Access for Discography

[SleepIsGood]

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Hey guys..I think this is in every Pain Physician's interest to check this link out. As you know CMS is questioning reimbursement for discography. Dr. Manchikanti has put this together.

Hopefully we can prevent CMS from making more cuts. Again, this takes 2 seconds literally to fill out...it goes to your congressman.

Thanks

http://www.capwiz.com/asipp/issues/alert/?alertid=14776446&type=CO

 

[Aether2000]

It may be ill advised to begin cajoling congress to deal with individual medical procedures such as discography. That is the purvue of the CAC committees and the national review organizations for CMS.

 

[SleepIsGood]

It may be ill advised to begin cajoling congress to deal with individual medical procedures such as discography. That is the purvue of the CAC committees and the national review organizations for CMS.

yah but they are starting to individually cut things. It's better to address these issues as they come up rather than 'waiting' and then trying to retroactively address them....Atleast ASIPP is trying to step up to the plate on this issue. It doesnt hurt..only helps our cause...

 

[Aether2000]

I don't disagree that proactive is better...there are several societies that have been working on this issue for some time now....
But the method of going to congress yelling the sky is falling everytime CMS examines a procedure is naive and is actually quite deleterious to pain medicine as a whole. It paints pain physicians as greedy bastards that oppose any effort to examine either the site of service or the efficacy of a particular procedure. Discography has not been covered in ASCs for some time now..... so what? Why not do these in your office? Why not a hospital?
My take on this is working within the means made available to us without trumpeting to congress and the president that we are fearful of having one procedure examined by CMS is a more valuable method of engagement. Frontal assaults rarely are successful, especially when politics are involved, and it takes those with connections and finesse to move mountains rather than pointing guns toward congress and aiming at them to change the CMS approach to a single procedure.

 

[ampaphb]

Lax/ASIPP has consistently been a far better friend to those pain docs who own ASCs than to the rest who practice in other locations.

In short, Lax tends to do what's best for ... Lax (not surprisingly)

 

[SleepIsGood]

I hear what you guys are saying.

I think people will have differing opinions on this stuff. However, as a member of almost every pain society that exists (just about). I can say that ASIPP is the only one which is actively lobbying.

Unfortunately when reimbursement is involved, people will misinterpret certain things as being greedy. I dont think it's greed...it's 'reimbursement'. You provide a service and expect a certain return that's FAIR...what you do not want is NOTHING.

In this respect, I think it behooves us to participate in lobbying. My opinion is put personal differences asides, this is something that effects everyone.

Also, I dont think ASIPP is ramming anything down Congress' throat. Look at their Annual Meeting Brochure. They have invited and will be having active dialogue with MULTIPLE congressman and senators. No other Pain society can boast that. They do know how to play the politics and so far I haven't seen anyone else that can do it better...

 

[drusso]

I don't disagree that proactive is better...there are several societies that have been working on this issue for some time now....
But the method of going to congress yelling the sky is falling everytime CMS examines a procedure is naive and is actually quite deleterious to pain medicine as a whole. It paints pain physicians as greedy bastards that oppose any effort to examine either the site of service or the efficacy of a particular procedure. Discography has not been covered in ASCs for some time now..... so what? Why not do these in your office? Why not a hospital?
My take on this is working within the means made available to us without trumpeting to congress and the president that we are fearful of having one procedure examined by CMS is a more valuable method of engagement. Frontal assaults rarely are successful, especially when politics are involved, and it takes those with connections and finesse to move mountains rather than pointing guns toward congress and aiming at them to change the CMS approach to a single procedure.

Why do it in a hospital?

The hospitals have been using *their* lobbyists to protect turf for a long time. Hospitals are threatened by ASC's which are, by and larger, friendlier to physicians, more convenient for patients, and more cost-effective.

 

[Aether2000]

Offices can make the same claim regarding being a threat to ASCs: They are much less expensive and have lower operating costs and patient charges. There is also one entity to bill instead of 2 (or 3 if there is an anesthesiologist involved). I operate out of a AAAHC accredited office that can deliver general anesthesia and perform surgery, and the patients much prefer having procedures there compared to an ASC or hospital. So I agree...why do these in a hospital? But if you are not the proud owner of an ASC that typically costs patients much more than office based procedures, then why not do discography in an office or in a hospital?
Regarding lobbying congress, ASIPP indeed is king in both lobbying, and also for taking credit when the results were not achieved by lobbying by ASIPP. The real questions revolve around why congress would give a flip about the ASC lobby and how they are being so poorly treated compared to hospitals and physician's offices by exclusion of certain procedures.

 

[SleepIsGood]

... The real questions revolve around why congress would give a flip about the ASC lobby .......

Because they like the $$ we donate and so they can get re elected next year.

And because they want better access for their constituents 😀

 

[Aether2000]

Guess I will have to disagree....I have been told by professional consultants that small medical societies have virtually no impact via their lobbying efforts since the money they spend is dwarfed by lawyer organizations and other special interests. I personally find attempts to buy off congress to be naive and offensive. But each to their own---but don't expect everyone to band together using these tactics when other methods have proven themselves to be much more fruitful.

