Pain vs OR

[Ligament]

Things can vary widely in private practice. I write fewer than 20 opioid prescriptions per MONTH on average. I like and enjoy most of my patients as we screen them and turn away many per week that are only interested in narcotics. This may not be the most financially rewarding model but it exists. Not sure how much longer this will work as overhead is ever increasing and payments decreasing, but other practices like mine exist. It is possible in the futuure only high volume opioid practices may survice with in house tox labs/compounding pharmacies/ascs, so i may have to eat crow...

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[CSmith912345]

This part is too true: In hindsight, I think most of the procedures being done were just so the patient can get there opiates or have continued pay and not work.

If a patient is already on SS disability, the patient's disability isn't dependent on further care by the pain physician. There is no contingency for SS disability that says you must get injections to remain on disability. So I don't understand this argument.



You can argue that workman's compensation people will continue with treatment to remain off of work or attempt to get disability through workman's compensation. However, workman's compensation will eventually require a functional evaluation and independent physician analysis. This will prevent long term abuse of the system.

A far stronger case for patient's getting permanent workman's compensation would be for patients who undergo fusion surgeries. I often see patients with only degenerative disc disease getting fusion surgeries and becoming "disabled for life". In fact, one could argue that a good amount of patients purposely get back surgery to get "disabled". Without the fusion surgery, they would be forced to go back to work because their pathology/functional status didn't warrant full disability. But after they are "fused", they can argue they have permanent disability.


As for opiates for procedures places, this is due to unscrupulous physicians. I would give a patient for a few Norcos per day if they have a herniated disc or multiple level degenerative disc disease but couldn't justify higher dosages of narcotics. Narcotic standards should prevent abuse of narcotic medications.

 

[101N]

Most "successful" PP IPM practices follow the same business model: interventional physian in procedure suite and a mid-level or two in the clinic for narcotic refills. Every 3 mo or so the mid- level is trained to refer some of the herd back to the MD/DO for another useless series of procedures that finance the whole charade. The patients that stay are complicit, there for narcotics, time off work, or support for disability/PI/WC.

Now add to this already toxic mix an in house UDS lab, ASC, and high dose opioids.

The core business in these pyramid shaped IPM practices is opioid Rx'ing. This is why so many IPM practices are such vocal opponents of 'universal dose limits' (120MED ceiling for all pracitioners). Getting rid of high dose opioids for CNP threatens the vary core of the IPM business model.

Here it is:https://www.google.com/url?sa=t&source=web&cd=9&ved=0CDAQFjAI&url=http://www.usatoday.com/story/news/nation/2014/12/15/doctors-prescription-painkillers/20428639/&ei=W62mVNrfH8zmoATMyYKgBw&usg=AFQjCNH4ThMkMK7PK-z80IB6fIrZg3YdsQ&sig2=gXqzn5acF9WwTZyjn2D7qg

 

[CSmith912345]

Most "successful" PP IPM practices follow the same business model: interventional physian in procedure suite and a mid-level or two in the clinic for narcotic refills. Every 3 mo or so the mid- level is trained to refer some of the herd back to the MD/DO for another useless series of procedures that finance the whole charade. The patients that stay are complicit, there for narcotics, time off work, or support for disability/PI/WC.

Now add to this already toxic mix an in house UDS lab, ASC, and high dose opioids.

The core business in these pyramid shaped IPM practices is opioid Rx'ing. This is why so many IPM practices are such vocal opponents of 'universal dose limits' (120MED ceiling for all pracitioners). Getting rid of high dose opioids for CNP threatens the vary core of the IPM business model.

Here it is:https://www.google.com/url?sa=t&source=web&cd=9&ved=0CDAQFjAI&url=http://www.usatoday.com/story/news/nation/2014/12/15/doctors-prescription-painkillers/20428639/&ei=W62mVNrfH8zmoATMyYKgBw&usg=AFQjCNH4ThMkMK7PK-z80IB6fIrZg3YdsQ&sig2=gXqzn5acF9WwTZyjn2D7qg

First off, I notice you skirted the issue of the disability racket. You made the erroneous claim that pain physicians are the ones pushing disability. This was a lie and I have proven that if all pain physicians were removed from the situation, the level of disability procurement would remain the same.

