Chronic is often read as permanent. A landmark trial began by calling type 2 diabetes a disorder that needs lifelong treatment. Then it put 149 people with it on a structured weight-loss program run in primary care. At one year, 46 percent were in remission against 4 percent. At two years it was 36 against 3 percent. And 40 percent were still on diabetes medicine against 84 percent. It is a diabetes trial, not a pain trial, and some who reached remission relapsed. It shows that a terrain labeled lifelong can move. The link between that terrain and pain is covered in what diabetes remission does to chronic pain, and the nervous-system side in the chapter on central sensitization.

The pain programs are real, and their effects are smaller. Team-based rehab beats usual care by about half a point on a ten-point pain scale. Where these programs earn their place is dependency. In a three-week program of 1,457 patients, 86.74 percent of opioid users were weaned. Still, 30.70 percent were back on an opioid within a year. Tapering works best when procedures keep a patient out of withdrawal and functioning. That is the approach in opioid tapering as a bridge. Continuity is the other lever. In a Norwegian registry of more than four million patients, keeping one family doctor past fifteen years went with a quarter lower odds of dying than a single year did.

The cheapest treatment of all is a conversation. Across 209 trials, decision aids made patients 1.75 times as likely to choose care that matched their own values. They added no regret and about ninety seconds to the visit.

Questions that turn a subscription back into a bridge

• What is supposed to change between this procedure and the next one?
• Have I had a real course of physical therapy, six visits or more?
• Does anyone involved have a financial interest in the scanner, therapy or facility?
• Which of my medications treats a side effect of another?
• If a stimulator is offered, whose explant rate am I being quoted?
• Is there a decision aid for this choice?

The Chapter 12 supplement lists each study above with its population, its number, and what it cannot prove. Fast, low-cost treatments paid less than slow ones are the thread from the cluster headache chapter, and whether the needle lands where the picture says is taken up in the chapter on image guidance.

Frequently asked questions

How many epidural steroid injections can you have?

There is no magic series and no fixed count that fits everyone. Shots should follow clinical need. Judge each one by how much relief it gave and what was done with that time. If the relief is shrinking and nothing changes between shots, the plan needs rethinking, not another date on the calendar. Read what an epidural steroid injection actually does to an inflamed nerve.

What is fee-for-service healthcare?

It is a payment model in which each visit, test and procedure is billed and paid separately. It rewards the number of services, not whether the patient gets better. In many health systems, doctor pay is still built mainly on volume. That holds even when the system has value-based contracts. See how medical necessity is established before a pain procedure.

Why does each injection seem to last less time?

Often nothing has failed in the procedure itself. The driver underneath keeps making pain while the shot only quiets it. That driver may be metabolic inflammation, poor sleep, lost fitness or an oversensitive nervous system. When the weeks of relief are not used to address those drivers, the relief tends to shrink. Here is why each injection can buy less time than the last.

Is a spinal cord stimulator worth it?

It can help the right patients, but outcome numbers vary with who reports them. Independent pooling found about 12 percent taken out by three years. A maker’s registry reported a yearly rate of 3.5 percent. Ask what the trial period is meant to prove and what happens if the device does not help. Learn what a spinal cord stimulator trial actually tells you.

How do I know whether my pain care is a plan or a routine?

A plan names the pain generator. It explains what each procedure is buying time for. And it changes something between visits: sleep, food, movement, medicines or the behavior work. A routine repeats the same procedure at the same interval with nothing else moving. If you cannot say what has changed in the last six months, ask. Which pain specialist to see when treatment has not helped.

Sources

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Medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, board certified in anesthesiology, pain medicine, interventional pain management, addiction medicine and obesity medicine. Adapted from Chapter 12 of The Pained Brain by Dr. Padda and Dr. KrisJay Fucanan, MD. Last reviewed September 2026.

Dr. Gurpreet Singh Padda, MD, MBA, MHP