 

[Tenesma]

it may be naive and/or offensive - but it works...

and while i couldn't care less about ASCs --- this issue is an important one... as soon as you allow govt to whittle down services here and there, it becomes a slippery slope.... and MOST of the time, when govt decreases ASCs reimbursements it is a direct result of hospitals lobbying against ASCs... what is next, clearly office procedures will be targeted bby hospitals as a diversion of potential income.

we better make a stand somehow, or else we will end up in the same boat as cardiology (hit with 30% decrease in reimbursement for ECHOs and Stress tests done in their office).

 

[Aether2000]

I have not seen this pattern at all, but I believe in some cases the greed of physicians has driven insurers into reduction in payments. For instance the guy nearby that is in network for a major insurer and has the physician component paid in full by insurance but purposefully does not contract his wholely owned ASC with same insurer, charges the patients $7,000 for 3 epidural injections. If they refuse to pay fully, he sues them in court and goes after their assets. Greedy doctors are part of the problem....why should I expend political capital in order to assist these charlatans?

 

[Jcm800]

I have not seen this pattern at all, but I believe in some cases the greed of physicians has driven insurers into reduction in payments. For instance the guy nearby that is in network for a major insurer and has the physician component paid in full by insurance but purposefully does not contract his wholely owned ASC with same insurer, charges the patients $7,000 for 3 epidural injections. If they refuse to pay fully, he sues them in court and goes after their assets. Greedy doctors are part of the problem....why should I expend political capital in order to assist these charlatans?

this is the scam in my neck of the woods also.

Had a patient that came to me for a repeat injection because the first one at the ASC cost him big bucks out of pocket. He as a provider is in network. The ASC that he OWNS is not. The patient was not made aware of this. They went after him for the balance

 

[drusso]

I have not seen this pattern at all, but I believe in some cases the greed of physicians has driven insurers into reduction in payments. For instance the guy nearby that is in network for a major insurer and has the physician component paid in full by insurance but purposefully does not contract his wholely owned ASC with same insurer, charges the patients $7,000 for 3 epidural injections. If they refuse to pay fully, he sues them in court and goes after their assets. Greedy doctors are part of the problem....why should I expend political capital in order to assist these charlatans?

This is clearly one (or several) bad apples. It's abuse and fraud. But, desiring to perform a procedure in a less intensive (and less expensive) venue of care should be permissable provided that alternative venue is safe.

 

[Aether2000]

Agree...but ASCs do NOT cost less than office based procedures...they frequently cost much much more. ASCs MAY cost less than hospitals, but they place temptation in the pocket of pain physicians when they are not ethical. When ethical behavior is mandated for ASC owners by law then I will gladly support them. ASCs are frequently used as a vehicle for patient overcharges by physicians and therefore I would submit hospitals may ultimately be better for patients until overcharges are eradicated.

 

[SleepIsGood]

it may be naive and/or offensive - but it works...

and while i couldn't care less about ASCs --- this issue is an important one... as soon as you allow govt to whittle down services here and there, it becomes a slippery slope.... and MOST of the time, when govt decreases ASCs reimbursements it is a direct result of hospitals lobbying against ASCs... what is next, clearly office procedures will be targeted bby hospitals as a diversion of potential income.

we better make a stand somehow, or else we will end up in the same boat as cardiology (hit with 30% decrease in reimbursement for ECHOs and Stress tests done in their office).

As he points out...what we do not want is to go down the 'slippery slope'. That's why we have to intervene.

 

[drusso]

Agree...but ASCs do NOT cost less than office based procedures...they frequently cost much much more. ASCs MAY cost less than hospitals, but they place temptation in the pocket of pain physicians when they are not ethical. When ethical behavior is mandated for ASC owners by law then I will gladly support them. ASCs are frequently used as a vehicle for patient overcharges by physicians and therefore I would submit hospitals may ultimately be better for patients until overcharges are eradicated.

My issue is the continued pealing away of bonafide medical judgment from physicians regarding the appropriate level of care required. I also feel like this is indicative of the current culture of medicine these days. If I feel I can safely do a procedure in my office (and have the staff and resources to do it), then the office is the appropriate venue. If I need the resources of an ASC (maybe dedicated anesthesia service or something), then an ASC is appropriate. If I need the whole enchilada of a hospital OR, then I'll do it there.

As far as ethics, I thought that was what specialty society white-papers, practice guidelines, position statements, and peer-review was for? I know it sounds a bit naive, but if physicians continue to turn to "the government" or "the hospital" for policing instead of policing ourselves, we will continue to devolve from being a profession to being a trade. Back in the "bad old days" doctors worked out these issues via "spirited" discussion in the Doctor's Lounge, served on hospital boards, determined their own privileges/credentialing issues, maintained their own active private practice, and were active in regional and national medical socities...

