Biggest Pains of Pain Practice

[Nonphysiologic]

Hey all,

Now that I am a couple years out of fellowship and in private practice I feel like my idealized view of pain medicine is not more realistic and somewhat more cynical.

I was having a discussion with a colleague of mine who recently just graduated fellowship and is excited to start a new job and I was going over some of the realities and biggest points of pain for the pain provider.

I was hoping to gain some insight into some other points of frustration or inefficiency other providers might have around the country and that are a few years senior to me. Itd be helpful to be as specific as possible. Ill start:

1. I find it difficult inheriting patients in heavy opioid dosing. I don't think its enough to simply start cutting down patients as there are reports of patients committing suicide after their opioids have been cut off and some doctors have been scolded by the medical boards. I think a lot of the people making decisions on reprimanding physicians either aren't physicians or not pain physicians and see the kind of patients we see.
2. I want patients to take control of their health but many are resigned to just taking their opioids. A lot of patients simply come for a refill of their meds and don't want a discussion on education and sometimes patients will get procedures done without really knowing or caring if they work because they think itll allow them to continue getting their meds.
3. A lot of times in private practice the reimbursement is so low for clinic visits that you have to have an extremely busy schedule to be productive. This is not conducive to providing proper patient education, physical exam, as well as psychiatric screening.
4. There are a lot of middle men in the personal injury/workman's comp system and a lot of ill intentioned people (patients, doctors, lawyers, third party marketers). The problem is its usually the physician that takes most of the risk involved in these cases. Furthermore we are subjugated to all these stark law violations so sometimes I've seen physicians get reprimanded for violating stark law without even necessarily trying to do anything wrong.
5. The patients we are seeing, especially new patients, have a very complicated history, require a ton of screening, and often times requires a psych evaluation and monitoring. This goes for follow ups too. The PAPERWORK required for documentation of all this is immense and so the work flow can get really disrupted or you have to do the note later which fuels physician burnout. Furthermore the reimbursement simply isn't enough to cover that visit, medical staff, rent, marketing, insurance, etc.
6. I don't like how these personal injury attorneys try to dictate how a physician practices. Although I never succumb to it its just an annoying part of my job because personal injury isn't something I can ignore.

Any other specific problem points? I think if I had to summarize what causes me the most problems its risk to the physician, to the patient, and interference workflow.

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[Ferrismonk]

I would add prior authorizations and insurance denials as my second biggest cause of burnout (opioids being my first).

 

[Nonphysiologic]

Yes I agree.
Other things that just came to my head:

1. How long procedures take to get authorized in the WC system and HMO
2. The pettiness of documentation required to get things authorized in WC and HMO
3. The lack of availability of good addiction specialists or psychologists in my area to be a part of a comprehensive plan to manage the chronic pain.
4. Patients going to physical therapy and not continuing their home exercise programs and no way of assessing it.
5. Any kind of disability forms. Its hard to say how much time someone will need off and also what specific tasks of the job they can or cannot do. These forms take time to fill as well. I understand that some docs just have the PCP or an occupational medicine specialist fill it out but a lot of my patients don't have time to go see a specialist or simply dont have one in the area. Also, a lot of my patients the PCP diverts the forms to be filled out by us.
6. Managing expectations of patients and getting them to "buy in" with the comprehensive approach to pain management.

 

[Ronin1]

Don’t do WC and PI and your life improves dramatically

 

[Ducttape]

points 1, 2, 3 and 5: don't see these patients if you are private practice. they take too long. they don't pay well. just refuse them...

tell them to go to an academic center or a hospital based pain clinic that can see them, and can still financially survive seeing them.

at least, until drusso manages to eliminate SOS.



points 4 and 6 - don't take PI. try not to take WC.

 

[TheLoneWolf]

Forgoing the temptation to have NPs and PAs do all evals and you live are in fluoro suite as the local block shop while they write narcs under your name and you sign notes at the end of the day. Those scripts likely filled by the time you read those notes and evals. Only seeing patients at time of procedure. Any complication could be quite problematic as there was no real patient physician relationship prior to injection.

Academic pain and PP pain are 2 different worlds and arguably have different patient populations.

PP has a long history of unofficial pills for shots model. Throw in some neuromodulation which I think would be ill advised without intensive prior PT and psych. These are largely nonviable in a lean PP model but possible in large PP groups. Hard to survive not writing unnecessary scripts when your clinic owner, administrator, referral base expects you to continue or increase opioids. Often times little say in how you can dictate your care other than leaving. Overhead. Ancillary services. After hours meetings to meet referring surgeons. Spending outside hours marketing services. Worrying about wrvus, compensation cuts, the DEA and finding time to go to conferences and learn new procedures.

Possible to practice purely interventional PP but unlikely to open for yourself in major metropolitan with overcrowding, overhead and other practices that will prescribe opiates in addition to procedures. May be a reality in suburban or rural areas.

Academic interventional pain usually weeds out heavy opioid users and those seeking long term opiate treatment. Not incentivized to stim, implant or inject. Referral base has expectation but relatively sheltered to make the decisions you want. Usually salaried and have to teach and supervise. Lots of patients who some PP had exhausted procedures and insurance would come to our clinic during fellowship on high dose opiates refusing wean or non opiate management.

