Big ticket items to starting a pain practice

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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?

still do IDET?

if somebody wants to monkey around with ultrasound -- sure, go ahead. it will make you a more complete pain practitioner. i dont see how it remunerates very well, unless somebody is gonna pony up for PRP/biologics. medical sense -- yes? financial sense? no

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still do IDET?

if somebody wants to monkey around with ultrasound -- sure, go ahead. it will make you a more complete pain practitioner. i dont see how it remunerates very well, unless somebody is gonna pony up for PRP/biologics. medical sense -- yes? financial sense? no
I prefer accutherm precutaneous disc decompression...on patients that are weary of spinal surgery and failed most options. And of course insurance compatibility.
 
The hospital administrators love making money of your hard work... Good thing you don't care too much....
I can think and practice safety first and remind myself that I am following my Hippocratic oath. I care more about that than $$.

And yes the hospital admin aren't always happy with that - but that's the price they pay. Cause The leaders preach safety and quality care...
 
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I can think and practice safety first and remind myself that I am following my Hippocratic oath. I care more about that than $$.

And yes the hospital admin aren't always happy with that - but that's the price they pay. Cause The leaders preach safety and quality care...

Thought he was talking to me. It is a joy practicing in the best interest of the patient without worrying about the finances of a practice or if it is time conducive. Slippery slope to VAMC lack of effort and peak inefficiency must be assessed every week though.
 
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I make $10 more on an ultrasound guided hip injection than I would with fluoro. Takes me same amount of time.
 
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I make $10 more on an ultrasound guided hip injection than I would with fluoro. Takes me same amount of time.


Q for you Jay.
which needle do you use? are you using a sterile sleeve? the few dollars it reimburses these days are quickly eaten away by sterile probe covers, sterile gel, etc etc

I'm sure you aren't using a 15 dollar echogenic needle since you wouldn't need it!
 
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.

At my institution, not a single senior medical student preparing for step II, or senior orthopedics resident preparing for boards, has ever encountered a question re: U/s guidance for peripheral joint injections.

I took my PMR MOC, not a single question on the same.

U/s guided injections might be great-- as you said, "In your opinion." And thank you for the links, there is some research going on. But not research that would make it worth the OP buying a U/S, in my opinion.

Like it or not, if the ortho's aren't behind it, OP could be looking at an expensive tie-rack.
 
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I can think and practice safety first and remind myself that I am following my Hippocratic oath. I care more about that than $$.

And yes the hospital admin aren't always happy with that - but that's the price they pay. Cause The leaders preach safety and quality care...
There are private practice pain doctors that are top physicians rated by their hospital colleagues and others, that make money, care for their patients, and have tremendous volume and respect in the community... You don't need a hospital administrator for that type of quality of care....not sure why the default "money=lack of patient care or ethics" hypothesis comes from?!.... Maybe that just helps you cope with the everyday humdrum of being an employee....
 
Q for you Jay.
which needle do you use? are you using a sterile sleeve? the few dollars it reimburses these days are quickly eaten away by sterile probe covers, sterile gel, etc etc

I'm sure you aren't using a 15 dollar echogenic needle since you wouldn't need it!

Intraarticular hip gets a 3.5" 22 gauge spinal needle. More superficial structures get a 2.5" 25 gauge needle.

I always use a sterile probe cover. Comes with sterile gel.
 
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There are private practice pain doctors that are top physicians rated by their hospital colleagues and others, that make money, care for their patients, and have tremendous volume and respect in the community... You don't need a hospital administrator for that type of quality of care....not sure why the default "money=lack of patient care or ethics" hypothesis comes from?!.... Maybe that just helps you cope with the everyday humdrum of being an employee....
it is in direct response to comments that imply that being a hospital based employee is akin to being a sheep or lemming, and that hospital employment is the root cause for all evils involving medical care. if that is not your implication, then i apologize for making an incorrect interpretation. or maybe not, based on the last line...

i would like to see whether the majority of these docs you mention are seeing the most "needy" and "vulnerable" - the medicaid and medicare patients. to have a viable practice with high volume medicaid, practicing in a manner that reduces risk - for the patient and society by reducing the tonnage volume of opioids out in the community - is a difficult financial proposition.

please show me a model of someone who does this and still makes enough money to be able to pay themselves and their staff.
 