Oh well, maybe Obama will fix it for us.

 

[Aether2000]

Apparently as far as physicians are concerned, ethics do not include discussions about physician avarice, fleecing of patients, or misrepresentation. Capitalism, in its most horrific form and with few controls, is embraced in health care as increasing numbers of "profit centers" within a physicians portfolio proliferate. The patients are being obscenely overcharged in ways that would be considered illegal in many industries. We have physician owners of ASCs that attempt to extract the maximum profit out of patients, causing bankrupcies and mortgaging of their houses due to physician misrepresentation of z-joint RF as a "cure" or "fix". We have cowboy spine surgery centers such as Microspine, Bonati institute, and Laser Spine that charge $25,000 in cash for 30-45 min procedures. There are physicians charging $400 to use ultrasound to do an injection that would have cost the patient $75 10 min before the physician acquired the ultrasound machine and with few studies demonstrating tangible benefits. We have pain physicians continuing to do a "series of 3" injections long after it has been shown to be nonsensical and in some situations, harmful due to adrenal suppression effects.
Perhaps it is time for the medical industry to begin to be held accountable for overcharges and profiteering that is definitely causing harm to patients. Perhaps ASCs, which can be solely owned by a physician who does procedures at these centers (self dealing) should come under scrutiny of regulators. After all, the original legal basis for the existence of ASCs were that they provided an extension of hte physician's office practice in lieu of hospital based procedures, but now with offices capable of being certified by the same national agencies certifying ASCs, and given the physician's inability to control themselves in overcharging patients they refer to their ASCs, perhaps it is time ASCs become relics in pain medicine. No, I think I will decline lobbying for more ASC influence and reimbursement. It is indeed a slippery slope when the owners of these profit centers begin crying foul. Interventional pain physicians are among the most highly compensated physicians in the country, both on the average, and at the extremes, and whining to congress about their inability to generate even more profit in their ASCs seems absurd to me.

 

[lobelsteve]

Apparently as far as physicians are concerned, ethics do not include discussions about physician avarice, fleecing of patients, or misrepresentation. Capitalism, in its most horrific form and with few controls, is embraced in health care as increasing numbers of "profit centers" within a physicians portfolio proliferate. The patients are being obscenely overcharged in ways that would be considered illegal in many industries. We have physician owners of ASCs that attempt to extract the maximum profit out of patients, causing bankrupcies and mortgaging of their houses due to physician misrepresentation of z-joint RF as a "cure" or "fix". We have cowboy spine surgery centers such as Microspine, Bonati institute, and Laser Spine that charge $25,000 in cash for 30-45 min procedures. There are physicians charging $400 to use ultrasound to do an injection that would have cost the patient $75 10 min before the physician acquired the ultrasound machine and with few studies demonstrating tangible benefits. We have pain physicians continuing to do a "series of 3" injections long after it has been shown to be nonsensical and in some situations, harmful due to adrenal suppression effects.
Perhaps it is time for the medical industry to begin to be held accountable for overcharges and profiteering that is definitely causing harm to patients. Perhaps ASCs, which can be solely owned by a physician who does procedures at these centers (self dealing) should come under scrutiny of regulators. After all, the original legal basis for the existence of ASCs were that they provided an extension of hte physician's office practice in lieu of hospital based procedures, but now with offices capable of being certified by the same national agencies certifying ASCs, and given the physician's inability to control themselves in overcharging patients they refer to their ASCs, perhaps it is time ASCs become relics in pain medicine. No, I think I will decline lobbying for more ASC influence and reimbursement. It is indeed a slippery slope when the owners of these profit centers begin crying foul. Interventional pain physicians are among the most highly compensated physicians in the country, both on the average, and at the extremes, and whining to congress about their inability to generate even more profit in their ASCs seems absurd to me.

This is the kind of speech that needs to get delivered in front of Congress. Or at least to the media.

 

[PMR 4 MSK]

Apparently as far as physicians are concerned, ethics do not include discussions about physician avarice, fleecing of patients, or misrepresentation. Capitalism, in its most horrific form and with few controls, is embraced in health care as increasing numbers of "profit centers" within a physicians portfolio proliferate. The patients are being obscenely overcharged in ways that would be considered illegal in many industries. We have physician owners of ASCs that attempt to extract the maximum profit out of patients, causing bankrupcies and mortgaging of their houses due to physician misrepresentation of z-joint RF as a "cure" or "fix". We have cowboy spine surgery centers such as Microspine, Bonati institute, and Laser Spine that charge $25,000 in cash for 30-45 min procedures. There are physicians charging $400 to use ultrasound to do an injection that would have cost the patient $75 10 min before the physician acquired the ultrasound machine and with few studies demonstrating tangible benefits. We have pain physicians continuing to do a "series of 3" injections long after it has been shown to be nonsensical and in some situations, harmful due to adrenal suppression effects.
Perhaps it is time for the medical industry to begin to be held accountable for overcharges and profiteering that is definitely causing harm to patients. Perhaps ASCs, which can be solely owned by a physician who does procedures at these centers (self dealing) should come under scrutiny of regulators. After all, the original legal basis for the existence of ASCs were that they provided an extension of hte physician's office practice in lieu of hospital based procedures, but now with offices capable of being certified by the same national agencies certifying ASCs, and given the physician's inability to control themselves in overcharging patients they refer to their ASCs, perhaps it is time ASCs become relics in pain medicine. No, I think I will decline lobbying for more ASC influence and reimbursement. It is indeed a slippery slope when the owners of these profit centers begin crying foul. Interventional pain physicians are among the most highly compensated physicians in the country, both on the average, and at the extremes, and whining to congress about their inability to generate even more profit in their ASCs seems absurd to me.

