future of PRIVATE pain management practice

[drpainfree]

There's several ongoing threads in anesthesia forum about the future of anesthesiologists in the face of ACO, CRNAs threats, etc, etc.

What do you think will happen to the PRIVATE pain management practices 5-10 years down the road, or 10 years beyond? Will PRIVATE pain management practices be able to survive 10 years down the road?

My take on this is NO.

Obviously reimbursement from medicare (and private carriers) will continue to come down. Financially it will get tougher and tougher to remain profitable to run a PRIVATE clinic.

More importantly, pain management specialty relies heavily on referrals, whether PCP or specialist (spine surgeons, i.e.). With the ever-encroaching CMS and inevitable progression towards ACO model (national-wide HMO), referrals will be dried out and reimbursement will be choked. In the process of forming ACO, local hospitals and large medical group will either buy out PRIVATE clinics with pennies on the dollar or they will simply squeeze you out of business by choking your referrals because all your referral sources will be part of ACO.

The difference between ACO and HMO that failed miserably in 80s and 90s is this time ACO is centered around hospitals as opposed to HMO is centered around IPA at least from physician's perspective. The hospitals will gobble up private practices for pure financial profitability. IPA back then at least is consisted of physicians and had no interest in buying up private practices.

Are we doomed to become the employees of Kaiser or academia, then gradually be replaced by NP/PA?

---

Members don't see this ad.

 

[mille125]

There's several ongoing threads in anesthesia forum about the future of anesthesiologists in the face of ACO, CRNAs threats, etc, etc.

What do you think will happen to the PRIVATE pain management practices 5-10 years down the road, or 10 years beyond? Will PRIVATE pain management practices be able to survive 10 years down the road?

My take on this is NO.

Obviously reimbursement from medicare (and private carriers) will continue to come down. Financially it will get tougher and tougher to remain profitable to run a PRIVATE clinic.

More importantly, pain management specialty relies heavily on referrals, whether PCP or specialist (spine surgeons, i.e.). With the ever-encroaching CMS and inevitable progression towards ACO model (national-wide HMO), referrals will be dried out and reimbursement will be choked. In the process of forming ACO, local hospitals and large medical group will either buy out PRIVATE clinics with pennies on the dollar or they will simply squeeze you out of business by choking your referrals because all your referral sources will be part of ACO.

The difference between ACO and HMO that failed miserably in 80s and 90s is this time ACO is centered around hospitals as opposed to HMO is centered around IPA at least from physician's perspective. The hospitals will gobble up private practices for pure financial profitability. IPA back then at least is consisted of physicians and had no interest in buying up private practices.

Are we doomed to become the employees of Kaiser or academia, then gradually be replaced by NP/PA?

If everything that you said is right (and we would all agree that it is speculative), what would stop the pain physician from joining the ACO that your referral sources join? Why wouldnt you do this?

 

[drpainfree]

a couple of reasons,

- It might not be an option at all. If hospitals are running ACO (very likely will) instead of medical group, they will likely buy out your practice from the onset. So you don't "join" ACO, you are "bought out" and become the employee of the hospital. Look at Cleveland, there are only two healthcare systems in town, Cleveland Clinic and University Hospital (of Case Western Reserve). All the hospitals and private practice clinics have been gobbled up by either of these two organizations. You are employed either by the Clinic or the UH, or not at all.

- You might not want to be part of the ACO. Just like most of us don't want to be part of HMO, at least not exclusively.

- ACO might not want you to be on their panels. Just like HMO has panel restriction because it only wants so many specialists on their panels, especially procedure-oriented specialists (such as pain management)

 

[mille125]

a couple of reasons,

- It might not be an option at all. If hospitals are running ACO (very likely will) instead of medical group, they will likely buy out your practice from the onset. So you don't "join" ACO, you are "bought out" and become the employee of the hospital. Look at Cleveland, there are only two healthcare systems in town, Cleveland Clinic and University Hospital (of Case Western Reserve). All the hospitals and private practice clinics have been gobbled up by either of these two organizations. You are employed either by the Clinic or the UH, or not at all.

- You might not want to be part of the ACO. Just like most of us don't want to be part of HMO, at least not exclusively.

- ACO might not want you to be on their panels. Just like HMO has panel restriction because it only wants so many specialists on their panels, especially procedure-oriented specialists (such as pain management)

The jury is still out on how the ACO approach is going to go. All of the ones in my area have been all inclusive and have tried to get docs of all specialties.

 

[drpainfree]

I think you are leaning towards the more optimistic side assuming ACO might not be feasible, and ACO will be private-practice-friendly...I wish both would turn out to be true.

