Pain Fellowships Lacking Practice Management Training

[drusso]

Do Pain Medicine Fellowship Programs Provide Education in Practice Management? A Survey of Pain Medicine Fellowship Programs. - PubMed - NCBI

Do Pain Medicine Fellowship Programs Provide Education in Practice Management? A Survey of Pain Medicine Fellowship Programs.
Przkora R, et al. Pain Physician. 2018.
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Abstract
BACKGROUND: We hypothesized that there is a gap between expectations and actual training in practice management for pain medicine fellows. Our impression is that many fellowships rely on residency training to provide exposure to business education. Unfortunately, pain management and anesthesiology business education are very different, as the practice settings are largely office- versus hospital-based, respectively.

OBJECTIVE: Because it is unclear whether pain management fellowships are providing practice management education and, if they do, whether the topics covered match the expectations of their fellows, we surveyed pain medicine program directors and fellows regarding their expectations and training in business management.

STUDY DESIGN: A survey.

SETTING: Academic pain medicine fellowship programs.

METHODS: After an exemption was obtained from the University of Texas Medical Branch Institutional Review Board (#13-030), an email survey was sent to members of the Association of Pain Program Directors to be forwarded to their fellows. Directors were contacted 3 times to maximize the response rate. The anonymous survey for fellows contained 21 questions (questions are shown in the results).

RESULTS: Fifty-nine of 84 program directors responded and forwarded the survey to their fellows. Sixty fellows responded, with 56 answering the survey questions.

LIMITATIONS: The responder rate is a limitation, although similar rates have been reported in similar studies.

CONCLUSIONS: The majority of pain medicine fellows receive some practice management training, mainly on billing documentation and preauthorization processes, while most do not receive business education (e.g., human resources, contracts, accounting/financial reports). More than 70% of fellows reported that they receive more business education from industry than from their fellowships, a result that may raise concerns about the independence of our future physicians from the industry. Our findings support the need for enhanced and structured business education during pain fellowship.

KEY WORDS: Business education, practice management, fellowship training, curriculum development, knowledge gaps, private practice.

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[emd123]

Lack of training in the business of medicine has been a downfall, for decades, in all specialties. As the business side of medicine, with ever increasing rules and regulations, and increasing complexities of billing/collecting/insurance, it's no wonder more and more doctors take employed jobs. It's just too much to keep up with, or at least more than most want to keep up with.

 

[Ligament]

Did they really need to have a hypothesis on this? I mean, everybody is 110% aware that no physician gets any business training in any specialty. Why are we wasting time studying things that need no studying?

 

[DokterMom]

Lack of training in the business of medicine has been a downfall, for decades, in all specialties. As the business side of medicine, with ever increasing rules and regulations, and increasing complexities of billing/collecting/insurance, it's no wonder more and more doctors take employed jobs. It's just too much to keep up with, or at least more than most want to keep up with.

I'd go so far as to suggest that this lack of business education is a critical danger to the profession. The business of medicine is endangering the art and practice of medicine.

We all believe in capitalism, but where physicians are not the ones in control of the resources, they are at the mercy of those who are. Who is making the rules that physicians are forced to live by? When it isn't the physicians, their livelihoods are at risk.

 

[drusso]

I'd go so far as to suggest that this lack of business education is a critical danger to the profession. The business. of medicine is endangering the art and practice. of medicine.

We all believe in capitalism, but where physicians are not the ones in control of the resources, they are at the mercy of those who are. Who is making the rules that physicians are forced to live by? When it isn't the physicians, their livelihoods are at risk.

Very smart observations!

 

[Ligament]

I spend about 50% or more of my working hours on business related topics as a private practice owner. I was served very poorly by all my training for 50% of my daily activities.

 

[nvrsumr]

best biz education for the fellows would be to search this forum. Why would anyone in academia know anything about the business of medicine?

 

[Ducttape]

Did they really need to have a hypothesis on this? I mean, everybody is 110% aware that no physician gets any business training in any specialty. Why are we wasting time studying things that need no studying?

BecSuse we don’t want to have another parachute argument.
Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials

 

[emd123]

I'd go so far as to suggest that this lack of business education is a critical danger to the profession. The business. of medicine is endangering the art and practice. of medicine.

We all believe in capitalism, but where physicians are not the ones in control of the resources, they are at the mercy of those who are. Who is making the rules that physicians are forced to live by? When it isn't the physicians, their livelihoods are at risk.