The counter-argument for ASCs is why should the hospitals get all the money? Most of them have spent their entire existence screwing patients and doctors in the name of money. Those that are privately owned and for-profit are the worst at it, while the publicly owned hospitals struggle to get repairs on basic equipment and infrastructure because of their insurance base (heavy Medicaid and uninsured).

Everything in medicine now comes down to money. If you are employed and salaried w/o financial incentives to make more money for the company you work for, you are most likely working inefficiently and at risk of being a financial loss for your employers. If you are fee-for-service or salary + bonus, you risk letting money become the motivating factor for treatment options.

From my discussion about medical economics with many people inside and outside of medicine, the overwhelming majority of non-physicians are of the opinion that a doctor should be the ultimate atruist, sacraficing himself, his economics and his family in favor of the patient. No one will come out and say this, but with their uneducated opinions on the matter, they believe that doctors should never consider finances when deciding on a treatment, unless it is they (the debator) who is the patient and has to spend their own money. No one wants to think of granny being forced out of a nursing home due to running out of money (yet the same people would likely be very against opening their own checkbooks to help granny stay in the NH).

Many interventional pani physicians indicate they want laws and/or rules regarding things like the "series of three" and over-utilization of MRIs or ASCs. Yet whenever the government steps in, doctors cry out "STAY OUTTA MY BUSINESS!!!" (see 9 out of 10 posts on Sermo e.g.). CMS could say "No more 'series of three' epidurals" and that would be interpreted as no more than 2/patient. Would that be per month, per year or per lifetime?

Doctors, by and large, are terrible at business, yet very protective of their finances. We tend not to have a really good grasp of the forces at work in the marketplace and see things from our limited point of view. We've had it good for many years, yet many forces are constantly attacking us - incursions by allied and mid-level practioners, reductions in payment by government and insurance comapnies and by the public in general who perceive us to be a greedy, unethical lot (except their personal physicians who are all good guys - it's all them other guys who are bad...).

Doctors are also guilty of being too altruistic, indeed sacraficing everything for a patient who may or may not appreciate it, and who, like the stray dog hit by a car, may symbolically bite us as we try to help them. Many of us, if not most, have had the pleasure of waiving fees, treating patients for free, staying late after hours only to have the patient we did that for turn around and file a complaint or lawsuit against us. In pain medicine, we've done that too much with opioids.

Medicine, like any other capitalist business in America, will always have people abusing the system from both sides, doctor and patient alike. Physicians are generally held to a higher standard, and should be, as we are the ones educated and trained. We all agree that a doctor who takes advantage of patients financially, emotionally or otherwise needs to ahve their license revoked. But there is a very large gray area of what constitutes fraud or abuse. What you consider fraud, they will call good business practices.

I agree we must be very cautious before demanding congress step in and help us, as we all know the scariest words you can hear - "I'm from the government and I'm here to help you!"

<Steps off soapbox for now>

 

[drusso]

Hospital CEO's are not our friends.

 

[Jcm800]

Hospital CEO's are not our friends.

they are mine. They told me today at a meeting. It must be true

 

[SleepIsGood]

The counter-argument for ASCs is why should the hospitals get all the money? Most of them have spent their entire existence screwing patients and doctors in the name of money. Those that are privately owned and for-profit are the worst at it, while the publicly owned hospitals struggle to get repairs on basic equipment and infrastructure because of their insurance base (heavy Medicaid and uninsured).

Everything in medicine now comes down to money. If you are employed and salaried w/o financial incentives to make more money for the company you work for, you are most likely working inefficiently and at risk of being a financial loss for your employers. If you are fee-for-service or salary + bonus, you risk letting money become the motivating factor for treatment options.

From my discussion about medical economics with many people inside and outside of medicine, the overwhelming majority of non-physicians are of the opinion that a doctor should be the ultimate atruist, sacraficing himself, his economics and his family in favor of the patient. No one will come out and say this, but with their uneducated opinions on the matter, they believe that doctors should never consider finances when deciding on a treatment, unless it is they (the debator) who is the patient and has to spend their own money. No one wants to think of granny being forced out of a nursing home due to running out of money (yet the same people would likely be very against opening their own checkbooks to help granny stay in the NH).

