forecast: tough to hard, getting harder

[jonnylingo]

I've been in practice almost 3 years. In this short time, I've only seen cuts. Some notable cuts:

• Less 99244, now it's almost entirely 99204 as of 2012 when insurers in my area followed suit with Medicare
• Less for EMG
• Less (SLASHED) Nerve Conduction Studies
• Likely less on the horizon for 76942.

To those who have seen a decade or three, has this been the general trend?
Have you ever been informed that a particular procedure/CPT is getting a significant increase, or is it always cuts? This may be impossible to answer given recent changes in healthcare.

I ask, first because this forecast looks gloomy and I need to vent, also I'm curious if the trend is up and down, or always less. If the bottom line keeps falling and we end up getting paid like a postal worker, I need to make plans to pay off these crappy loans off sooner than later.

Thoughts? I'll now go consult magic 8 ball.

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[stim4u]

but at least the poor have subsidized health care now.......
all your aforementioned changes occurred primarily during this administration. Consult codes have been around for 30 years.

 

[lobelsteve]

Sgr fix. 1/2% raise per year for 5 yrs

 

[Gauss]

devil's in the details:

• Provide positive annual payment updates of 0.5% for 5 years
• Install a Merit-Based Incentive Payment System (MIPS), which would include prospectively set performance thresholds and offer flexibility in the imposition of performance requirements that are inappropriate for some specialties
• Delay the effective date of the MIPS program 1 year, from 2017 to 2018
• Increase the MIPS funding pool and adjust the phase-in of penalty risks for those who fall in the lowest performance quartile to be capped at a maximum of 9% (as opposed to the previous 12%)
• Sustain a 5% incentive payment for physicians participating in alternative payment models
• Double original funding for technical assistance to small practices of 15 or fewer professionals
• Recognize the development of functional status quality measures as a priority

 

[powermd]

devil's in the details:

• Provide positive annual payment updates of 0.5% for 5 years
• Install a Merit-Based Incentive Payment System (MIPS), which would include prospectively set performance thresholds and offer flexibility in the imposition of performance requirements that are inappropriate for some specialties
• Delay the effective date of the MIPS program 1 year, from 2017 to 2018
• Increase the MIPS funding pool and adjust the phase-in of penalty risks for those who fall in the lowest performance quartile to be capped at a maximum of 9% (as opposed to the previous 12%)
• Sustain a 5% incentive payment for physicians participating in alternative payment models
• Double original funding for technical assistance to small practices of 15 or fewer professionals
• Recognize the development of functional status quality measures as a priority

Did anyone else get a headache trying to understand this?

 

[clubdeac]

Yeah sounds like a bunch of governmental gobbledegoo nonesense. Sounds great but doesn't mean ****

 

[stim4u]

but sgr fixes don't necessarily protect high volume specialities from the advisory board's wrath, with direct cuts to pain medicine, ophtho, etc.
pain management cuts will continue in spite of sgr fixes, correct?

 

[Disciple]

but sgr fixes don't necessarily protect high volume specialities from the advisory board's wrath, with direct cuts to pain medicine, ophtho, etc.
pain management cuts will continue in spite of sgr fixes, correct?

Latest e-mail from ASIPP states that the next step will be figuring out how the SGR repeal will be financed.

Probably with more procedure cuts, encouragement of cheap opioids and sedatives i.e. (oxycodone/Soma) and more pseudo psyche sessions provided by the Pain doctor (since they don't pay for CBT).

In all seriousness, it looks like there will be a 5 year window so they have time to figure out a payment system based on quality/performance based measures, where the top quartile gets a small bonus and the bottom quartile gets penalized.

Basically, they want to create incentive for you to make patients happy without actually doing anything.

 

[emd123]

Latest e-mail from ASIPP states that the next step will be figuring out how the SGR repeal will be financed.

Probably with more procedure cuts, encouragement of cheap opioids and sedatives i.e. (oxycodone/Soma) and more pseudo psyche sessions provided by the Pain doctor (since they don't pay for CBT).

In all seriousness, it looks like there will be a 5 year window so they have time to figure out a payment system based on quality/performance based measures, where the top quartile gets a small bonus and the bottom quartile gets penalized.

Basically, they want to create incentive for you to make patients happy without actually doing anything.

What is this yet to be determined and yet to be invented method of not paying more for "quantity" but paying more for "quality"?

Has this system of pay been invented yet?

Has anyone asked this question yet?

How the hell are they going to actually do this?

 

[hyperalgesia]

What is this yet to be determined and yet to be invented method of not paying more for "quantity" but paying more for "quality"?

Has this system of pay been invented yet?