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it is in direct response to comments that imply that being a hospital based employee is akin to being a sheep or lemming, and that hospital employment is the root cause for all evils involving medical care. if that is not your implication, then i apologize for making an incorrect interpretation. or maybe not, based on the last line...

i would like to see whether the majority of these docs you mention are seeing the most "needy" and "vulnerable" - the medicaid and medicare patients. to have a viable practice with high volume medicaid, practicing in a manner that reduces risk - for the patient and society by reducing the tonnage volume of opioids out in the community - is a difficult financial proposition.

please show me a model of someone who does this and still makes enough money to be able to pay themselves and their staff.
.
50% of my practice is Medicare. The needy medicaid patients are seen by community centers as my state does not have one pain physician in the medicaid network or accepting patients .... The hospitals don't really care for these vulnerable medicaid patients either as none of their pain guys are willing to see them long term...I don't think being hospital based ensures you are helping the poor. They are administrators, the care about the yearly booty....to assume pp doesn't take care of the needy is sophomoric at best...
 
i find it surprising that hospital pain clinics are not seeing chronic pain patients. my understanding is that any hospital that accepts medicaid from government cannot refuse outpatient medicaid patients. are you saying that pp is seeing most of these medicaid patients? that is atypical from the areas i am aware of, including a good portion of the NE US.

if these pain doctors dont want to, that is a different issue. they may have bought into the $$ as the primary goal, or realize that medicaid patients are difficult population to manage, much more "labor" intensive in multiple ways.

50% of your practice is medicare. what percentage is medicaid?
 
i find it surprising that hospital pain clinics are not seeing chronic pain patients. my understanding is that any hospital that accepts medicaid from government cannot refuse outpatient medicaid patients. are you saying that pp is seeing most of these medicaid patients? that is atypical from the areas i am aware of, including a good portion of the NE US.

if these pain doctors dont want to, that is a different issue. they may have bought into the $$ as the primary goal, or realize that medicaid patients are difficult population to manage, much more "labor" intensive in multiple ways.

50% of your practice is medicare. what percentage is medicaid?
I stopped taking medicaid years ago due to standard issues, no shows, drug seeking, litigious, etc.
What I see is a anesthesia pain guy covering a hospital pain clinic. They offer spinal injections and limited overall options to medicaid patients. Thus they fulfill their obligations and the hospital gets their state medicaid grant money... The pain guy gets sick of the dumps, moves into anesthesia, or leaves and a new grad comes in for few years.... Then allow this process to occur every 2-3 years... Aca never addressed the true medicaid issues, just dumped millions into a failing system, like the va. Not sure how this model is caring for the vulnerable medicaid community... At least our Medicare patients love our practice and care...maybe your state has a better set up
 
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i agree...

but i like to think that some of us, such as 101N, have a new focus amongst pain doctors that is willing to help the Medicaid population and is going to be better geared towards being productive in an era of ACOs. there are going to be limited overall options for medicaid patients already. their pain management cannot be successfully managed with injections, but require multiple dimensions, especially in the psychological front, to improve their condition.
 
i agree...

but i like to think that some of us, such as 101N, have a new focus amongst pain doctors that is willing to help the Medicaid population and is going to be better geared towards being productive in an era of ACOs. there are going to be limited overall options for medicaid patients already. their pain management cannot be successfully managed with injections, but require multiple dimensions, especially in the psychological front, to improve their condition.
I remember during my fellowship training in Philly the anesthesia chair and pain director arguing about the lost revenue due to medicaid patients. I got so heated, the director left....The pain group was considered the leppers and they didn't take call, worked 9-5pm and should be paid less. On top of that the hospital didn't want idets, scs trials, pumps unless approved by the executive administrators... Not sure how that is working out now with even worse reimbursement.... But money issues don't disappear in training hospitals or community hospitals, it can be even worse, that's for sure...
 