Agree

 

[KHE]

I am an optometrist and I own a multi million dollar practice and I have practiced in three different states over the course of an 18 year career.

Let me make a suggestion or two to those interested in the business of medicine and/or wanting to own a private practice.

People make the mistake of assuming that they need the business of acumen of Warren Buffet and that unless they do everything absolutely perfectly from the moment they buy or open a practice, they are doomed to a lifetime of personal and professional financial ruination as well as professional mockery. That is not true.

I would not worry so much about billing and coding while in training. The problem with that stuff is that it actually varies in different parts of the country. What is successful in Nevada at getting you paid may not be successful in New York. What requires a prior authorization in Idaho may not in Florida. Sadly, this is true even with medicare which in theory should be a federal standard but the individual medicare contractors have their own variations. So basically, you have to learn what works in the area you want to practice in. If you're not training or doing a fellowship in that area, it's not worth investing a bunch of time learning stuff that may well be wrong.

To me, the successful practices think about the staff they hire and the policies they put in place.

A story about my own PCP....

Nice guy, seems competent, been with him for several years. His office is a damn disaster. The receptionists are incredibly rude. The billing people, fuhgedaboutit. The environment, a nightmare. Dingy office, dingy furniture, window blinds that haven't been dusted in ages that are bent. The glass separating the receptionists from the waiting area is literally covered with papers held up with scotch tape saying things like "COPAYMENTS DUE AT THE TIME OF SERVICE" "48 HOURS NOTICE REQUIRED TO CANCEL AN APPOINTMENT OR A $50 CHARGE." "THIS OFFICE CHARGES $25 TO FILL OUT FORMS." etc. etc. Not the most inviting environment. In fact, I'd say the DMV is more inviting.

And here's the thing....it's perfectly fine and probably even wise to have similar policies in place. I'm sure you all have policies relating to opiate prescribing that some, perhaps many patients aren't excited about. But you can convey those policies in a more relaxed way. Your goal should be to create an environment and an experience in which patients not only want to come to your office, but to send their family and friends there. People don't get upset when they get bad news. They get upset when they get unexpected news. If your car is making a horrible noise and you take it to the shop and they tell you it's $800 to repair it, you're annoyed but you get it. If you take it in for a routine oil change and they tell you you need $800 worth of repairs, you're going to be pissed right off.

So if private practice is your goal, read practice management journals that talk about what other people did getting off the ground. Talk to you faculty members who might be adjunct and who have their own practices outside of academia. Ask them what worked for them, what didn't, what mistakes they made and what advice they would give you. You'll find that you hear a lot of things that make you think "hmmmm....I never really thought of that. I like that idea." You'll also have the opposite where you think "hmmmm.....I don't think that's the kind of thing I'd like to do."

So don't get caught up in the notion that you need to know ever nuance about MIPS and MACRA and billing and coding and all of that. THat's not where you need to focus your attention.

 

[lonelobo]

Who knew selling glasses and contacts was so damn lucractive

 

[emd123]

I am an optometrist and I own a multi million dollar practice and I have practiced in three different states over the course of an 18 year career.

Let me make a suggestion or two to those interested in the business of medicine and/or wanting to own a private practice.

People make the mistake of assuming that they need the business of acumen of Warren Buffet and that unless they do everything absolutely perfectly from the moment they buy or open a practice, they are doomed to a lifetime of personal and professional financial ruination as well as professional mockery. That is not true.

I would not worry so much about billing and coding while in training. The problem with that stuff is that it actually varies in different parts of the country. What is successful in Nevada at getting you paid may not be successful in New York. What requires a prior authorization in Idaho may not in Florida. Sadly, this is true even with medicare which in theory should be a federal standard but the individual medicare contractors have their own variations. So basically, you have to learn what works in the area you want to practice in. If you're not training or doing a fellowship in that area, it's not worth investing a bunch of time learning stuff that may well be wrong.

To me, the successful practices think about the staff they hire and the policies they put in place.

A story about my own PCP....

Nice guy, seems competent, been with him for several years. His office is a damn disaster. The receptionists are incredibly rude. The billing people, fuhgedaboutit. The environment, a nightmare. Dingy office, dingy furniture, window blinds that haven't been dusted in ages that are bent. The glass separating the receptionists from the waiting area is literally covered with papers held up with scotch tape saying things like "COPAYMENTS DUE AT THE TIME OF SERVICE" "48 HOURS NOTICE REQUIRED TO CANCEL AN APPOINTMENT OR A $50 CHARGE." "THIS OFFICE CHARGES $25 TO FILL OUT FORMS." etc. etc. Not the most inviting environment. In fact, I'd say the DMV is more inviting.