On the other hand, as we have seen from what's happening in some major markets and the advocacy of Cleveland Clinic/Mayo Clinic/Kaiser model, I would be surprised if it's not going to be the model of the future for cost containment. After all, I don't think too many people argue Kaiser system is not cost-effective. Obviously, I wouldn't never take Kaiser insurance or receive Kaiser healthcare even if my wife works there and my family can get them for free. The quality of care sucks (in a subtle way only known to small segments of populations, such as physicians).

Obviously if you already have a mature practice, you just have to continue the operation and wait to see what's going to happen. For some of us who started private practice not too long ago (<2, 3 yrs) and is still gradually building and growing the practice and will have to do this for the next 5 years, the question become: is it going to survive in 10 years? if not is it still worth it?

 

[mille125]

I think you are leaning towards the more optimistic side assuming ACO might not be feasible, and ACO will be private-practice-friendly...I wish both would turn out to be true.

On the other hand, as we have seen from what's happening in some major markets and the advocacy of Cleveland Clinic/Mayo Clinic/Kaiser model, I would be surprised if it's not going to be the model of the future for cost containment. After all, I don't think too many people argue Kaiser system is not cost-effective. Obviously, I wouldn't never take Kaiser insurance or receive Kaiser healthcare even if my wife works there and my family can get them for free. The quality of care sucks (in a subtle way only known to small segments of populations, such as physicians).

Obviously if you already have a mature practice, you just have to continue the operation and wait to see what's going to happen. For some of us who started private practice not too long ago (<2, 3 yrs) and is still gradually building and growing the practice and will have to do this for the next 5 years, the question become: is it going to survive in 10 years? if not is it still worth it?

You mentioned anesthesiology. When I was in med school anesthesiology tanked. Prestigous programs did not fill. There are fewer residents. Attending hiring decreased. The thought was that new managed care standards would decrease the number of surgeries.

What actually happened? These lean years caused a shortage and salaries increase. Yes, you hear grumbling in the anesthesiology forums. But are they better off now than 10 or 15 years ago. I would say yes.

Doom and gloom is always in the forecast. You have to position yourself to be better. In the current ACO issue, talk with your PCP's. They will see that you help their patients and that you are a valuable part of the team. They will not want to manage chronic pain by themselves and will insist that you be a part......if you want it. If you dont want it, then you can't really cry about any adverse effects.

 

[drpainfree]

I would argue this time around it's very different.

- the country (fed) is broke in general and medicare is broke
- this time we have obamacare, a nationalized effort to bring down the cost
- this time we're not talking about anesthesia, or pain management, we're talking about the cost containment in all aspects of medicine. one of major mechanisms to achieve this (at least in obama's mind) is to eventually replace physicians with cheaper providers, whether through ACO or eventually nationalized healthcare.
- last time we don't have government subsidizing training of NP/PA
- last time it's IPA as the center of HMO, who might not be the best businessmen to run a successful business. This time you're talking about hospital administrators who are professional businessmen to run the ACO.

I have not be pessimistic about the future of the country as a declining powerhouse despite the overall economical recession. But, I felt the medicine in general in this country is going down, financially and professionally, all specialties included.

Time to think about alternatives to diversify

You mentioned anesthesiology. When I was in med school anesthesiology tanked. Prestigous programs did not fill. There are fewer residents. Attending hiring decreased. The thought was that new managed care standards would decrease the number of surgeries.

What actually happened? These lean years caused a shortage and salaries increase. Yes, you hear grumbling in the anesthesiology forums. But are they better off now than 10 or 15 years ago. I would say yes.

Doom and gloom is always in the forecast. You have to position yourself to be better. In the current ACO issue, talk with your PCP's. They will see that you help their patients and that you are a valuable part of the team. They will not want to manage chronic pain by themselves and will insist that you be a part......if you want it. If you dont want it, then you can't really cry about any adverse effects.

 

[Ligament]

The future of medicine and the country is gloomy with this socialist president in office.

He will not be in office much longer.

After that, everything will change again. Obamacare will kill millions of baby boomers, decreasing medicare costs, and Obamacare will be reversed after he leaves office.

Just gotta hang in there until he is gone.

 

[PinchandBurn]

If everything that you said is right (and we would all agree that it is speculative), what would stop the pain physician from joining the ACO that your referral sources join? Why wouldnt you do this?

Problem is that all the docs will be hospital employees and potentially "cap" our income. On the flip side, you woudl get all the in network referrals.