Many interventional pani physicians indicate they want laws and/or rules regarding things like the "series of three" and over-utilization of MRIs or ASCs. Yet whenever the government steps in, doctors cry out "STAY OUTTA MY BUSINESS!!!" (see 9 out of 10 posts on Sermo e.g.). CMS could say "No more 'series of three' epidurals" and that would be interpreted as no more than 2/patient. Would that be per month, per year or per lifetime?

Doctors, by and large, are terrible at business, yet very protective of their finances. We tend not to have a really good grasp of the forces at work in the marketplace and see things from our limited point of view. We've had it good for many years, yet many forces are constantly attacking us - incursions by allied and mid-level practioners, reductions in payment by government and insurance comapnies and by the public in general who perceive us to be a greedy, unethical lot (except their personal physicians who are all good guys - it's all them other guys who are bad...).

Doctors are also guilty of being too altruistic, indeed sacraficing everything for a patient who may or may not appreciate it, and who, like the stray dog hit by a car, may symbolically bite us as we try to help them. Many of us, if not most, have had the pleasure of waiving fees, treating patients for free, staying late after hours only to have the patient we did that for turn around and file a complaint or lawsuit against us. In pain medicine, we've done that too much with opioids.

Medicine, like any other capitalist business in America, will always have people abusing the system from both sides, doctor and patient alike. Physicians are generally held to a higher standard, and should be, as we are the ones educated and trained. We all agree that a doctor who takes advantage of patients financially, emotionally or otherwise needs to ahve their license revoked. But there is a very large gray area of what constitutes fraud or abuse. What you consider fraud, they will call good business practices.

I agree we must be very cautious before demanding congress step in and help us, as we all know the scariest words you can hear - "I'm from the government and I'm here to help you!"

<Steps off soapbox for now>

Excellent post.

Here's what I think. All physicians who have done med school (better be everyone then right) and a US residency has done essentially 8 years of 'volunteer' work. What other profession limits themselves to somtimes 100 hour weeks (oops it's 80 😎) and receives nominal or NO pay (3rd, 4th year med students).

I think as physicians we need to demand what's deserved. Yes, it's true that we all voluntarily went into this, but who would patients rather have? The high school dropout who attended a community college and barely got by taking care of their child, mother, father,etc? Common sense says no.

For physicians to get reimbursed is not being greedy. It's simply being fair. We all need to get out of the mindset of being residents and students and working for free. Everyone has got expenses.

 

[Aether2000]

Residency, with its long hours, is not only a rite of passage, but represents a concentrated educational experience that is rarely replicated after that time. 60 years ago, the physician would pay to have the opportunity to do a residency program, but now physicians whine about having to spend a few years working long hours to the degree that some residencies are actively considering lengthening the training years required due to inadequate exposure of residents to sufficient pathology to be competent (neurosurgery is considering expansion to 7 years because of government imposed restrictions on work hours that were brought about in part by resident complaints). Residency is not working for free, and in fact residents today are paid salaries well above the average income, nearly twice as much, as the average US worker income. Pain physicians earn in the top 1 percentile of the entire country and it could easily be argued this is undeserved compared to not only other physicians, but to the general population. I suppose I do not subscribe to the sense of entitlement to wealth some physicians claim since there are many other professions in which the work is just as difficult, the educational experience is as challenging, and the risks are high, but the incomes are low. I am personally gratified by having a high income but in no way believe I am entitled to it because of residency experience, long hours (I typically work a 40 hour week), or educational achievements (some of my friends have 2 PhD degrees and work far more hours to make only a fraction of what I make). I can't justify high income through call obligations since I receive around 1 call every 2-3 weeks at night and go into the hospital for emergencies around twice a year. Risks? Yes, they are there but I don't lose sleep over them, and try to mitigate risk through patient education and documentation. The medical risks are a part of what we do and are trained to do, and that is why we carry malpractice insurance. The business risks are not really any different than running any business...if you buy gold plated equipment that is 2-10 times as expensive as other units available, are you being wise or foolish financially- it depends...so one has to stratify business risks just as any business does.
Given the above, on what basis should I go to Congress, as a person earning in the top 1% of the country, and cry about not being able to do discography in an ASC I own in order to generate more income? I am no friend of the hospitals as they develop their oligarchy of ownership of surgery centers, MRIs, physician practices, etc. They have acquired legal protective status that shields them from antitrust and monopoly concerns at the same time physicians are punished via Stark should they attempt to do the same thing hospitals are doing. But I find it difficult to justify petitioning congress to force CMS to change a single rule in order to enrich myself even further. If people are really concerned about hospitals making all the money, why not simply do the procedures in your office?

 

[Tenesma]

here is a side issue w/ 1% of income earners... and i thought it appropriate considering it is tax season...

first of all 1% of income earners is anybody over $400k (based on one report i read).... I have to pay the same rate of tax regardless of my expenses....
So my lawyer who makes as much as I do, but who has no student loans, pays the same amount of tax as I do with tons of student loans... argh...