Fellows I graduated with routinely writing narcs out in PP. Some explicitly told they have to get x stop number, medical marijuana prescribing. A dude who does about 40 procedures a day as a fresh grad 5 days per week. Runs between 2 procedure rooms. Another who joined large group of orthos and nsg who has freedom to practice how he pleases and is conservative overall but has to pay overhead of little over 50% of total billings.


Not against proper prescribing of opiates based off of CDC guidelines with close follow up but lots of what I had seen in PP is outside of that. Most I seen have no real indication for being on opiates in the first place

Avoid WC and PI.

Field is awesome but lot of frustration with prior auths, dealing with insurance, long documentation, medicolegal risks, patient and referring physician expectation. Heavy marketing of new devices based on weak data. Currently the pain world rewards higher volume procedure driven practice though movement to ACO or managed care model may change this.

 

[Nonphysiologic]

Yeah I'm not sure why we take so much HMO and WC. When I looked into the reimbursement, it isn't much better if at all than Medicare. Especially with workman's comp the paper work and frustration makes it simply not worth it. After looking at it Medicare reimbursement is actually higher than PPO for a new patient but the epidurals pay a little more. I feel like having a primarily medicare and PPO practice with NO WC and PI is reasonable. The thing with PI and WC and even HMO is you need to add more staff to follow up with authorizations, make sure documentation is appropriate, coordinate with lawyers etc.

I think you can have a pretty lean practice with simply PPO and Medicare. What do you guys think?

 

[deleted993114]

Hey all,

Now that I am a couple years out of fellowship and in private practice I feel like my idealized view of pain medicine is not more realistic and somewhat more cynical.

I was having a discussion with a colleague of mine who recently just graduated fellowship and is excited to start a new job and I was going over some of the realities and biggest points of pain for the pain provider.

I was hoping to gain some insight into some other points of frustration or inefficiency other providers might have around the country and that are a few years senior to me. Itd be helpful to be as specific as possible. Ill start:

1. I find it difficult inheriting patients in heavy opioid dosing. I don't think its enough to simply start cutting down patients as there are reports of patients committing suicide after their opioids have been cut off and some doctors have been scolded by the medical boards. I think a lot of the people making decisions on reprimanding physicians either aren't physicians or not pain physicians and see the kind of patients we see.
2. I want patients to take control of their health but many are resigned to just taking their opioids. A lot of patients simply come for a refill of their meds and don't want a discussion on education and sometimes patients will get procedures done without really knowing or caring if they work because they think itll allow them to continue getting their meds.
3. A lot of times in private practice the reimbursement is so low for clinic visits that you have to have an extremely busy schedule to be productive. This is not conducive to providing proper patient education, physical exam, as well as psychiatric screening.
4. There are a lot of middle men in the personal injury/workman's comp system and a lot of ill intentioned people (patients, doctors, lawyers, third party marketers). The problem is its usually the physician that takes most of the risk involved in these cases. Furthermore we are subjugated to all these stark law violations so sometimes I've seen physicians get reprimanded for violating stark law without even necessarily trying to do anything wrong.
5. The patients we are seeing, especially new patients, have a very complicated history, require a ton of screening, and often times requires a psych evaluation and monitoring. This goes for follow ups too. The PAPERWORK required for documentation of all this is immense and so the work flow can get really disrupted or you have to do the note later which fuels physician burnout. Furthermore the reimbursement simply isn't enough to cover that visit, medical staff, rent, marketing, insurance, etc.
6. I don't like how these personal injury attorneys try to dictate how a physician practices. Although I never succumb to it its just an annoying part of my job because personal injury isn't something I can ignore.

Any other specific problem points? I think if I had to summarize what causes me the most problems its risk to the physician, to the patient, and interference workflow.

Welcome to reality.

It is still an interesting field.

1. Pain meds
a. just say you adhere to the CDC guidelines: 90 mg or 50mg with benzos
b. have NPs see all med patients
c. don't prescribe narcotics
d. prescreen the med management patients and don't take them

2. Take control- that will never happen. You are viewing the average person through your own prism of the world.

3. Reimbursement
a. have NPs see all med management pts.
b. Manage your schedule so that you have no more than 50% medicare and less than 5% medicaid
c. work faster- new grads can't work fast enough
d. see more patients
e. move to an area with a better payer mix
f. add IMEs to your practice. At $2-$3K per pop, it can add up

4. You can refuse work comp if you want .Those patients never get better and take a lot of time. Just look at the efficacy of stim in work comp (less than 5%)- that should tell you everything you need to know.

5. "Complicated" = Medicaid. Medicaid pays next to nothing and the patients always "no show". Again, cap your monthly number of Medicaid patients and only take them from your otherwise "good" referral sources. You should not be taking more than 10 minutes with each patient. Allow each Medicaid patient one "no show" before dismissing. I, as a patient, have never had a "no show" in my life for a doctor's appointment (and God knows, with two rounds of different cancers, I have had hundreds of them).

