ACOs and bundled payments

[clubdeac]

We are repeatedly being told that the way providers and hospitals are currently paid will dramatically change in the next 2-3 years. We will move away from fee for service to “value based care” with large payers reimbursing a lump sum for a particular ICD-10 code. It will then be up to the hospitals to determine how that money is spent. Is anyone else hearing this and what does it mean for our future salaries? I’m assuming the worst but I really don’t have any facts or insight to base this on. Also where is this change coming from? Is this part of the ACA??

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[drusso]

We are repeatedly being told that the way providers and hospitals are currently paid will dramatically change in the next 2-3 years. We will move away from fee for service to “value based care” with large payers reimbursing a lump sum for a particular ICD-10 code. It will then be up to the hospitals to determine how that money is spent. Is anyone else hearing this and what does it mean for our future salaries? I’m assuming the worst but I really don’t have any facts or insight to base this on. Also where is this change coming from? Is this part of the ACA??

It means "Welcome to the Post Office." It means that patients in capitated health plans will receive their aliquot of population-based "Government Cheese" medical treatment while patients with access to resources will be receiving personalized medical treatment in the private sector. FWIW, the Mayo Clinic doubling down the personalized medical treatment pathway and letting others dole out the Government Cheese...

 

[SSdoc33]

It means "Welcome to the Post Office." It means that patients in capitated health plans will receive their aliquot of population-based "Government Cheese" medical treatment while patients with access to resources will be receiving personalized medical treatment in the private sector. FWIW, the Mayo Clinic doubling down the personalized medical treatment pathway and letting others dole out the Government Cheese...

nonsense as usual.

if you have something concrete to say, then say it. your post is just bitching and propaganda. you dont know anything more than clubdeac at this point

 

[lonelobo]

We are repeatedly being told that the way providers and hospitals are currently paid will dramatically change in the next 2-3 years. We will move away from fee for service to “value based care” with large payers reimbursing a lump sum for a particular ICD-10 code. It will then be up to the hospitals to determine how that money is spent. Is anyone else hearing this and what does it mean for our future salaries? I’m assuming the worst but I really don’t have any facts or insight to base this on. Also where is this change coming from? Is this part of the ACA??

Been hearing this for over 5 years...have not seen it in my area

 

[drusso]

nonsense as usual.

if you have something concrete to say, then say it. your post is just bitching and propaganda. you dont know anything more than clubdeac at this point

Because whenever the Government gets involved, things get better? You're ignorant of the serious work that has been done in this area and the potential damage that M4A/single-payer/Federalized ACO proposals pose to the doctor-patient relationship and the independent practice of medicine.

‘Medicare for All’ Gets Much-Awaited Report. Both Sides Can Claim Victory. (Published 2019)

The Congressional Budget Office usually offers detailed estimates, but not in this case.

www.nytimes.com

"Would the government eliminate the denials and other red tape that annoy Americans about the private health insurance system? Maybe, or maybe not. The paper notes that requiring patients to see a primary care doctor before a specialist; denying a treatment that is unusual; or requiring patients to try less expensive drugs before more expensive alternatives would all be possible under single-payer, and are limitations with such systems in other countries."

https://www.cbo.gov/system/files/2019-05/55150-singlepayer.pdf

 

[SSdoc33]

"Would the government eliminate the denials and other red tape that annoy Americans about the private health insurance system? Maybe, or maybe not. The paper notes that requiring patients to see a primary care doctor before a specialist; denying a treatment that is unusual; or requiring patients to try less expensive drugs before more expensive alternatives would all be possible under single-payer, and are limitations with such systems in other countries."

https://www.cbo.gov/system/files/2019-05/55150-singlepayer.pdf

[/QUOTE]

why do you think i am in favor of single payor? you are using me as a tool in your "me against the world" philosophy.



the OP wanted to know if and when the value based care/capitation model will go into effect. if you know, great. tell us. if not, zip it, dude. your schtick is tiresome

 

[DOctorJay]

We are repeatedly being told that the way providers and hospitals are currently paid will dramatically change in the next 2-3 years. We will move away from fee for service to “value based care” with large payers reimbursing a lump sum for a particular ICD-10 code. It will then be up to the hospitals to determine how that money is spent. Is anyone else hearing this and what does it mean for our future salaries? I’m assuming the worst but I really don’t have any facts or insight to base this on. Also where is this change coming from? Is this part of the ACA??