Unless you can provide any evidence that there is a higher per capita disability rate that is dependent on the number of pain physicians in an area, your argument has no validity.

The disability racket is being supported more by disability lawyers, psychiatrists, surgeons, PCPs, etc than pain physicians. I don't ever sign disability papers for patients, yet there are no shortage of new patients that are getting disability either for post surgical reasons or "psychiatric" reasons.


Second, the article you linked only said they will be tracking the highest prescribing physicians for narcotic medications. If you actually read who the highest prescribing physicians are, many of them are in fields outside of IPM. In fact, when the pill mills were shut down in Florida, most of the physicians were in outside fields including former ortho surgeons, PCPs, OB/GYN, etc. Look it up.

In my practice, I rarely prescribe over 60 Morphine Equivalents per day. The patients who get over that in dosing are often patients who have gotten multiple fusion surgeries, have cancer, or some other major issue. The most common patients on higher dosage narcotics are definitely the post fusion patients. So if you are concerned with the opiate epidemic, maybe that is where you should look.

Also, I'd like to know your background? Are you a PMR physician? Surgeon?

 

[lobelsteve]

This was a lie and I have proven that if all pain physicians were removed from the situation, the level of disability procurement would remain the same.

You have proven nothing.

Unless you can provide any evidence that there is a higher per capita disability rate that is dependent on the number of pain physicians in an area, your argument has no validity.

This is the internet, providing evidence that does not exist is not necessary.

The disability racket is being supported more by disability lawyers, psychiatrists, surgeons, PCPs, etc than pain physicians. I don't ever sign disability papers for patients, yet there are no shortage of new patients that are getting disability either for post surgical reasons or "psychiatric" reasons.

You are leaving money on the table. YOu could jsut get $100 for each form from the patients.

Second, the article you linked only said they will be tracking the highest prescribing physicians for narcotic medications. If you actually read who the highest prescribing physicians are, many of them are in fields outside of IPM. In fact, when the pill mills were shut down in Florida, most of the physicians were in outside fields including former ortho surgeons, PCPs, OB/GYN, etc. Look it up.

In my practice, I rarely prescribe over 60 Morphine Equivalents per day. The patients who get over that in dosing are often patients who have gotten multiple fusion surgeries, have cancer, or some other major issue. The most common patients on higher dosage narcotics are definitely the post fusion patients. So if you are concerned with the opiate epidemic, maybe that is where you should look.

You poke them and give them a little narcotic, then they sell those and get high off the good stuff.

Also, I'd like to know your background? Are you a PMR physician? Surgeon?

Five posts in and taking a roll call? Most folks here like their anonymity. This forum is all Pain Docs. Anes, PMR, and a few ER docs.

See how easy this gets....Slow down. You've proven nothing but that you have a chip on your shoulder. Role of WORLDS GREATEST PAIN DOC has been filled. And you didn't make the top 10. (nope, neither did I)

 

[CSmith912345]

1) "You have proven nothing": I have proven (the best I can on an anonymous internet message board) that in a large multidisciplinary group with a good amount of pain physician partners, we are not writing disability for patients. Yet in our area, there appears to be many people getting disability regardless. I am very confident adding a few more pain physicians into the mix won't increase the disability roles. We specifically make it a priority not to do disability as this is a hassle for our practice. Therefore, we rarely do it unless its very obvious (I have personally not signed off on any disability claims). However, there doesn't appear to be any shortage of people getting disability in my area.

His argument that pain physicians are putting people on disability in large numbers is dubious at best. Sure there are some corrupt pain physicians, but I see far more of the disability racket among Chiros, PMR physicians, Surgeons, etc. There are over 80 disability lawyers in our area alone. Many surgeons will operate on these patients and then write them disability after their operations or at least give them the excuse to be "disabled" due to surgery.