I remember during my fellowship training in Philly the anesthesia chair and pain director arguing about the lost revenue due to medicaid patients. I got so heated, the director left....The pain group was considered the leppers and they didn't take call, worked 9-5pm and should be paid less. On top of that the hospital didn't want idets, scs trials, pumps unless approved by the executive administrators... Not sure how that is working out now with even worse reimbursement.... But money issues don't disappear in training hospitals or community hospitals, it can be even worse, that's for sure...
No they don't. It's an illusion, until someone notices a specific department/facility/physician is losing money. Then, "Department shut down," and reality sets in and *poof* the illusion is gone.
 
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Efficacy? not just if your needle is there, but are the results better?

That's what I meant by clinical research.

There ARE clinical studies out there, (not just my opinion) do your own research and you will find it if you are truly interested in reading about. If you just want to argue what you perceive without reading some studies its not worth engaging. Maybe we can do you journal club style review? that would be more educational than going back and forth.
BTW - I agree with Steve. Practice whats in the best interest of my patient, outcome not incomes and not abusing the "system"
 
Ducctape the private practice vs hospital debate and subsequent optimal clinical care will never end... It's like the east coast vs west coast debate... It's a mute/moot ;) point since we all know that the east coast rocks....
 
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There ARE clinical studies out there, (not just my opinion) do your own research and you will find it if you are truly interested in reading about. If you just want to argue what you perceive without reading some studies its not worth engaging. Maybe we can do you journal club style review? that would be more educational than going back and forth.
BTW - I agree with Steve. Practice whats in the best interest of my patient, outcome not incomes and not abusing the "system"
 
I do botox for medicaid patients, stroke/CP/ SCI. I don't get paid for it in my state and with my payers.

State pays for the med, but not the botox. I do it anyway because it helps.

I would not do it if I had to pay for the botox.

do you feel strongly enough about U/s outcomes that you would you would use U/s if you weren't being paid for U/s?
 
There ARE clinical studies out there, (not just my opinion) do your own research and you will find it if you are truly interested in reading about. If you just want to argue what you perceive without reading some studies its not worth engaging. Maybe we can do you journal club style review? that would be more educational than going back and forth.
BTW - I agree with Steve. Practice whats in the best interest of my patient, outcome not incomes and not abusing the "system"

I think his point is that if you compare image guided procedures, there isn't a difference. It is a valid point. There are some studies showing that ultrasound vs fluoro is equal.

My point is that image guidance is needed - and that for many (like the intricisies of shoulder injections), fluoro isn't good enough.
 
"Image Guided" do you mean fluoro? US is also image guidance. US is great for peripheral nerve blocks / injections or some jts. I would not consider flouro superior for median n, LFCN, peroneal n, tennis elbow, occipital n, shoulder (GH jt/ biceps tendon), just to name a few. Spine stuff all gets flouro, no doubt it can be useful as second imaging tool in other injections to r/o vascular uptake, i.e. stellate. Those are the some of the examples where I see using US useful in application, and yes useful regardless of reimbursement. FYI the bundling is only for major jt since that was the one that was over utilized with review of ortho injections, it was scrutinized. I have a dystonia patient that I use EMG and US, I don't get paid for both but I like the US precision to know when I inject SCM an obliquus capitius inferior I am clear of vascular structures, EMG helps mapping and finding the motor points but doesn't give the visualization.
 
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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.
Steve send me that add!
 
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Very eloquently said
Agreed.

This thread was not about whether or not it was cool, it was about if U/s machine was a wise purchase up front.

To OP: depending on your community, you may be relying on referrals for patients. The referring docs don't care if you are slaughtering a chicken and pouring neck blood on them as long as they don't have to hear the patients talk to them about chronic pain.

buy chickens.
 
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