And here's the thing....it's perfectly fine and probably even wise to have similar policies in place. I'm sure you all have policies relating to opiate prescribing that some, perhaps many patients aren't excited about. But you can convey those policies in a more relaxed way. Your goal should be to create an environment and an experience in which patients not only want to come to your office, but to send their family and friends there. People don't get upset when they get bad news. They get upset when they get unexpected news. If your car is making a horrible noise and you take it to the shop and they tell you it's $800 to repair it, you're annoyed but you get it. If you take it in for a routine oil change and they tell you you need $800 worth of repairs, you're going to be pissed right off.

So if private practice is your goal, read practice management journals that talk about what other people did getting off the ground. Talk to you faculty members who might be adjunct and who have their own practices outside of academia. Ask them what worked for them, what didn't, what mistakes they made and what advice they would give you. You'll find that you hear a lot of things that make you think "hmmmm....I never really thought of that. I like that idea." You'll also have the opposite where you think "hmmmm.....I don't think that's the kind of thing I'd like to do."

So don't get caught up in the notion that you need to know ever nuance about MIPS and MACRA and billing and coding and all of that. THat's not where you need to focus your attention.

My only question is, why the heck is this guy still your PCP?

 

[Agast]

Who knew selling glasses and contacts was so damn lucractive

They make bank off of each pair of glasses sold, unfortunately there are online retailers offering bogus refractions and cheaper glasses/contact lenses that are poised to disrupt the retail end unless optometrists can get some sort of legal ruling in their favor. Basically the same problems brick and mortar stores face in the age of Amazon.

I started giving a yearly private practice talk to the local pain fellows. The basic structure of my talk is: What are our services actually worth. I go over the different office visit codes and expected reimbursement for office visits and procedures done in office vs. done in ASC. Then I show them my monthly clinic expenses. I have them work out how many patients they expect to see in clinic and how many procedures they want to do in a week, and then do the math and find out it's much less in collections than expected. Factor in vacation time, buying fancy cars, all the stuff you dream of as a fellow. We talk a little about ancillaries and out of network billing. So many pitfalls of being a young and hungry doctor practicing in an area of medicine that can turn shady. My recommendation to any specialty resident/fellow is to talk to their billing department and see how much (or little) they get paid for what they do. Knowledge of billing and coding for a proceduralist is an absolute must.

 

[drusso]

They make bank off of each pair of glasses sold, unfortunately there are online retailers offering bogus refractions and cheaper glasses/contact lenses that are poised to disrupt the retail end unless optometrists can get some sort of legal ruling in their favor. Basically the same problems brick and mortar stores face in the age of Amazon.

I started giving a yearly private practice talk to the local pain fellows. The basic structure of my talk is: What are our services actually worth. I go over the different office visit codes and expected reimbursement for office visits and procedures done in office vs. done in ASC. Then I show them my monthly clinic expenses. I have them work out how many patients they expect to see in clinic and how many procedures they want to do in a week, and then do the math and find out it's much less in collections than expected. Factor in vacation time, buying fancy cars, all the stuff you dream of as a fellow. We talk a little about ancillaries and out of network billing. So many pitfalls of being a young and hungry doctor practicing in an area of medicine that can turn shady. My recommendation to any specialty resident/fellow is to talk to their billing department and see how much (or little) they get paid for what they do. Knowledge of billing and coding for a proceduralist is an absolute must.

I would like to see all Fellows complete an elective month of Private Practice Pain.

 

[Ducttape]

I would like to see all Fellows complete an elective month of Private Practice Pain.

My concern is what you would sacrifice to have this month.

Bread and butter procedures? Inpatient service?
Cause there is already insufficient time dedicated to palliative care, opioid prescribing/ addiction evaluation (I did not specify treatment), psychology, etc.

 

[DOctorJay]

I would like to see all Fellows complete an elective month of Private Practice Pain.

we had this available to us and these rotations were very well received

 

[244913]

I would like to see all Fellows complete an elective month of Private Practice Pain.

In my region it would be instructive for the fellows to follow the IPM midlevels prescribing the opioids. Give them an idea of where the procedural patients "go" once the needle is out. And how they are doing.