 

[Paindoc13]

Sorry Algosdoc, how much is your student loan? And what was it when you graduated? It's much easier to say the things you are saying being in your current shoes. Why don't you stop and put yourself in the shoes of the "new doctor?" Sorry, I have PhD friends as well and they make less but don't work nearly as hard as I do (not just talking hours) and don't have nearly the debt I do. With this all being said, I have no opinion on the whole ASC, but I'm very frustrated with the senior docs letting us young docs get the shaft. And no offense but the "senior docs" are what have gotten us in this position.

 

[Jcm800]

Sorry Algosdoc, how much is your student loan? And what was it when you graduated? It's much easier to say the things you are saying being in your current shoes. Why don't you stop and put yourself in the shoes of the "new doctor?" Sorry, I have PhD friends as well and they make less but don't work nearly as hard as I do (not just talking hours) and don't have nearly the debt I do. With this all being said, I have no opinion on the whole ASC, but I'm very frustrated with the senior docs letting us young docs get the shaft. And no offense but the "senior docs" are what have gotten us in this position.

i have been in practice for 4 years, and each year i have made about the same, despite working harder every year. I think it is easy for someone to say yes we make in the 1% of incomes, when they have made that income (and likely, much much more than i ever have in a single year "back in the day") for 15-20-25 years.
I dont need to make MORE money than i do now, but I would like to make the SAME amount for some time, at least until I have broken even with my business collegues with 4 year education, and 14 years of earning potential compared to my last 4.

Its easy for those who have made the money for a long time to say that we make too much.

but why is it considered greedy that I would like to earn the same in my lifetime as they have in theirs?

 

[Aether2000]

Since my debts were incurred over a quarter of a century ago, I can put it in perspective for you: my debt on finishing residency was approximately 1/3 the average debt today. My starting salary was 1/3 of the salary I am now making. My resident salary was 1/3 that of residents today. My debt was paid off in 4 years because I made a concerted effort to do so. I agree the sums of today's debts are staggering!

 

[Tenesma]

DocShark - i agree 100%... my volume is growing by about 20% per year ---and yet my income is slipping away steadily... it is beyond frustrating and disheartening.

 

[Aether2000]

If that is happening, then there is something wrong with your business model. Examine the reasons for this.....insurers are not cutting reimbursement by 20% a year so there must be something terribly wrong with the balance sheet. I have not seen this 20% a year decrease but we do stay on top of everything financial including minimizing our expenses, competitive bidding on supplies, and collecting copays and deductables before the patient is seen. Our AR is quite manageable.

 

[lobelsteve]

I do not own, nor am I a partner. I do not concern myself with expenses. I do get peeved when I have no say on incompetent staff, but I trade that off with not having any responsibility other than to patients.

 

[Aether2000]

Ah, it is true different practice models allow for varying amounts of control. Working for a hospital gives you the least amount of administrative headaches but virtually no control, and having to accept whatever payor class mix comes to the door (increasing Medicaid=decreasing physician income). Being a partial owner of a practice means having to deal with the other partners and their idiosyncracies. Being totally independent of hospitals and ASCs and partnerships gives you the most flexibility in what you will or won't accept, but is laced with multiple administrative decisions that must be made every day. Each model has benefits and downsides...

 

[drusso]

Ah, it is true different practice models allow for varying amounts of control. Working for a hospital gives you the least amount of administrative headaches but virtually no control, and having to accept whatever payor class mix comes to the door (increasing Medicaid=decreasing physician income). Being a partial owner of a practice means having to deal with the other partners and their idiosyncracies. Being totally independent of hospitals and ASCs and partnerships gives you the most flexibility in what you will or won't accept, but is laced with multiple administrative decisions that must be made every day. Each model has benefits and downsides...

*Rant On*

I chose private practice realizing that my generation would probably be the last generation to have a legitimate opportunity to own the means of one's labor in medicine. Unfortunately, the way medical students and residents are being acculturated these days is geared toward becoming an employed physician.

I believe that this affects the way the doctors practice in subtle and not-so-subtle ways. The emphasis and locus of practice is shifted away from the individual doctor-patient relationship and toward "the system." Residency programs no longer inculcate their trainees in the Hippocratic tradition where the physician is the "captain of the ship" and instead steep them in "system-baseed practice," and "evidenced-based medicine," eschewing individual judgement, accountability, and autonomy.

I believe that the hospital-employed/large group model, absent strong physician leadership, can lead to a certain kind of "learned helplessness" and "group-think" mentality among the rank-and-file physicians who practice in these venues. I saw this during my training. Time-clock punching doctors with no knowledge, interest, or drive to understand the larger economic and political forces that influence their day-to-day choices.

I see this when I attend the mixed medical staff meetings at our hospitals. The private practice doctors are usually the vigorous contrarians and skeptical opposers of new hospital policies and procedures while the hospital employed physicians sit silently and "take the lumps." For them to disagree is insubordination.

Every time I see this I'm reminded of the final stanza of T.S. Eliot's poem The Hollow Men.