2) "You poke them, give them a little to sell and get off the high stuff": Selling Norco 5/325 PO TID PRN is worth approximately 15 dollars/day on the street. We UDS test them for any illegal substances and run drug monitoring screens to make sure they aren't doctor shopping. So if they are doing that, we can often find this out. They are kicked out for using illegal substance or just have their narcotic meds stopped. You can usually catch these people if you are watching them.

Today, >50% of the people I treated today were on no narcotics, just some Gabapentin, Mobic and Injections. The other 40% were on low dose Norco (5/325 PO BID or so), then about 10% are on higher dosages but less than 60 Morphine Equvilents for the about 26 patients I saw today. Only a few patients are on higher than 60 Morphine Equivalents in my practice.

We have no UDS profit center (although I should consider this option since the UDS companies are making a killing, don;t see why the physicians shouldn't get some of that revenue) despite the fact that I drug test all narcotic patients at least once a year, with higher risk patients getting many more UDS. I make no profit on this.

I don't appreciate the lie that we are either giving them disability or just drugging them all up.

3) He can remain anonymous and still tell me the field he is coming from. I would like to know since "people who live in glass houses shouldn't throw stones".

Often, the our biggest critics have their own axe to grind for obvious reasons. If I knew his background, I can often tell why they have a certain opinion.

Since he said basically all pain practices are corrupt, he is essentially calling you corrupt as well.

Yet I see corruption in many fields of medicine:

1) Spine Surgeons doing tons of fusion surgeries for DDD: patients on work comp or disability. These people will often want to get first crack at the patients and are angry with any pain physicians who "prevent patients from going to surgery".
2) PMR who work for and against auto insurance. They will take either side depending on who pays the bills. Plenty of people hired by auto insurance/work comp will say about 99% of patients are fine despite having obvious pathology that came from the accident/job
3) PMR guys who are upset that we are "taking patients from them" since we have our own PT and Behavioral Group. They are also upset that a lot of people prefer our method of treatment and will ask their PCPs to go see our group. Competition leads to anger issues.

I have a "chip on my shoulder" because this clown basically said we are all corrupt and no good in his comments. Since he basically said the same thing about you, you should maybe have more of a chip huh?

 

[101N]

1) "You have proven nothing": I have proven (the best I can on an anonymous internet message board) that in a large multidisciplinary group with a good amount of pain physician partners, we are not writing disability for patients. Yet in our area, there appears to be many people getting disability regardless. I am very confident adding a few more pain physicians into the mix won't increase the disability roles. We specifically make it a priority not to do disability as this is a hassle for our practice. Therefore, we rarely do it unless its very obvious (I have personally not signed off on any disability claims). However, there doesn't appear to be any shortage of people getting disability in my area.

His argument that pain physicians are putting people on disability in large numbers is dubious at best. Sure there are some corrupt pain physicians, but I see far more of the disability racket among Chiros, PMR physicians, Surgeons, etc. There are over 80 disability lawyers in our area alone. Many surgeons will operate on these patients and then write them disability after their operations or at least give them the excuse to be "disabled" due to surgery.

2) "You poke them, give them a little to sell and get off the high stuff": Selling Norco 5/325 PO TID PRN is worth approximately 15 dollars/day on the street. We UDS test them for any illegal substances and run drug monitoring screens to make sure they aren't doctor shopping. So if they are doing that, we can often find this out. They are kicked out for using illegal substance or just have their narcotic meds stopped. You can usually catch these people if you are watching them.

Today, >50% of the people I treated today were on no narcotics, just some Gabapentin, Mobic and Injections. The other 40% were on low dose Norco (5/325 PO BID or so), then about 10% are on higher dosages but less than 60 Morphine Equvilents for the about 26 patients I saw today. Only a few patients are on higher than 60 Morphine Equivalents in my practice.