Ask whoever is telling you this to provide something in writing for you to review. I think this is simply a tactic to negotiate contracts down at this point.


Sent from my iPhone using SDN

 

[clubdeac]

just had to complete several training modules on ACOs and bundled payments yesterday. Apparently my health care system will be completely done with the fee for service payment model by 2021.... and I will yet again be forced to look for another job... shoot me now!!

 

[Ferrismonk]

It's still the rarity, although I've seen some. I used to work closely with a large PCP ACO in my area. They would refer all their pain patients to me and I would handle their opiate problems (basically). They stopped referring after about a year and a half because 1) I did too many procedures which were costing them money 2) I did injections "which help for a while but the patient just needs to go to physical therapy more to actually fix the problem" (I send basically everyone to PT or document why it doesn't make sense) 3) I made opiate patients see me every month for evaluation (why can't you just see them every 3 months?) and 4) I was "stealing" their simple joint injections in office which they use as a money maker for their non-ACO patients.

tlr - They wanted everyone to get q3 month opiates and no injections due to bundled payments

Also, my group absorbed a certain hospital's pain service (by their request) because the cost of the pain clinic vs the measurable benefit made them look less efficient to payors and was hurting their numbers.

I see this happening more and more, at least until people revolt and refuse to participate.

 

[drusso]

just had to complete several training modules on ACOs and bundled payments yesterday. Apparently my health care system will be completely done with the fee for service payment model by 2021.... and I will yet again be forced to look for another job... shoot me now!!

Welcome to the post office. The Noctor will see you now. Go private.

 

[deleted993114]

We are repeatedly being told that the way providers and hospitals are currently paid will dramatically change in the next 2-3 years. We will move away from fee for service to “value based care” with large payers reimbursing a lump sum for a particular ICD-10 code. It will then be up to the hospitals to determine how that money is spent. Is anyone else hearing this and what does it mean for our future salaries? I’m assuming the worst but I really don’t have any facts or insight to base this on. Also where is this change coming from? Is this part of the ACA??

The ACO contracts are made by hospitals and providers, but the main driver are primary care groups. So far, pain management is not a "big fish" for anyone to worry about. However, I was recently a part of a very large primary care group and my main responsibility was to:

1. cut unnecessary imaging costs, which were huge. This will be a big function for pain docs in the future.
2. offer pain services as cheaply as possible in an office based setting
3. provide guidelines for the primary care docs involving cost effective, appropriate care for different diagnostic groups.
4. reduce opioid doses to be in compliance with the CDC guidelines, or get off narcotics.
5. reduce ER visits, primarily for headache patients.

In our practice, the primary care docs made 50% of their money on value based contracts. In 5 years, they estimate that it will go up to 75%.

How quickly will this affect pain? Who knows. However, due to my efforts, one practice was "dried up", as they were a procedure only based practice at a surgery center and were a very high cost, poor outcome, practice. Only last year did blue cross add "back pain" as one of their quality indicators. I would assume this will spread to other insurers and encompass neck pain and headaches.

 

[drusso]

The ACO contracts are made by hospitals and providers, but the main driver are primary care groups. So far, pain management is not a "big fish" for anyone to worry about. However, I was recently a part of a very large primary care group and my main responsibility was to:

1. cut unnecessary imaging costs, which were huge. This will be a big function for pain docs in the future.
2. offer pain services as cheaply as possible in an office based setting
3. provide guidelines for the primary care docs involving cost effective, appropriate care for different diagnostic groups.
4. reduce opioid doses to be in compliance with the CDC guidelines, or get off narcotics.
5. reduce ER visits, primarily for headache patients.

In our practice, the primary care docs made 50% of their money on value based contracts. In 5 years, they estimate that it will go up to 75%.

How quickly will this affect pain? Who knows. However, due to my efforts, one practice was "dried up", as they were a procedure only based practice at a surgery center and were a very high cost, poor outcome, practice. Only last year did blue cross add "back pain" as one of their quality indicators. I would assume this will spread to other insurers and encompass neck pain and headaches.

Lots of Big Assumptions. Assumes we know what value is, how to measure it. Assumes costs are legitimate. I would bet against Big Government solutions and double down on disruptive innovation, decentralized/person-centered medicine, direct primary care, etc. Costco offer great deals on toilet paper and laundry detergent but where do you go when you need your teeth cleaned?