- ex 61N

 

[IN2B8R]

Private practice success hinges on practicing good medicine and having good relationships with your patients and your referring docs. The rest is learnable. Yes, that simple, but often hard to execute....


Sent from my iPhone using SDN mobile app

 

[KHE]

They make bank off of each pair of glasses sold, unfortunately there are online retailers offering bogus refractions and cheaper glasses/contact lenses that are poised to disrupt the retail end unless optometrists can get some sort of legal ruling in their favor. Basically the same problems brick and mortar stores face in the age of Amazon.

.

Wow, I wish that were true. lol

Regarding online, that all just cannibalizes the low end of the market which is already super saturated and not really what my practice caters to. Does the Ritz Carlton care if a Motel 6 opens up down the street? Not really. So be the Ritz Carlton, not the Motel 6.

 

[drusso]

Does the Ritz Carlton care if a Motel 6 opens up down the street? Not really. So be the Ritz Carlton, not the Motel 6.

Pain Medicine has so much to learn from this analogy!

 

[Agast]

Wow, I wish that were true. lol

Regarding online, that all just cannibalizes the low end of the market which is already super saturated and not really what my practice caters to. Does the Ritz Carlton care if a Motel 6 opens up down the street? Not really. So be the Ritz Carlton, not the Motel 6.

Hmmm, well all I can say is there is a pretty active OD Facebook group where every day people are complaining about Hubble, Warby Parker, 1800 contacts et al. and thinking about ways to prevent giving out prescriptions so that cheap millennials can’t price match online. I found it particularly fascinating that letting patients know what their pupillary distance is is considered bad for business. The old guard may be millionaires - as is true for the older physicians in many specialties - but the youngun’s who are just starting out are entering a vastly different landscape.

Now, my fiancé actually did get practice management lectures in Optometry school so at least there’s *some* preparation for the road ahead.

 

[KHE]

Hmmm, well all I can say is there is a pretty active OD Facebook group where every day people are complaining about Hubble, Warby Parker, 1800 contacts et al. and thinking about ways to prevent giving out prescriptions so that cheap millennials can’t price match online. I found it particularly fascinating that letting patients know what their pupillary distance is is considered bad for business. The old guard may be millionaires - as is true for the older physicians in many specialties - but the youngun’s who are just starting out are entering a vastly different landscape.

Now, my fiancé actually did get practice management lectures in Optometry school so at least there’s *some* preparation for the road ahead.

That facebook group is populated largely by losers and small time thinkers who do nothing but bitch and complain. And they take things far too personally. I'm not saying I never lose a patient to online Cl ordering or some population of patients who want to get glasses at Walmart because they're less expensive than what I offer but that's fine. I get that some people in my community like me as a provider but can't afford the materials I offer. That's totally fine. A private optometry practice is a unique thing in that professional ethics dictate that we treat all patients the same. But once you get into the eyeglass dispensing area, you really CAN'T treat all people the same. You can't be all things to all people. So find the market you wish to target and go after it.

The point of my posting wasn't really to talk about my practice. It was to point out that the "key" to success in private practice isn't really about understanding all the ins and outs of billing and coding and MIPS and MACRA or even being about the greatest clinician. Those are important, of course but that's not the real secret. It's about creating an environment and an experience that makes patients not only want to come to your office but to enthusiastically tell OTHER people to go to your office for whatever issues they may have. I think physicians (and optomtrists, dentists, etc. etc.) don't spend nearly enough time focusing on that aspect.

 

[drusso]

It's about creating an environment and an experience that makes patients not only want to come to your office but to enthusiastically tell OTHER people to go to your office for whatever issues they may have. I think physicians (and optomtrists, dentists, etc. etc.) don't spend nearly enough time focusing on that aspect.

Unfortunately, very few de-prescribers are focusing on this.

 

[244913]

Unfortunately, very few de-prescribers are focusing on this.

Return rate is generally better when you have midlevels doling out the candy drusso.

Do you want to go around and around on this? Broken record

- ex 61N

 

[drusso]

Return rate is generally better when you have midlevels doling out the candy drusso.

Do you want to go around and around on this? Broken record

- ex 61N

This is a ripe area for Chief Experience Officers to address!

New C-suite position to watch: Chief experience officers

These roles support a larger executive trend: chief experience officer (CXO), which is driven by the desire to improve the larger patient experience—a combination of excellence in clinical care and patient perception—and the experience of caregivers.