 

[drpainfree]

Problem is that all the docs will be hospital employees and potentially "cap" our income. On the flip side, you woudl get all the in network referrals.

in Kaiser system, a physician is just like another worker, probably worse because nurses actually have union to protect them. It's not only a financial issue, but also a professional one.

I personally think in 10 years, private practice will struggle to survive.

 

[SSdoc33]

The future of medicine and the country is gloomy with this socialist president in office.

He will not be in office much longer.

After that, everything will change again. Obamacare will kill millions of baby boomers, decreasing medicare costs, and Obamacare will be reversed after he leaves office.

Just gotta hang in there until he is gone.

lets be clear. the future of medicine in this country is not gloomy. the future of us GETTING PAID is gloomy. socialized medicine works quite well in many many countries, and overall, we do a crappy job with our public health. im not saying obamacare is the right way to approach things, but dont confuse whats best for the country with whats best for your bank account.

ligament, you wanna make a little gentleman's bet on who is in the white house jan 21st, 2013? the rick perry, michelle bachman, mitt romney choice is not exactly lighting the world on fire.

 

[PMR 4 MSK]

Medicine will continue to be practiced, and many docs will migrate towards whatever aspect grants them the highest paycheck. Even in socialized countries, like England, docs make highly variable salaries, with some making $300 - 400K equivalent, others making $50K. There are countries where docs make $500/month - $6K per year.

Most countries subsidize medical education and residents don't come out into practice $300K in debt. That would be a big start - medical school is free. Instead, there have been ideas proposed to government that we do the reverse and have residents pay tuition and not draw a salary.

Pain will continue to be a field, but won't pay like it does now. When an ESI pays no more than an office visit, it's going to be amazing how many docs suddenly proclaim that ESI's don't help as much as we thought they did.

 

[Tenesma]

1) ssdoc33: how does socialized medicine work quite well in many countries? and if it works so well there, why do they come here for medical care? we shouldn't confuse efficacy of our health care with accessability... i think our medical care is far superior, but our access to care sucks...

2) mille: I am worried about ACOs... interventionalists are doomed to a certain degree, as ACOs are incentivized to minimize any type of costly care - and if you are within an ACO, and you are causing the ACO to loose money on their bundled payments, you will quickly get side-lined because the PCPs will feel the pinch first as they won't be able to split the benefits of the "cost-savings" of your care...

 

[Tenesma]

PMR 4 MSK - you realize that the professional fee for a Cervical Inter-laminar ESI is quite close to a 99214???

 

[mille125]

1) ssdoc33: how does socialized medicine work quite well in many countries? and if it works so well there, why do they come here for medical care? we shouldn't confuse efficacy of our health care with accessability... i think our medical care is far superior, but our access to care sucks...

2) mille: I am worried about ACOs... interventionalists are doomed to a certain degree, as ACOs are incentivized to minimize any type of costly care - and if you are within an ACO, and you are causing the ACO to loose money on their bundled payments, you will quickly get side-lined because the PCPs will feel the pinch first as they won't be able to split the benefits of the "cost-savings" of your care...

Assuming that their are any benefits or cost savings......

 

[Tenesma]

well the concept would be that Medicare pays a bundled service to ACO - with the goal of shared-savings versus shared-losses... ie: Medicare pays $1000 for non-specific low back pain to be bundled amongst all physicians, all PT, all imaging across that ACO. So why would PCP refer that patient to PT/Pain doc, if they can rx vico/flexeril/nsaid and have pt f/u in 6 months... if the actual care of PCP is about $100, then the ACO gets to "share" in the $1,000. If the care involves imaging, PT, pain doc, and ends up costing $4000, then the ACO loses $3k....

 

[drpainfree]

well the concept would be that Medicare pays a bundled service to ACO - with the goal of shared-savings versus shared-losses... ie: Medicare pays $1000 for non-specific low back pain to be bundled amongst all physicians, all PT, all imaging across that ACO. So why would PCP refer that patient to PT/Pain doc, if they can rx vico/flexeril/nsaid and have pt f/u in 6 months... if the actual care of PCP is about $100, then the ACO gets to "share" in the $1,000. If the care involves imaging, PT, pain doc, and ends up costing $4000, then the ACO loses $3k....

good example! So what's your backup, Tenesma?

I'm debating if I should continue to build my clinic for next 5 years only to find it's not survivable in 10 years, being either squeezed out of referrals or bought out with whatever hospitals want to pay.

