Big ticket items to starting a pain practice

[oreosandsake]

what are the big ticket items necessary for a pain practice? this is for a hospital that is looking to bring pain in house

I have only come up with a short list so far.

Fluoroscopy unit
RF generator (I know there was a thread on this. can anyone recommend a unit that has 4 channels, can do pulsed and bipolar RF) I think the cosman and neurotherm can both do this. not sure how to make a decision on this. I doubt I will be doing any cooled RF
Ultrasound machine

help appreciated.

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[geauxg8rs]

what are the big ticket items necessary for a pain practice? this is for a hospital that is looking to bring pain in house

I have only come up with a short list so far.

Fluoroscopy unit
RF generator (I know there was a thread on this. can anyone recommend a unit that has 4 channels, can do pulsed and bipolar RF) I think the cosman and neurotherm can both do this. not sure how to make a decision on this. I doubt I will be doing any cooled RF
Ultrasound machine

help appreciated.

Fluoro table
Man cave

 

[lobelsteve]

C arm
fluoro table
rf unit
Cardiac monitor (can avoid if not sedating)
Computers.
EHR

 

[BobBarker]

Stryker multigen. It is good, can do all you want. They can do a fee per disposable so no up front cost for hospital. That is what we are doing. Same situation as you.

 

[pmrmd]

What about the space itself? Desks, chairs. Blinds for the windows can cost up to 15k in all. Exam tables in the room are 300-500 each and that is for a basic table. The expense is huge.

 

[emd123]

Delete US machine. Not worth the cost any more. Otherwise it's a good start Oreo

 

[Ducttape]

would still ask for ultrasound machine. most hospitals have them, for the anesthesiology service. usually easy to tag on an extra machine to their orders, or get one of the left over ones that isnt being used for OR.

other things to get from the hospital:
crash cart
defib machine
automated BP machines/pulse ox/
EMR
Dictation services, or better yet a scribe!!

in lieu of exam tables, get hospital gurneys. cheaper.

obviously HOPD space. on campus. probably the most expensive part.

 

[Yo GabbaPentin]

Delete US machine. Not worth the cost any more. Otherwise it's a good start Oreo

I strongly agree with this. This technology is no longer worth it. You can thank the clowns who used it to refill their hundreds of pump patients and for every trigger point injection.

Otherwise, you seem to have it nailed down. The most expensive thing for you could potentially be employees if you overstaff. Run lean and try not to be an a-hole... which will cut down on turnover.

 

[freddydpt]

I have a strong feeling Oreo will be using US in his practice no matter what

 

[Ligament]

US machine is invaluable in my practice. Its too bad reimbursement has been destroyed by our POS government.

 

[bedrock]

I would still ask for the US machine if somebody else is paying for it, but yes, it would be the lowest priority compared to the other big ticket items.

Still handy to have US for peripheral nerve blocks, ICBs, and tendon injection, but I wouldn't pay for a new US machine myself in pp.

 

[BobBarker]

Anesthesia department has probably upgraded and there is an abandoned US machine somewhere. I would get that versus a new one and running up your tab with the hospital. You want to run as lean as possible to negotiate a better conversion factor next year.

 

[Aether2000]

Hospitals have more money than God and continue to enrich their bloated coffers every year. If the hospital is the deep pocket then buy the best of everything including RF machines with cooled RF, SI RF, epimed blunt needles, and the most expensive US machine you can buy. Dont forget the discectomy equipment and disc fx. If a non overpaid entity is doing the buying, then you can be more reasonable.

 

[Louisville04]

would still ask for ultrasound machine. most hospitals have them, for the anesthesiology service. usually easy to tag on an extra machine to their orders, or get one of the left over ones that isnt being used for OR.

other things to get from the hospital:
crash cart
defib machine
automated BP machines/pulse ox/
EMR
Dictation services, or better yet a scribe!!

in lieu of exam tables, get hospital gurneys. cheaper.

obviously HOPD space. on campus. probably the most expensive part.

Do you mean like a MA (not a nurse) to see every patient with you and input the H&P and orders?

