If you have an empty room and holes in your schedule, you might consider filling them both with pain management cases. For a relatively low startup cost — plan to spend around $200,000 on a new C-arm and an adjustable fluoroscopy table — you can add pain to your list of surgical services, the in-demand specialty with a profile that's hard not to like: quick cases, fast turnaround (no blood or bodily fluids!) and, despite recent cuts in reimbursement, good profit potential.

"Compared to many specialties, pain is an inexpensive procedure to add," says Vivian Wisniewski, RN, director of nursing at the Harrisburg (Pa.) Interventional Pain Management Center. Adds Kathryn Kelleher, RN, BSN, administrator of Hyde Park (Mass.) Pain Management: "Buying the equipment, setting it up, putting it all together — that was the easy part. The regulations and hoops that you have to go through? So much is so exacting."

Don't sell pain short as a revenue generator. Many pain cases involve more than 1 billable procedure. For example, a bilateral facet injection with an additional level adds up to 4 billable procedures. As Amy Mowles, president and CEO of Mowles Medical Practice Management in Edgewater, Md., points out, if you're getting Medicare rates on such a multiple procedure encounter, that's close to $1,000 in reimbursement for a 15-minute procedure.

It's a short capital equipment shopping list. For such common pain procedures as epidural steroid injections, dorsal medial nerve branch blocks and facet joint injections, which are quick and require only single-use supplies, all you'll need is a C-arm and a table, preferably one that tilts or is adjustable. You'll only need a radiofrequency machine for more advanced neuroablation procedures.

The essential C-arm
The single largest expense associated with pain management is your C-arm, which costs around $130,000 new, says Ms. Mowles. Best case scenario: Put that underused C-arm that your facility already has to work in your new pain room.

Fluoroscopic guidance is the standard of care in pain management. "No physician is going to feel comfortable doing injections in a spine that contains hardware from a failed back surgery without being guided by that fluoroscopy," says Mary Beth Calder, administrator of York Adams Pain Specialists in Hanover, Pa. Adds Ms. Wisniewski: "A C-arm makes your injections more accurate and comfortable for the patient. Physicians can get to where they're working very quickly without poking and prodding."

Ms. Mowles recommends a 9-inch image intensifier, patient annotation, internal image storage and a printer. We live in a digital world, but a printout of where the physician placed the needle is a low-tech way to document the position that gave the patient good pain relief, says Ms. Wisniewski. "This way, you can replicate that position on the next visit," she says.

To reduce radiation exposure, Ms. Wisniewski suggests a C-arm with a laser aimer, a red light that shows you where the C-arm's beam is focused. "You'll have better accuracy and take fewer X-ray images, which means less radiation exposure," she says.

Consider the space limitations of the procedure room to make sure you can maneuver the C-arm you select around the table in whatever location the table will actually sit, says healthcare facility design expert William E. Lindeman, AIA, NCARB, president of WEL Designs in Tucson, Ariz. "If a radiology tech will be positioning the C-arm, make sure the procedure room depth provides room for her behind the maneuvering handles."

Ms. Calder has experience with both new and used C-arms, and she recommends you invest in a new C-arm, which should last you 15 to 20 years with regular maintenance. "Maintenance is expensive: $10,000 a year includes 2 routine visits and any service calls," she says. "That's the cost of doing business." But, she adds, new C-arms require a lot less service than used models. Plus, newer models have better image quality, storage capacity and capabilities. Then there's the manufacturer-supplied on-site training you'll get when you buy new. The biggest benefit of remanufactured is upfront cost. About 10 years ago, Ms. Calder saved her startup facility $50,000 when she bought a used C-arm for around $70,000. After 4 years of use, she sold it for $20,000 to another startup pain center.

"Operational and maintenance costs can make initially cheaper equipment a lot more expensive in the long run than newer alternatives," warns Mr. Lindeman. "Used equipment is often difficult to service due to its age, or expensive to use relative to newer equipment on the market."

C-arm table
The other piece of capital equipment you'll need for pain management cases is a C-arm table, preferably one that tilts and holds up to 500-lb. patients. "If the C-arm can't get to a particular spot because of a larger patient, it helps if you can tilt the table from side to side," says Ms. Calder. You can use tables that don't adjust or tilt, but you'll need to use foam wedges to help position the patient. Several companies will offer the C-arm and table as an all-in-one package. Like the C-arm, you may consider leasing or buying a refurbished table to offset the cost. A new C-arm table can cost around $25,000, while a refurbished or used table may cost around $8,000.

A fixed-height pain management imaging table is adequate, but a motorized fluoro table that elevates is better, says Ms. Wisniewski. This way, your physicians don't have to stretch or strain to reach the patient. Let patients get on the table in the low position, and then your doctor can raise the table to a comfortable position.

If you're outfitting multiple procedure rooms for pain, buy a separate C-arm and fluoro table for each, says Mr. Lindeman. "Time lost to rolling the C-arm and monitors between rooms usually eliminates any potential volume increase, and subjects the equipment to accelerated wear and damage," he says.