"This is the way the world ends
This is the way the world ends
This is the way the world ends
Not with a bang but a whimper. "

To each his own I suppose. When I began my medical training I was groomed for a career in academic medicine. But years of training in academic centers showed me the perils of handing one's "balls" over to a department Chairman or administrator and being lulled into a false sense of career security. In my training when I vocally opposed certain policies and methods in my department I was told by the department Chair that I had "trust issues." Interesting...

So, when I hear that yet another Bull has been issued from on high about where, when, or what I can do for my patients to diagnose and treat their pain (be it access to discography, reimbursement for neuromodulation, indications for RFA, etc) I get angry. How did *we* (expert physicians) let it come to this? By trusting the judgement of others (meta-analysisticians, insurance company medical directors, utilization reviewers, etc) above our own I suppose. Oops, my trust issues are showing again.

*Rant Off*

 

[Aether2000]

I cannot agree more with your comments about "group think" by current training programs. Doctors are made to feel it is somehow alright to sell their medical practices to hospitals or become hospital employees or become slaves to the clipboard nurses that administrate how to wash your hands to the types of needles physicians will use. It is such physician passive acquiescence that ultimately turns out to be a Faustian bargain: the hospitals could care less about physician welfare. Hospitals have one goal in mind, whether they be non-profit, not-for profit, academic, or for profit: they all want to make money. Lots of money. And they can best do it by getting their physician staff to order as many tests as possible, do as many surgeries as possible, and utilize lower paid physician employees. Nearly every hospital in a 50 mile radius from me has either added on major new units or built entirely new hospitals in the last 2 years. They can only do this by amassing a fortune, and physicians become unwitting accomplices to their avarice.
Residents are emasculated by their training programs by not being given the practical tools and training to develop an independent medical practice with its own set unique of problems that academic programs fail to address.

 

[Jcm800]

I cannot agree more with your comments about "group think" by current training programs. Doctors are made to feel it is somehow alright to sell their medical practices to hospitals or become hospital employees or become slaves to the clipboard nurses that administrate how to wash your hands to the types of needles physicians will use. It is such physician passive acquiescence that ultimately turns out to be a Faustian bargain: the hospitals could care less about physician welfare. Hospitals have one goal in mind, whether they be non-profit, not-for profit, academic, or for profit: they all want to make money. Lots of money. And they can best do it by getting their physician staff to order as many tests as possible, do as many surgeries as possible, and utilize lower paid physician employees. Nearly every hospital in a 50 mile radius from me has either added on major new units or built entirely new hospitals in the last 2 years. They can only do this by amassing a fortune, and physicians become unwitting accomplices to their avarice.
Residents are emasculated by their training programs by not being given the practical tools and training to develop an independent medical practice with its own set unique of problems that academic programs fail to address.

this is spot on. Hospitals have used and abused the employed physician with a new re-invented vigor as of late. Anesthesiologists are most guilty of this. Turining over COMPLETE control, so as to "improve their lifestyles" i know many employed physicians make good money and a good lifestyle, but I know many private anesthesiologists make AMAZING money, and pretty good life as well. Hospitals dont want you to know that...

Residency programs frown upon independant thought and interest in determining their own futures. entrepreneurship is looked upon as greed. Hospitals make money hand over fist, and it is at the expense of the emplyed physicians, all the while lulling them to believe they have a great deal. Residency programs work for the hospitals, interestingly...

by making us believe we couldnt possibly "manage the headache" of being in a solo or small physician group, we feel there is no option but to join the hospital so they can "help us" have a good lifestyle. Large mulit-specialty groups are not much better.

CLearly as shown by many of us on this board, being solo or in a small group can be done. Its just a different spectrum of headaches and issues to deal with. But I for one, would take my specific running of a business set of headaches, versus the set of headaches that came with the subtle "just remember, you work for me" that was echoed from the hospital administrator, the hospital medical staff, the nurses, the patients, and at times i felt even by the cafeteria folk...

 

[PMR 4 MSK]

It's all about risk assesment when deciding solo vs group.

Risk averse = lower pay with group, at least in theory. Risk tolerant = solo.

However, I can tell you from personal experience that private groups can come with better negotiating power for contracts, lower overhead due to economies of scale and the ability to employ smart people who improve your cash flow more than what it costs to employ them. The con side is loss of autonomy.

Hospital groups come with tons of red tape, more rules and regulations than you could possibly learn, and more politics than anywhere outside of Washington. If you are good with politics, they will stroke your ego all day and night. The only plus is the name affiliation, if it is a good name in the community.

 

[pjuer]

Lax/ASIPP has consistently been a far better friend to those pain docs who own ASCs than to the rest who practice in other locations.

In short, Lax tends to do what's best for ... Lax (not surprisingly)

It could be because he owns two surgery centers

 

[SleepIsGood]

It could be because he owns two surgery centers

Who cares...

Dont hate the player, hate the game.