Has anyone asked this question yet?

How the hell are they going to actually do this?

This is typical top-down, politico-bureaucratic crap. Someone needed a plan, so a plan was presented. Someone got paid. But I love the "Outcome measure" for this project. Reaching the outcome goal only requires someone to "recognize" something (as a priority).

 

[clubdeac]

This is what I'm envisioning from these bastards: Your pay will be determined by documenting preventative measures such as smoking cessation, diet and lifestyle counseling; by patient satisfaction surveys and finally by direct utilization outcomes i.e. if your intervention results in less prescription use and doctors visits you will get reimbursed otherwise you'll eat the cost of the procedure.

 

[emd123]

This is what I'm envisioning from these bastards: Your pay will be determined by documenting preventative measures such as smoking cessation, diet and lifestyle counseling; by patient satisfaction surveys and finally by direct utilization outcomes i.e. if your intervention results in less prescription use and doctors visits you will get reimbursed otherwise you'll eat the cost of the procedure.

This whole concept is so warped. It has nothing to do with being a good physician. Does anyone think these "quality measures" actually measure quality doctoring or make you a better doctor or provide better care? Reading textbooks and journals does, but this crap doesn't. Why are we marching in lockstep to this BS? The #1 darling quality measure of physicians, "patient satisfaction," has already been shown to correlate with higher costs and higher mortality. The most recent evidence shows it kills people, yet it's still government and hospital policy, as a standard, nationwide. Take a look at this article in JAMA:

http://archinte.jamanetwork.com/article.aspx?articleid=1108766

They insist we need "evidence" to get paid for what we do, yet the evidence shows their policies kill people. Does that even matter? No. The the policies just march on. Anyone who voted for this crew should seriously take a look at their politics, and re-examine their views on healthcare and government. These are the people telling us how to take care of patients now. The American public, and doctors, should be scared, very scared.

 

[SeniorWrangler]

What is this yet to be determined and yet to be invented method of not paying more for "quantity" but paying more for "quality"?

Has this system of pay been invented yet?

Has anyone asked this question yet?

How the hell are they going to actually do this?

Answers:
No, yes, and nobody knows. But it has been decided from on high that we will all be moving from fee-for-service to pay-for-performance, and every doctor will get their turn in the barrel.

My personal opinion is that pain medicine, as a sub-specialty not tightly tied to a single specialty, doesn't have of a voice in CMS or in the RUC which divides up the spoils among the different specialties. As a field of medicine which has greatly increased its volume of procedures and is therefore expensive (look up the Medicare epidural data sometime), we are an easy target.

I read some news stories a while back about the cruise ship that was abandoned due to illness, and how all the rats on board started to starve and eat each other since there was no more food on board and no way off. Well, pain medicine is a fat, slow rat on the deck of the cruise ship and it's being carved up to delay the day of reckoning of other, better-connected specialties. I don't think there's any way around this for the individual pain doc than either learning to live on less, going for a boutique practice, or moving out of pain. When all the pain specialists out there converge on the few remaining well-compensated procedures, that will be the cue for the govt to cut their reimbursement as well.

 

[emd123]

Answers:
No, yes, and nobody knows. But it has been decided from on high that we will all be moving from fee-for-service to pay-for-performance, and every doctor will get their turn in the barrel.

My personal opinion is that pain medicine, as a sub-specialty not tightly tied to a single specialty, doesn't have of a voice in CMS or in the RUC which divides up the spoils among the different specialties. As a field of medicine which has greatly increased its volume of procedures and is therefore expensive (look up the Medicare epidural data sometime), we are an easy target.

I read some news stories a while back about the cruise ship that was abandoned due to illness, and how all the rats on board started to starve and eat each other since there was no more food on board and no way off. Well, pain medicine is a fat, slow rat on the deck of the cruise ship and it's being carved up to delay the day of reckoning of other, better-connected specialties. I don't think there's any way around this for the individual pain doc than either learning to live on less, going for a boutique practice, or moving out of pain. When all the pain specialists out there converge on the few remaining well-compensated procedures, that will be the cue for the govt to cut their reimbursement as well.

Right. Like any other market or bubble it will (or has) burst, but at some point will hit a sustainable rock bottom. We don't know what that bottom is yet. I doubt pain will ever be the lowest paid medical specialty, but will likely never again be on the top end of the curve.

 

[Disciple]

Here is the issue, when the specialty hits rock bottom, if 80% of your income is from high volume E&M where you are constantly pressured to write for generic short acting opiates, personally provide pseudo CBT, and all worthwhile ancillary income streams are gone, will you quit?

The majority of current pain physicians probably will.