We have no UDS profit center (although I should consider this option since the UDS companies are making a killing, don;t see why the physicians shouldn't get some of that revenue) despite the fact that I drug test all narcotic patients at least once a year, with higher risk patients getting many more UDS. I make no profit on this.

I don't appreciate the lie that we are either giving them disability or just drugging them all up.

3) He can remain anonymous and still tell me the field he is coming from. I would like to know since "people who live in glass houses shouldn't throw stones".

Often, the our biggest critics have their own axe to grind for obvious reasons. If I knew his background, I can often tell why they have a certain opinion.

Since he said basically all pain practices are corrupt, he is essentially calling you corrupt as well.

Yet I see corruption in many fields of medicine:

1) Spine Surgeons doing tons of fusion surgeries for DDD: patients on work comp or disability. These people will often want to get first crack at the patients and are angry with any pain physicians who "prevent patients from going to surgery".
2) PMR who work for and against auto insurance. They will take either side depending on who pays the bills. Plenty of people hired by auto insurance/work comp will say about 99% of patients are fine despite having obvious pathology that came from the accident/job
3) PMR guys who are upset that we are "taking patients from them" since we have our own PT and Behavioral Group. They are also upset that a lot of people prefer our method of treatment and will ask their PCPs to go see our group. Competition leads to anger issues.

I have a "chip on my shoulder" because this clown basically said we are all corrupt and no good in his comments. Since he basically said the same thing about you, you should maybe have more of a chip huh?

This: "I have a "chip on my shoulder"

 

[Ligament]

Most "successful" PP IPM practices follow the same business model: interventional physian in procedure suite and a mid-level or two in the clinic for narcotic refills. Every 3 mo or so the mid- level is trained to refer some of the herd back to the MD/DO for another useless series of procedures that finance the whole charade. The patients that stay are complicit, there for narcotics, time off work, or support for disability/PI/WC.

Now add to this already toxic mix an in house UDS lab, ASC, and high dose opioids.

The core business in these pyramid shaped IPM practices is opioid Rx'ing. This is why so many IPM practices are such vocal opponents of 'universal dose limits' (120MED ceiling for all pracitioners). Getting rid of high dose opioids for CNP threatens the vary core of the IPM business model.

Here it is:https://www.google.com/url?sa=t&source=web&cd=9&ved=0CDAQFjAI&url=http://www.usatoday.com/story/news/nation/2014/12/15/doctors-prescription-painkillers/20428639/&ei=W62mVNrfH8zmoATMyYKgBw&usg=AFQjCNH4ThMkMK7PK-z80IB6fIrZg3YdsQ&sig2=gXqzn5acF9WwTZyjn2D7qg

I'm fine with in house UDS lab as long as the prescribing is ethical. I'd much rather see the physician profit off the UDS rather than a lab tech who takes no risk but lots of profit. The catch is when practices use opioids as the crux of the profit driving engine. There is such a practice in my area (no its not MY practice!)

 

[CSmith912345]

This: "I have a "chip on my shoulder"

LOL I notice you don't answer any of my questions.

You have a "chip on your shoulder" with assertions you can't back up. You have made a claim that pain physicians are the cause of promoting disability and narcotics. You have no evidence to prove this assertion. I have given many counter arguments to this claim.

You appear to have an axe to grind.

Which field of medicine are you in? What is your practice like? These are important questions to know before I can understand how you come up with your biased conclusions. Often, the biased opinion is done from a self serving position.

 

[CSmith912345]

I'm fine with in house UDS lab as long as the prescribing is ethical. I'd much rather see the physician profit off the UDS rather than a lab tech who takes no risk but lots of profit. The catch is when practices use opioids as the crux of the profit driving engine. There is such a practice in my area (no its not MY practice!)

I agree with this.

I would like to get profit off of the UDS in the future, since I test anyone on narcotics at least once a year. Higher risk patients get tested far more frequently.

Don't see why the UDS company should get all the profit and none goes to the physician who is doing the work of managing these patients.