 

[bronchospasm]

Fluoro machine-- Pulsera
Needles
Support tray
chloraprep
Dexamethasone
Methylpred
Lidocaine V/s Normal Saline
Omnipaque
Lead gown
Dosimeter
C-arm Table - Oakworks
Exam room tables
Exam room chairs
Spine models
Wall charts- dermatome charts
Patient education videos - Swarm interactive
trigger point injection setup
Dragon medical if using
Procedure templates
Referral forms
Practice website
Opioid contracts
Patient handouts for injections etc
Home exercise program handouts
Frame certificates
exam room chairs
Waiting room chairs
Waiting room magazines

Credentialing

Receptionist
Telephone system
Medical asistants
BP machine
Pulse OX
Weighing scale

UDS ???

EMR training

Registering for PDMP

That's all that I can think of right now..

Hope this helps..

what are the big ticket items necessary for a pain practice? this is for a hospital that is looking to bring pain in house

I have only come up with a short list so far.

Fluoroscopy unit
RF generator (I know there was a thread on this. can anyone recommend a unit that has 4 channels, can do pulsed and bipolar RF) I think the cosman and neurotherm can both do this. not sure how to make a decision on this. I doubt I will be doing any cooled RF
Ultrasound machine

help appreciated.

 

[pastafan]

Phone system
Fax machines

 

[oreosandsake]

Hospitals have more money than God and continue to enrich their bloated coffers every year. If the hospital is the deep pocket then buy the best of everything including RF machines with cooled RF, SI RF, epimed blunt needles, and the most expensive US machine you can buy. Dont forget the discectomy equipment and disc fx. If a non overpaid entity is doing the buying, then you can be more reasonable.

Fluoro machine-- Pulsera
Needles
Support tray
chloraprep
Dexamethasone
Methylpred
Lidocaine V/s Normal Saline
Omnipaque
Lead gown
Dosimeter
C-arm Table - Oakworks
Exam room tables
Exam room chairs
Spine models
Wall charts- dermatome charts
Patient education videos - Swarm interactive
trigger point injection setup
Dragon medical if using
Procedure templates
Referral forms
Practice website
Opioid contracts
Patient handouts for injections etc
Home exercise program handouts
Frame certificates
exam room chairs
Waiting room chairs
Waiting room magazines

Credentialing

Receptionist
Telephone system
Medical asistants
BP machine
Pulse OX
Weighing scale

UDS ???

EMR training

Registering for PDMP

That's all that I can think of right now..

Hope this helps..

Thanks to everyone for the advice. bronchospasm, that list only goes to show how much I will need to learn and organize to get this thing going.
I will have to see how UDS works in this hospital system. I imagine they would get sent through the hospital lab?

they are in the midst of building a new HOPD for multispecialty group. I am told it will have 2 fluoro suites next to each other. this practice will start with a snails pace in the existing hospital. That said, a lot of the items suggested will exist in the hospital already. If my memory is correct, they have a OEC 9900 that is under utilized and waiting for me. I haven't even started looking at the CA fluoro license yet. the hospital will have the fluoro table, crash cart etc.

any other big ticket items specific to pain practice not expected to be found in an OR?

Algosdoc and Bob Barker - thanks for the advice. I will look into the Stryker machine. We used that one in residency, but we never did pulsed RF. I would assume it has a pulsed RF mode as well? (efficacy/EBM for another time please!)

 

[BobBarker]

Yes, it has pulsed. We have used it a few times for intercostals and genitofemoral.

Most hospitals will have to send out their urine quants. Neither the university or the 11 story private hospital down the street do quants here. They should be able to do qual screenings.

I am going to do my procedures in an unused cath lab. There is no other good procedure area and the OR is on a different floor than preop so that wasnt a good option.

 

[Aether2000]

Some hospital labs don't know the difference between quantitative and qualitative analysis. You can know the difference by requiring your reporting lab to give you the ng/ml concentrations of each primary drug and metabolite in the urine drug test. If the list "below cutoff" then the lab may be using qualitative (ie. junk) analysis. Even the quantitative labs sometimes list cutoffs but these make no sense since the detection of GC/MS or LC/MS are usually in the range of 1 ng/ml for opioids. Ask for the actual value. Qualitative UDS is not only useless, it is dangerous to the physician who may be sued for acting on a test that has a high false positive/false negative rate.

 

[emd123]

Qualitative UDS is not only useless, it is dangerous to the physician who may be sued for acting on a test that has a high false positive/false negative rate.