 

[deleted993114]

It's still the rarity, although I've seen some. I used to work closely with a large PCP ACO in my area. They would refer all their pain patients to me and I would handle their opiate problems (basically). They stopped referring after about a year and a half because 1) I did too many procedures which were costing them money 2) I did injections "which help for a while but the patient just needs to go to physical therapy more to actually fix the problem" (I send basically everyone to PT or document why it doesn't make sense) 3) I made opiate patients see me every month for evaluation (why can't you just see them every 3 months?) and 4) I was "stealing" their simple joint injections in office which they use as a money maker for their non-ACO patients.

tlr - They wanted everyone to get q3 month opiates and no injections due to bundled payments

Also, my group absorbed a certain hospital's pain service (by their request) because the cost of the pain clinic vs the measurable benefit made them look less efficient to payors and was hurting their numbers.

I see this happening more and more, at least until people revolt and refuse to participate.

If pain providers "revolt", most of the primary care ACO docs won't care.

The future of pain practices will to be a PART OF (and not an enemy of) quality contracts. The group I was a part of is one of the leaders in the country for quality contracts. For my services, however, they had no current way to have pain docs benefit from the quality contracts as they do. Perhaps this will be an area to be explored in the future.

However, the trend will be toward less, not more, procedures and in a more cost effective environment. Rather than get mad, understand that this WILL OCCUR and make plans to adapt to the climate. Pain docs can save plans millions with their knowledge- it just needs to be spelled out and explored.

 

[deleted993114]

Lots of Big Assumptions. Assumes we know what value is, how to measure it. Assumes costs are legitimate. I would bet against Big Government solutions and double down on disruptive innovation, decentralized/person-centered medicine, direct primary care, etc. Costco offer great deals on toilet paper and laundry detergent but where do you go when you need your teeth cleaned?

One thing that can definitely be measured is imaging per capita, total medicine costs, and "checklists" for discussion of core exercises, remaining active, and proper lifting mechanics. Just like other quality contracts, there are questions that need to be answered to achieve "credit".

Keep in mind that quality contracts shift money from the inefficient to the efficient.

 

[drusso]

If pain providers "revolt", most of the primary care ACO docs won't care.

The future of pain practices will to be a PART OF (and not an enemy of) quality contracts. The group I was a part of is one of the leaders in the country for quality contracts. For my services, however, they had no current way to have pain docs benefit from the quality contracts as they do. Perhaps this will be an area to be explored in the future.

However, the trend will be toward less, not more, procedures and in a more cost effective environment. Rather than get mad, understand that this WILL OCCUR and make plans to adapt to the climate. Pain docs can save plans millions with their knowledge- it just needs to be spelled out and explored.

Coincidentally, I’m on a plane to attend a “visioning session” to map out the future of pain. I doubt airline economics and working for the post office will be popular options. I would double down in being nimble, patient-centered, and offering an escape hatch for patients who are tired of government-cheese medical care.

 

[drusso]

One thing that can definitely be measured is imaging per capita, total medicine costs, and "checklists" for discussion of core exercises, remaining active, and proper lifting mechanics. Just like other quality contracts, there are questions that need to be answered to achieve "credit".

Keep in mind that quality contracts shift money from the inefficient to the efficient.

Sounds like buying a Taxi Medallion in the age of Uber and Lyft.

 

[Ducttape]

the general progression of most businesses is toward consolidation and merger.

 

[hyperalgesia]

just had to complete several training modules on ACOs and bundled payments yesterday. Apparently my health care system will be completely done with the fee for service payment model by 2021.... and I will yet again be forced to look for another job... shoot me now!!

Easy for me to say this but I always feel like I can do better. This could be your opportunity to find something even better...

 

[deleted993114]

just had to complete several training modules on ACOs and bundled payments yesterday. Apparently my health care system will be completely done with the fee for service payment model by 2021.... and I will yet again be forced to look for another job... shoot me now!!

Adapt and become part of the solution. You, as a pain doc, have a tremendous amount of knowledge and skill that can be used in an ACO to SAVE MONEY.