 

[Tenesma]

best ways of surviving? gearing up for cash based practice - that will only work if

1) in a large metropolitan area you are the chairman of the dept at a major well respected university and run a cash-based practice on the side - most depts won't allow that though.
2) develop a reputation for being an expert in a sub-field where few dare (ie: rectal pain)
3) work in a wealth community where patients are willing to be snobbish enough to call you their doctor...

 

[drpainfree]

best ways of surviving? gearing up for cash based practice - that will only work if

1) in a large metropolitan area you are the chairman of the dept at a major well respected university and run a cash-based practice on the side - most depts won't allow that though.
2) develop a reputation for being an expert in a sub-field where few dare (ie: rectal pain)
3) work in a wealth community where patients are willing to be snobbish enough to call you their doctor...

cash based pain management...hmmm, we talked about this topic somewhere. How do you establish and run this clinic without being viewed as pill mill? of course, you can say i don't prescribe opioids. how are you getting your patients then when every medicare patient is on ACO plan?

 

[Tenesma]

i don't have cash based currently -

but I do have medicare patients who pay cash for
1) chiropractic
2) acupuncture
3) massage
4) homeopathic medications...
5) certain treatments that are perceived superior in delivery/outcome (although that is questionable) - plastic surgery, laser spine surgery, minimally invasive hip replacements, etc..

 

[bedrock]

i don't have cash based currently -

but I do have medicare patients who pay cash for
1) chiropractic
2) acupuncture
3) massage
4) homeopathic medications...
5) certain treatments that are perceived superior in delivery/outcome (although that is questionable) - plastic surgery, laser spine surgery, minimally invasive hip replacements, etc..

I've thought about creating a spine wellness center, with PT, acupuncture, massage, +/- chiro, at some point in the future when it no longer makes financial sense to spend the majority of my time to seeing patients, but to shift most of my time to running such a center and collecting the ancillary income......

 

[101N]

i've thought about creating a spine wellness center, with pt, acupuncture, massage, +/- chiro, at some point in the future when it no longer makes financial sense to spend the majority of my time to seeing patients, but to shift most of my time to running such a center and collecting the ancillary income......

1+

 

[painstop]

I've thought about creating a spine wellness center, with PT, acupuncture, massage, +/- chiro, at some point in the future when it no longer makes financial sense to spend the majority of my time to seeing patients, but to shift most of my time to running such a center and collecting the ancillary income......

Would there be any Stark violations referring to a chiropractor you employ? Or are you not including Medicare patients?

 

[SSdoc33]

1) ssdoc33: how does socialized medicine work quite well in many countries? and if it works so well there, why do they come here for medical care? we shouldn't confuse efficacy of our health care with accessability... i think our medical care is far superior, but our access to care sucks...

QUOTE]


i said we do a crappy job with out public health. i dont see how this can be legitimately argued. any metric you want to use: life expectancy, infant mortality, obesity, diabetes, etc, we are well befing comparable industrialized countries.

people travel here for medical care because we definitely do a lot of things well. i think specialty care in the states may be the best in the world. unfortunately, in the grand scheme of things, specialty care is not as important as primary care.

access IS a problem, but that is part of public health.

it works "quite well" because you dont see japanese or germans or norwegians spending as much on health care for such poor PUBLIC health.

 

[SSdoc33]

I've thought about creating a spine wellness center, with PT, acupuncture, massage, +/- chiro, at some point in the future when it no longer makes financial sense to spend the majority of my time to seeing patients, but to shift most of my time to running such a center and collecting the ancillary income......

god help us all of it comes to this.

 

[PMR 4 MSK]

PMR 4 MSK - you realize that the professional fee for a Cervical Inter-laminar ESI is quite close to a 99214???

For medicare, yes. When no one is paying more than that, people will stop doing them as much. I get 3-5X MC for most insurances, WC 8-10X.

I've thought about creating a spine wellness center, with PT, acupuncture, massage, +/- chiro, at some point in the future when it no longer makes financial sense to spend the majority of my time to seeing patients, but to shift most of my time to running such a center and collecting the ancillary income......

We have several of those in town. They live on WC, PI and cash, although some take insurance, but not Medicare. Everyone gets the DRX9000 5x/week, chiropractic 4-5 areas 5x/week and PT 3-5 units 3-5x/week. After 8-12 weeks, they go down to 2-3x/wk. I've seen totals bills from them for PI cases exceeding $100K/month.

They have MD figureheads so they can advertise under "physicians" in the yellow pages and for insurance. The chiros are running the shops and are often the principle owners. They usually have agreements with local freestanding MRI businesses to make money of those as well.

 

[bedrock]

For medicare, yes. When no one is paying more than that, people will stop doing them as much. I get 3-5X MC for most insurances, WC 8-10X.