I dont care if he owns 100 surgery centers. If the guy is smart, business savvy, and is doing well. Great for him! I just think Physicians should be making decisions about medical care, not insurance companies/hospitals.

 

[clubdeac]

This is great stuff to read and very enlightening for a young physician like myself who is recently out on my own. I think one of the problems is our medical training (med school and residency). Nowhere are physicians properly educated and prepared for the financial and economical aspects of medicine. I think it would be good to have a core curriculum on the business side of medicine. After all, most of us are so focused on medicine, and have been for so many years, that we are clueless when it comes to anything remotely outside of medicine.... at least that's where I am right now

 

[Disciple]

Lax/ASIPP has consistently been a far better friend to those pain docs who own ASCs than to the rest who practice in other locations.

In short, Lax tends to do what's best for ... Lax (not surprisingly)

If I'm not mistaken, there's language in the health care bill doing away with physician ownership in facilities, or expansion of existing ones.

Interesting to see what ASIPP does about that one.

 

[ampaphb]

If I'm not mistaken, there's language in the health care bill doing away with physician ownership in facilities, or expansion of existing ones.

Interesting to see what ASIPP does about that one.

I received this email from the PHA (Physicians Hospitals of America) today:

PHA Members and Associates:

As all of you are undoubtedly aware, last night the US House passed healthcare reform legislation on a vote of 219 to 212. Subsequently, the House also passed its package of amendments to that bill through with a 220 to 211 vote to pass the reconciliation bill. It is expected that the President will sign the bill into law tomorrow.

The Senate will begin the process of considering the House reconciliation package Tuesday. Twenty hours of debate on the bill will be allowed, equally divided by Democratic and Republican members. Under the Rules of the Senate, unlimited amendments can be offered during this process. The Republicans are expected to offer numerous amendments. Leader Reid and other high ranking Democratic Senators have ensured the members of the House that the reconciliation package will pass the Senate. Only 51 votes are needed to pass reconciliation in the Senate.

Once the reconciliation package passes the Senate, it too will be signed into law and will officially amend the healthcare reform package just passed by the House. Please keep in mind that should the Senate change the reconciliation package just passed by the House, those changes will go back to the House for further approval and possibly a House/Senate conference.

Impact of Legislation on Physician Hospitals:

As stated above, the base healthcare reform package will be signed into law tomorrow. The bill is the same as that passed by the Senate on December 24th, 2009. The following bullet points detail the impact of this bill:

1. Physician hospitals who have Medicare Certification in place by August 1, 2010 and who meet specific requirements within 18 months of the enactment of the legislation, will be grandfathered.

2. All hospitals in existence on the date of enactment (tomorrow), will be grandfathered.

3. As a grandfathered hospital, the aggregate percentage of your physician ownership cannot be increased after the date of the passage of the bill (tomorrow).

4. Also, as a grandfathered hospital, you would be required to meet 4 specific requirements in order to be allowed to apply to HHS to grow your hospital. If you do not meet these requirements, you cannot add beds, ORs or procedure rooms. According to our latest study, taking into account every physician hospital of which we are aware, no physician owned hospital currently meets each of the 4 requirements. In other words, none of our physician hospitals will be allowed to grow as of the date of the passage of the bill (tomorrow).

5. If you have an existing physician hospital that is currently under construction, it is unclear whether you will be allowed to have new beds, new ORs and new procedure rooms certified upon completion.

6. The impact of the restrictions on growth and change in percentage ownership on those hospitals that anticipate receiving initial Medicare certification by August 1, 2010 are not entirely clear. However, we believe that these hospitals will have until the date of their application for Medicare certification to grow and adjust percentages of physician ownership.

7. Additional requirements must be met in order for existing hospitals to be grandfathered and for hospitals under development that will be completed by August 1, 2010 to be grandfathered. These requirements are not new and require such things as disclosure of ownership, disclosure of physician coverage, ability to meet EMTALA standards, and other financial disclosure requirements that are already in place.

8. Finally, according to the language of the final legislation, if a physician owned hospital does not have its Medicare Provider Number by August 1, 2010, it will not be grandfathered. Whether those hospitals will be able to receive Medicare certification at all is not clear at this time. What is clear is that physician owners will not be allowed to bring Medicare/Medicaid patients to those hospitals.

Obviously, these provisions are extremely harmful… They virtually destroy many of the hospitals that are currently under development, and leave little room for the future growth of the industry. I will provide a more formal analysis of this language shortly. However, because regulations are not expected to be promulgated for at least 18 months, there are certain to be many grey areas in interpreting this language.

You will notice that in the impact analysis above, I did not include the new date of December 31st, 2010 that was included in the House reconciliation package. I also did not include the new provision regarding growth of hospitals that are the highest Medicaid provider in the county… I want to make certain this is clear – until the Senate passes the reconciliation package as well, the December 31st date for hospitals under development and new growth provision do not apply. The August 1, 2010 deadline and old growth provisions still apply.

 

[Disciple]

The term "hospitals" doesn't include surgery centers though, correct?