Agree. That's why I don't even run them anymore

 

[drusso]

Agree. That's why I don't even run them anymore

Except most clinical guidelines for COT recommend toxicology surveillance. Licensing boards might interpret your behavior as "turning a blind eye" to the issue.

 

[Ducttape]

A scribe to type in the entire note. Pay prob MA or lower rates. They go in room with you...

 

[emd123]

Except most clinical guidelines for COT recommend toxicology surveillance. Licensing boards might interpret your behavior as "turning a blind eye" to the issue.

Slow down.

"Qualitative"

I wrote that I don't do "qualitative" tox screens (ie, worthless in-office UDS dipsticks). I do frequently (and religiously) do reliable and worthwhile quantitative, ie, LC/MS confirmatory tox screens. Algos was making the same distinction. I'm not turning a blind eye to anything. Again, show me any reason to order a qualitative dipstick UDS, when you are just going to ignore any result that doesn't align with your pre-test probability, and then send out a quantitative GC- or LC-MS test for the real result?

 

[BIGphysician]

Hot nurses with slutty uniforms

 

[drusso]

Slow down.

"Qualitative"

I wrote that I don't do "qualitative" tox screens (ie, worthless in-office UDS dipsticks). I do frequently (and religiously) do reliable and worthwhile quantitative, ie, LC/MS confirmatory tox screens. Algos was making the same distinction. I'm not turning a blind eye to anything. Again, show me any reason to order a qualitative dipstick UDS, when you are just going to ignore any result that doesn't align with your pre-test probability, and then send out a quantitative GC- or LC-MS test for the real result?

POC dips are worthless. Immunoassays done on instrumented and calibrated analyzer can be acted upon as presumptively positive until a quantitative confirmation is obtained by a second analytic method. Your lab should be able to get a turnaround on a qualitative, high complexity, immunoassay with in 24 hours while a confirmative quant is pending. In fact, I'd demand it.

 

[BobBarker]

A good desktop analyzer is $50,000.

 

[freddydpt]

Hot nurses with slutty uniforms

Actually, the uniforms have such little material that it keeps costs down. Why do you think Hooters was able to expand so rapidly?

 

[NJPAIN]

Bail money

 

[powermd]

Productivity maximization hardware.

http://venusformen.com/store/

 

[freddydpt]

I had no idea what that link was and I clicked on it at work. NSFW people!

 

[BIGphysician]

Productivity maximization hardware.

http://venusformen.com/store/

Hahaha that's hilarious, sending that out tomorrow to some people for sure

 

[epidural man]

Delete US machine. Not worth the cost any more. Otherwise it's a good start Oreo

WHAT THE?!

Sorry, ridiculous comment.

First off -use of ultrasound will continue to expand as technology expands - better to stay on the wave.

Second - better to look for ways to use ultrasound to cut down on your own fluoroscopic exposure (think caudals...). As things get more bundled, it won't matter what you use, the pay will be the same.

Thirdly - if you want to be a pain physician that cares about outcomes and success, I strongly feel you should use this technology. It has been shown that using the ultrasound increases successful placement in many places (knee, hip, etc.) Also, as biologics come online - it will be IMPERATIVE to place the stuff in a very specific place. I don't have data, but I would suspect that putting the small volume substance into the tear will work a lot better than "somewhere in the vicinity". With ultrasound, I can course the supraspinatous, infraspinatous, supscapular, bicep tendons from insertion to proximal - getting very specific where I want to inject. Hip injections are so easy and very specific with ultrasound. You wouldn't think it matters with knee injections, but apparently - if you believe in science, it makes a huge difference in actually getting medicine in the joint (as opposed to blind).

I agree, you can run a well functioning, excellent pain clinic without one - but it isn't that much to add one.

I don't think the right answer is "well insurance companies have stopped paying for them so I won't get one" - rather the right thought is to see that more and more is being done with them daily, technology is improving - and every specialty is finding ways to clinically apply them - not for money, but because of utility. In fact, ultrasound will be like the chest xray - medical students will learn how to use ultrasound as part of their curriculum (already happening....). Some of the new technology is pretty cool. I signed an NDA with GE so can't tell you what I saw from them - but it is pretty cool. Point is...it isn't going away just because insurance currently is being obtuse.

 

[emd123]

WHAT THE?!

Sorry, ridiculous comment.