We have several of those in town. They live on WC, PI and cash, although some take insurance, but not Medicare. Everyone gets the DRX9000 5x/week, chiropractic 4-5 areas 5x/week and PT 3-5 units 3-5x/week. After 8-12 weeks, they go down to 2-3x/wk. I've seen totals bills from them for PI cases exceeding $100K/month.

They have MD figureheads so they can advertise under "physicians" in the yellow pages and for insurance. The chiros are running the shops and are often the principle owners. They usually have agreements with local freestanding MRI businesses to make money of those as well.

those sound like bull**** operations. I'm talking about a real spine wellness center, where you use PT when it's indicated, massage when indicated, acupuncture when indicated etc, its a holistic approach, not about raping the PI and WC systems.

I get 3-5X MC for most insurances, WC 8-10X.

really? most insurance companies pay you 3-5x MC so a professional fee of $750-$1250 for a single cervical ESI?

If so, I need to move to indiana/illinois? to practice.

 

[Jcm800]

i am indiana, and i get 1.2, 1.3 x medicare for commercial payers...

those sound like bull**** operations. I'm talking about a real spine wellness center, where you use PT when it's indicated, massage when indicated, acupuncture when indicated etc, its a holistic approach, not about raping the PI and WC systems.




really? most insurance companies pay you 3-5x MC so a professional fee of $750-$1250 for a single cervical ESI?

If so, I need to move to indiana/illinois? to practice.

 

[PMR 4 MSK]

really? most insurance companies pay you 3-5x MC so a professional fee of $750-$1250 for a single cervical ESI?

If so, I need to move to indiana/illinois? to practice.

Yes, my clinic is the 800# gorilla in town, and our CEO is a bulldog of a negotiator.

I don't have in-office fluoro, I get facility fee schedule payment from MC, so mine's around 1/2 what you'd get in the clinic. However, I looked at the last CESI I did that has been paid, insurance allowed around 9X what MC pays me for the same procedure, or close to 5X non-facility MC allowable. Another one before that with a separate insurance was about 6x my MC payment. That's just my professional fees being paid. I do not have access to how much the ASC gets paid for that. I'll bet WC pays more than that, but I haven't gone far enough back in my schedule to see.

I'd post the exact #'s, but someone would undoubtedly call the collusion police on SDN and remove the post.

This, combined with phenomenally low overhead, is why I work 28 - 32 hours per week, but still make the money of docs working 50 hours per week.

Work smarter my friends, not harder.

 

[SSdoc33]

Yes, my clinic is the 800# gorilla in town, and our CEO is a bulldog of a negotiator.

I don't have in-office fluoro, I get facility fee schedule payment from MC, so mine's around 1/2 what you'd get in the clinic. However, I looked at the last CESI I did that has been paid, insurance allowed around 9X what MC pays me for the same procedure, or close to 5X non-facility MC allowable. Another one before that with a separate insurance was about 6x my MC payment. That's just my professional fees being paid. I do not have access to how much the ASC gets paid for that. I'll bet WC pays more than that, but I haven't gone far enough back in my schedule to see.

I'd post the exact #'s, but someone would undoubtedly call the collusion police on SDN and remove the post.

This, combined with phenomenally low overhead, is why I work 28 - 32 hours per week, but still make the money of docs working 50 hours per week.

Work smarter my friends, not harder.

and the direct line for your HR department is?????

 

[Tenesma]

PMR --- your numbers sound like you are out-of-network w/ those insurers...

 

[Jcm800]

intersting. i work 50 hours a week, and make what someone who works 25 hours a week, haha

Yes, my clinic is the 800# gorilla in town, and our CEO is a bulldog of a negotiator.

I don't have in-office fluoro, I get facility fee schedule payment from MC, so mine's around 1/2 what you'd get in the clinic. However, I looked at the last CESI I did that has been paid, insurance allowed around 9X what MC pays me for the same procedure, or close to 5X non-facility MC allowable. Another one before that with a separate insurance was about 6x my MC payment. That's just my professional fees being paid. I do not have access to how much the ASC gets paid for that. I'll bet WC pays more than that, but I haven't gone far enough back in my schedule to see.

I'd post the exact #'s, but someone would undoubtedly call the collusion police on SDN and remove the post.

This, combined with phenomenally low overhead, is why I work 28 - 32 hours per week, but still make the money of docs working 50 hours per week.

Work smarter my friends, not harder.

 

[PMR 4 MSK]

PMR --- your numbers sound like you are out-of-network w/ those insurers...

Nope, 99% of pts I see are in-network.