1. 40% of lumbar MRIs ordered are unnecessary. Show the ACO and primary care docs guidelines for ordering imaging and how YOU can save them millions in imaging costs by referring spine patients to YOU before they get unnecessary imaging. The savings there is huge.

2. Use the CDC guidelines as a template and develop pain medicine guidelines for the primary care docs. PCPs (like everyone else) are required to abide by state guidelines for pain medicines. Incorporate the "check list" (UDS,contract, PMP site) into their EMR system to verify compliance.

3. Do your procedures in the office and show the ACO the relative cost of those procedures vs surgery center or hospital.

4. Demonstrate the cost savings over time of SCS vs care as usual for "failed back" patients.

5. Help develop a preferred med list of cheaper medicine alternatives for different pain states and the savings in cost per patient annually.


YOU CAN do well in an ACO environment- you just need to adapt and look at your role in a new fashion. My previous group was one the leaders in quality contracts for the US. This WILL be enacted more and more and those who fail to adapt may have problems. However, YOU can be the solution to high costs and help provide good care at a lower cost. I spent the last couple years setting up pain protocols and practice guidelines for a very large primary care group. It was a low reimbursement area, yet the lowest paid internist made $400K per year due to these quality contracts. It is the way of the future and one must adapt.

 

[SSdoc33]

doing nothing for pain patients is very inexpensive. somehow, i dont think patients or docs will be satisfied if we spend our time talking about lifting mechanics and tylenol vs. ibuprofen

in primary care, you can measure quality by looking at hemoglobin h1c and and hospital readmission rates. how do you measure quality in pain medicine?

this whole idea sucks for pain medicine in general. maybe it IS the wave of the future, but it is a complete and 100% paradigm shift for how we are paid. if i get paid per head, and every MRI i order or every shot i do costs me money ---- lets just say that it will be constant battle between the patient and the doc

 

[drusso]

doing nothing for pain patients is very inexpensive. somehow, i dont think patients or docs will be satisfied if we spend our time talking about lifting mechanics and tylenol vs. ibuprofen

in primary care, you can measure quality by looking at hemoglobin h1c and and hospital readmission rates. how do you measure quality in pain medicine?

this whole idea sucks for pain medicine in general. maybe it IS the wave of the future, but it is a complete and 100% paradigm shift for how we are paid. if i get paid per head, and every MRI i order or every shot i do costs me money ---- lets just say that it will be constant battle between the patient and the doc

Cash pay. Office MRI is $700. HOPD MRI is $3,000. Lots of Regen Med docs putting magnets in their offices. Makes sense. Cheaper than a PRP in some markets.

 

[SSdoc33]

Cash pay. Office MRI is $700. HOPD MRI is $3,000. Lots of Regen Med docs putting magnets in their offices. Makes sense. Cheaper than a PRP in some markets.

if patients cant get an MRI or a shot from an ACO doc, then this may have legs. seems like like a long way off, though

 

[drusso]

if patients cant get an MRI or a shot from an ACO doc, then this may have legs. seems like like a long way off, though

It's my world every day.

 

[SSdoc33]

It's my world every day.

yes, yes, of course it is. everyone knows that MRIs and epidurals are outlawed in oregon. SMH

 

[drusso]

yes, yes, of course it is. everyone knows that MRIs and epidurals are outlawed in oregon. SMH

Only outlaws get epidurals...

 

[deleted993114]

doing nothing for pain patients is very inexpensive. somehow, i dont think patients or docs will be satisfied if we spend our time talking about lifting mechanics and tylenol vs. ibuprofen

in primary care, you can measure quality by looking at hemoglobin h1c and and hospital readmission rates. how do you measure quality in pain medicine?

this whole idea sucks for pain medicine in general. maybe it IS the wave of the future, but it is a complete and 100% paradigm shift for how we are paid. if i get paid per head, and every MRI i order or every shot i do costs me money ---- lets just say that it will be constant battle between the patient and the doc

I am not suggesting that you "do nothing". However, with value systems here to stay, cost of any treatment are going to be under scrutiny. It is a paradigm shift in how we get paid- that is the point- control costs. Procedures in pain management have been a little over done, and this is just a normal reaction to those practices.

I think that one can practice effective pain management in an aco/quality contract environment. However, "block shops" of just doing a bunch of injections, particularly in higher cost centers, will take a hit. Of course, there will be differences in different parts of the US regarding the penetration of quality based contracts. I would imagine that geographic "islands" would be relatively unaffected by such efforts.