With Disability forms:
a. charge for that
b. Have your NPs do it
c. You determine work restrictions by an FCE. You cannot possibly measure all the things that can be done in an FCE.
d. Have lists of "generic" restrictions
e. Don't allow those patients to schedule more than once every three months- that is plenty.

6. Personal injury- Do what you think or don't take it. If the lawyers don't like how you practice, tell them to send the people elsewhere. If you have good results, they won't complain.

In many instances, the higher the cost of medical costs, the more the lawyers make. They shouldn't bitch. If a patient has been "coached" by an attorney, tell them to go to hell.


Life is what you make it. If you don't like your situation, change it. Don't sit there and be miserable.

Options:

1. Do insurance reviews
2. Work as staff at a university
3. Do IME exams
4. Join a spine group and just be their pain guy- they usually have TONS of "teed up" procedures they want done.
5. Be a hospital employee where you get paid, regardless of the payer mix
6. Go back to OR anesthesia- it is easy, but call can be tiring.

 

[deleted993114]

Yeah I'm not sure why we take so much HMO and WC. When I looked into the reimbursement, it isn't much better if at all than Medicare. Especially with workman's comp the paper work and frustration makes it simply not worth it. After looking at it Medicare reimbursement is actually higher than PPO for a new patient but the epidurals pay a little more. I feel like having a primarily medicare and PPO practice with NO WC and PI is reasonable. The thing with PI and WC and even HMO is you need to add more staff to follow up with authorizations, make sure documentation is appropriate, coordinate with lawyers etc.

I think you can have a pretty lean practice with simply PPO and Medicare. What do you guys think?

You are in a TERRIBLE payer environment. I have usually had medicare rates at 1/5th that of private insurance.

Hints: The best reimbursement is in the Midwest and southeast (sans Florida). You are not in a good payer environment. At medicare rates, it can be awfully tough to make a buck. There are other good "pockets" around the country, but those two regions in general are the best. If you go to Siberia (North Dakota, Northern MN, ect) the pay is very good, but you have to live in Siberia.

You can have my job if you want- it pays very well and is easy. I think I might be going back to academics.

 

[Nonphysiologic]

Just to be clear I'm not unhappy with my job. I'm looking to see what are problem areas for most pain providers throughout the nation. Im trying to think of solutions in how to remedy them.

 

[Ronin1]

decide what you want or don’t want to see. For example I don’t see headache patients. Pre screen all new patients. Check pmp. I don’t accept any pts for medication management either. Every new patient into the clinic I review and approve. Might be difficult if you are just starting out but be firm and build a practice that you want to be proud of

 

[deleted993114]

Just to be clear I'm not unhappy with my job. I'm looking to see what are problem areas for most pain providers throughout the nation. Im trying to think of solutions in how to remedy them.

I just listed a bunch of solutions for you above.

 

[geauxg8rs]

I would add prior authorizations and insurance denials as my second biggest cause of burnout (opioids being my first).

Add patient lack of understanding of the situation.

I didn’t pick your crappy Medicare advantage plan that wants an auth for everything.

That’s why no procedure until next week.

I prescribe you the medication that i think is best for you, your crappy insurance doesn’t want to cover it. I do you a favor by submitting paperwork to the insurance company so they will cover it for you. If it takes three days for them to approve it, again it is not my fault. I am doing you a favor.

Patients think we should spend all day doing prior auths, peer to peers. My favorite now is the patient calls the insurance Company to check on the status of the mri/injection/med and they tell the patient that they will approve the desired service if “your doctor will just talk to us.” Poor helpless insurance company wants to approve it, and they are diligently waiting by the phone.
Such crap

 

[drpainfree]

points 1, 2, 3 and 5: don't see these patients if you are private practice. they take too long. they don't pay well. just refuse them...

tell them to go to an academic center or a hospital based pain clinic that can see them, and can still financially survive seeing them.

at least, until drusso manages to eliminate SOS.



points 4 and 6 - don't take PI. try not to take WC.

basically, you just told the guy/gal to close his/her office.

 

[Ducttape]

What I’m suggesting he do immediately if he is PP is to control the incoming patients and essentially eliminate most of the poor/non paying patients. Before it’s too late...

 

[deleted993114]

decide what you want or don’t want to see. For example I don’t see headache patients. Pre screen all new patients. Check pmp. I don’t accept any pts for medication management either. Every new patient into the clinic I review and approve. Might be difficult if you are just starting out but be firm and build a practice that you want to be proud of

Headache is fun for me. The new CRGP drugs are pretty cool. In addition, there are a TON of cervicogenic headaches that are called "migraine" that you can help with. Botox works well for many headaches and sphenopalantine rf works well for clusters, refractory V2 Tics, and atypical fascial pain.

I pick up a bunch of cervical rf in headache patients that have concurrent neck pain.

If you are in a direct fee for service, private practice setting, the reality of pain management there is the economics. In those situations, you have to manage your patient population or risk going belly up. That is why I left that style of practice, as I don't want to discriminate based on payer mix or presenting pathology. You just have to make the choices that work best for your practice and your conscience.