First off -use of ultrasound will continue to expand as technology expands - better to stay on the wave.

Second - better to look for ways to use ultrasound to cut down on your own fluoroscopic exposure (think caudals...). As things get more bundled, it won't matter what you use, the pay will be the same.

Thirdly - if you want to be a pain physician that cares about outcomes and success, I strongly feel you should use this technology. It has been shown that using the ultrasound increases successful placement in many places (knee, hip, etc.) Also, as biologics come online - it will be IMPERATIVE to place the stuff in a very specific place. I don't have data, but I would suspect that putting the small volume substance into the tear will work a lot better than "somewhere in the vicinity". With ultrasound, I can course the supraspinatous, infraspinatous, supscapular, bicep tendons from insertion to proximal - getting very specific where I want to inject. Hip injections are so easy and very specific with ultrasound. You wouldn't think it matters with knee injections, but apparently - if you believe in science, it makes a huge difference in actually getting medicine in the joint (as opposed to blind).

I agree, you can run a well functioning, excellent pain clinic without one - but it isn't that much to add one.

I don't think the right answer is "well insurance companies have stopped paying for them so I won't get one" - rather the right thought is to see that more and more is being done with them daily, technology is improving - and every specialty is finding ways to clinically apply them - not for money, but because of utility. In fact, ultrasound will be like the chest xray - medical students will learn how to use ultrasound as part of their curriculum (already happening....). Some of the new technology is pretty cool. I signed an NDA with GE so can't tell you what I saw from them - but it is pretty cool. Point is...it isn't going away just because insurance currently is being obtuse.

One of two things is going on here:

1-Either you already have an US machine that's paid off or you've committed to paying off, or more likely

2-You have an US machine someone else has paid off or has committed to paying off for you.

I've personally used ultrasound for years (15 to be exact) in various capacities. I'm well aware of the wide range of uses of ultrasound. But right now, in my current set up, at this point in time, I personally am not going to drop $20,000 of my personal cash flow on a machine. I'm not stupid. I'm still paying back practice debt on my other equipment, which was six figures and has taken years to dig out of. I'm not saying I never would get a machine, but $20,000 is $20,000. You find it's worth $20,000 of someone else's money. I agree. An US machine is worth $20,000 to me. Of someone else's money.

When I work for Waste-C-O General, I'll definitely get ultrasound. Right now, it's fluoro or landmarks. No one in their right mind, in private practice is buying an US machine right now, if they don't already have one. If that degrades the practice of healthcare, it's not my fault. It's the fault of Medicare who sees it has little to no value, as evidenced by their ceasing to apt for it. If they think it's crucial for their beneficiaries, they can raise the reimbursement to, or above break even price.

Go perform a bunch of MILDs, IDET, pulsed RFA and a bunch of other stuff no one pays for. I'm fine with it. But personally I can't stand by and flush $20,000 down the toilet with CMS crushing reimbursement every year. But then again, I'm in private practice so I don't get to live in a worry-free cost-Utopia. For those that do, by all means, shoot for the moon, and spend as much of someone else's money as you can.

 

[BIGphysician]

One of two things is going on here:

1-Either you already have an US machine that's paid off or you've committed to paying off, or more likely

2-You have an US machine someone else has paid off or has committed to paying off for you.

I've personally used ultrasound for years (15 to be exact) in various capacities. I'm well aware of the wide range of uses of ultrasound. But right now, in my current set up, at this point in time, I personally am not going to drop $20,000 of my personal cash flow on a machine. I'm not stupid. I'm still paying back practice debt on my other equipment, which was six figures and has taken years to dig out of. I'm not saying I never would get a machine, but $20,000 is $20,000. You find it's worth $20,000 of someone else's money. I agree. An US machine is worth $20,000 to me. Of someone else's money.

When I work for Waste-C-O General, I'll definitely get ultrasound. Right now, it's fluoro or landmarks. No one in their right mind, in private practice is buying an US machine right now, if they don't already have one. If that degrades the practice of healthcare, it's not my fault. It's the fault of Medicare who sees it has little to no value, as evidenced by their ceasing to apt for it. If they think it's crucial for their beneficiaries, they can raise the reimbursement to, or above break even price.

Go perform a bunch of MILDs, IDET, pulsed RFA and a bunch of other stuff no one pays for. I'm fine with it. But personally I can't stand by and flush $20,000 down the toilet with CMS crushing reimbursement every year. But then again, I'm in private practice so I don't get to live in a worry-free cost-Utopia. For those that do, by all means, shoot for the moon, and spend as much of someone else's money as you can.

Very eloquently said

 

[drusso]

buy a used machine off ebay...

 

[Ducttape]

it can cut the cost in at least half. i see the US machine i use for $10K.

i know you can only bill roughly $34 per US... remember im not a private practice guy, but can you not deduct the capital expense and/or depreciate the US machine and have some positive tax implications?

 

[tchoupdoc]

WHAT THE?!

Sorry, ridiculous comment.

First off -use of ultrasound will continue to expand as technology expands - better to stay on the wave.

Second - better to look for ways to use ultrasound to cut down on your own fluoroscopic exposure (think caudals...). As things get more bundled, it won't matter what you use, the pay will be the same.

Thirdly - if you want to be a pain physician that cares about outcomes and success, I strongly feel you should use this technology. It has been shown that using the ultrasound increases successful placement in many places (knee, hip, etc.) Also, as biologics come online - it will be IMPERATIVE to place the stuff in a very specific place. I don't have data, but I would suspect that putting the small volume substance into the tear will work a lot better than "somewhere in the vicinity". With ultrasound, I can course the supraspinatous, infraspinatous, supscapular, bicep tendons from insertion to proximal - getting very specific where I want to inject. Hip injections are so easy and very specific with ultrasound. You wouldn't think it matters with knee injections, but apparently - if you believe in science, it makes a huge difference in actually getting medicine in the joint (as opposed to blind).

I agree, you can run a well functioning, excellent pain clinic without one - but it isn't that much to add one.

I don't think the right answer is "well insurance companies have stopped paying for them so I won't get one" - rather the right thought is to see that more and more is being done with them daily, technology is improving - and every specialty is finding ways to clinically apply them - not for money, but because of utility. In fact, ultrasound will be like the chest xray - medical students will learn how to use ultrasound as part of their curriculum (already happening....). Some of the new technology is pretty cool. I signed an NDA with GE so can't tell you what I saw from them - but it is pretty cool. Point is...it isn't going away just because insurance currently is being obtuse.

WHAT THE?!

Sorry, ridiculous comment.

First off -use of ultrasound will continue to expand as technology expands - better to stay on the wave.

Second - better to look for ways to use ultrasound to cut down on your own fluoroscopic exposure (think caudals...). As things get more bundled, it won't matter what you use, the pay will be the same.

Thirdly - if you want to be a pain physician that cares about outcomes and success, I strongly feel you should use this technology. It has been shown that using the ultrasound increases successful placement in many places (knee, hip, etc.) Also, as biologics come online - it will be IMPERATIVE to place the stuff in a very specific place. I don't have data, but I would suspect that putting the small volume substance into the tear will work a lot better than "somewhere in the vicinity". With ultrasound, I can course the supraspinatous, infraspinatous, supscapular, bicep tendons from insertion to proximal - getting very specific where I want to inject. Hip injections are so easy and very specific with ultrasound. You wouldn't think it matters with knee injections, but apparently - if you believe in science, it makes a huge difference in actually getting medicine in the joint (as opposed to blind).

I agree, you can run a well functioning, excellent pain clinic without one - but it isn't that much to add one.

I don't think the right answer is "well insurance companies have stopped paying for them so I won't get one" - rather the right thought is to see that more and more is being done with them daily, technology is improving - and every specialty is finding ways to clinically apply them - not for money, but because of utility. In fact, ultrasound will be like the chest xray - medical students will learn how to use ultrasound as part of their curriculum (already happening....). Some of the new technology is pretty cool. I signed an NDA with GE so can't tell you what I saw from them - but it is pretty cool. Point is...it isn't going away just because insurance currently is being obtuse.

I have worked at a medical school for 13 years and I can promise you that there is no interest in ultrasound for musculoskeletal symptoms.

I think that it would be great, but it it is not happening. And in the current payer environment, it won't in the forseeable future. Likewise for biologics.

 

[lonelobo]

i know you can only bill roughly $34 per US... remember im not a private practice guy, but can you not deduct the capital expense and/or depreciate the US machine and have some positive tax implications?

Really? Good thing you are employed

 

[Ducttape]

well, answer the question then.

can you buy an US machine and deduct the expense of the device onto your taxes? or can you depreciate the value over 3 to 5 years and have some positive tax ramifications on the overall expense of the device?
(ASIPP fee schedule for 76942 is $34.01 for office based practice).

 

[lonelobo]

well, answer the question then.

can you buy an US machine and deduct the expense of the device onto your taxes? or can you depreciate the value over 3 to 5 years and have some positive tax ramifications on the overall expense of the device?
(ASIPP fee schedule for 76942 is $34.01 for office based practice).

Yes you could deduct it, but it would be so minimal it would not come close to the amount of time and effort you spend for the reimbursement you would get from procedure.

 

[epidural man]

I have worked at a medical school for 13 years and I can promise you that there is no interest in ultrasound for musculoskeletal symptoms.

I think that it would be great, but it it is not happening. And in the current payer environment, it won't in the forseeable future. Likewise for biologics.

Please -
STAR this post. Someone put it on their calendar to review this post in 5 years. Please, please please.

 

[bedrock]

I have worked at a medical school for 13 years and I can promise you that there is no interest in ultrasound for musculoskeletal symptoms.
.

No offense, but you must work at an undesirable medical school.

I went to a top twenty medical school, residency, and fellowship. All three use ultrasound for MSK issues.

 

[lobelsteve]

No offense, but you must work at an undesirable medical school.

I went to a top twenty medical school, residency, and fellowship. All three use ultrasound for MSK issues.

Great level of pompousness. All opinion. No fact. US has a role. Due to it's marked overuse for profit it was killed off early and can hopefully make a comeback. I think the bundling was a great idea to end a lot of the nonsense uses and overutilization. Just like vng,emg,uds,esi,mbb blind,sij, etc. Pain journal has an add for starting salary 700k in this month.

 

[bedrock]

The original post was pompous. "I work at a medical school so automatically I'm right...."

I agree that US was initially overpaid and overutilized. However, CMS overcorrected, and now many physicians won't use ultrasound because they lose money on the machine and on US cases which take a bit more time to do.

I disagree with your view on bundling. Using US for peripheral joints makes sense as those are perfect cases to do in office with portable ultrasound. A moderate reasonable unbundled payment for joint guidance makes sense. Even with shoulder and knees, you don't achieve good joint flow all the time you think you do with blind injections.

Similarly EMG could have used a modest reduction, but instead was cut far too much, and now it's hard to find good people to perform EMGs as they also need to save for their kids college fund, and many docs have stopped performing EMGs.

 

[tchoupdoc]

I didn't say that because I work at a medical school, I was right. I said I worked at a medical school.

I will clarify: if u/s is to become to MSK medicine what the CXR is to internal medicine, then it needs to be incorporated into the first four years.

If it is going to be paid for, then it is only right for the payers to see some EBM that a u/s guided block has better results than blind.

I will clarify: that research does not appear to be happening.

Somebody posted this earlier (I paraphrase): "U/S is in the 2000's what EMG was in the 80's."

 

[epidural man]

I will clarify: that research does not appear to be happening.

."

http://lmgtfy.com/?q=blind+knee+injection+vs+ultrasound+guided+injection

 

[olafa]

The is literally tons of research on US and more everyday on biologics and using US for guidance for this procedure. You may want to review some of the the current research out there and you will find most articles support image guidance, why would you not want to use it for accuracy, if available it only adds precision?
Ie LFCN been done blind for years using ASIS anatomy, but is much better w US in my opinion and check the papers also, so is intercostal block, I could go on but I won't.

 

[Stim4me]

I still perform idets, accutherm, discograms due to my wc and pi work. Us will never assist me in these procedures, nor will it help with intra discal therapeutics. Maybe it can help with routine mbb, esi, tfesi, but I doubt it. Peripheral nerve block and msk is great but what does it pay?? Can somebody tell me whether it's worth the cost in private practice. Anybody doing well with its limited application in the real world in terms of saving time, better relief and reimbursement?

 

[Ducttape]

its not all about money (time being directly related to money)...

oh wait, in PP it is.

 

[Stim4me]

its not all about money (time being directly related to money)...

oh wait, in PP it is.

The hospital administrators love making money of your hard work... Good thing you don't care too much....