 

[hyperalgesia]

Aside from doing procedures, we can also educate like no one else. It's a greater value add than surgery in many cases.

 

[Ferrismonk]

Aside from doing procedures, we can also educate like no one else. It's a greater value add than surgery in many cases.

True, but that's only because it doesn't pay.

 

[Dr. Ice]

Adapt and become part of the solution. You, as a pain doc, have a tremendous amount of knowledge and skill that can be used in an ACO to SAVE MONEY.

1. 40% of lumbar MRIs ordered are unnecessary. Show the ACO and primary care docs guidelines for ordering imaging and how YOU can save them millions in imaging costs by referring spine patients to YOU before they get unnecessary imaging. The savings there is huge.

2. Use the CDC guidelines as a template and develop pain medicine guidelines for the primary care docs. PCPs (like everyone else) are required to abide by state guidelines for pain medicines. Incorporate the "check list" (UDS,contract, PMP site) into their EMR system to verify compliance.

3. Do your procedures in the office and show the ACO the relative cost of those procedures vs surgery center or hospital.

4. Demonstrate the cost savings over time of SCS vs care as usual for "failed back" patients.

5. Help develop a preferred med list of cheaper medicine alternatives for different pain states and the savings in cost per patient annually.


YOU CAN do well in an ACO environment- you just need to adapt and look at your role in a new fashion. My previous group was one the leaders in quality contracts for the US. This WILL be enacted more and more and those who fail to adapt may have problems. However, YOU can be the solution to high costs and help provide good care at a lower cost. I spent the last couple years setting up pain protocols and practice guidelines for a very large primary care group. It was a low reimbursement area, yet the lowest paid internist made $400K per year due to these quality contracts. It is the way of the future and one must adapt.

In my area MRIs are required prior to any spinal injection including mbb/facets. Have had several denials bc of lack of advanced imaging. How does this fit into aco?

 

[SSdoc33]

In my area MRIs are required prior to any spinal injection including mbb/facets. Have had several denials bc of lack of advanced imaging. How does this fit into aco?

this has to be a single LCDs. surely not all of them? i actually get an MRI before any ESI or any MBB myself, but it is not mandatory in my area

 

[deleted993114]

In my area MRIs are required prior to any spinal injection including mbb/facets. Have had several denials bc of lack of advanced imaging. How does this fit into aco?

That will change. I had some idiot reviewer for blue cross who wanted me to get a lumbar MRI prior to intra-articular lumbar facet injections on an oldster with isolated low back pain and no "red flags". The guy said he would NEVER do any injections on the spine without an MRI. I told him he was outdated and that the literature would tend to disagree with him. I asked him what he could possibly find on a lumbar MR on a patient with back pain (again-no red flags) that would possibly change his treatment plan. He just circled and said that "in his training program", everybody got an MRI prior to injections. The conversation ended after I told him his training program probably sucked.

Look at the data for inappropriate imaging and the need for advanced imaging in situations of axial pain. Certainly if anyone has radicular symptoms, stenosis, or "red flags", imaging is indicated. However, even in clear lumbar radiculitis without radiculopathy, you can get by with clinical exam and history if you are going to simply do an injection and the patient is not a surgical candidate as far as an initial treatment plan.

The era of "everyone gets an MRI" is ending, as it should.

 

[SommeRiver]

No reason for an MRI prior to a facet injxn, MBB/RFA, SIJ, hip, etc...

I get the MRI before an epidural of course...In my group, we have 3 MRI machines and you WILL get an MRI if you see a midlevel. Infuriating to me...

75 yo M with 20 years of back pain comes in with golf ball facets and they MRI out the gate...Makes me so angry bc the much older guys in the group love that BS bc they're making money off those ancillary income dollars.

 

[lobelsteve]

No reason for an MRI prior to a facet injxn, MBB/RFA, SIJ, hip, etc...

I get the MRI before an epidural of course...In my group, we have 3 MRI machines and you WILL get an MRI if you see a midlevel. Infuriating to me...

75 yo M with 20 years of back pain comes in with golf ball facets and they MRI out the gate...Makes me so angry bc the much older guys in the group love that BS bc they're making money off those ancillary income dollars.

Job security.

 

[SSdoc33]

No reason for an MRI prior to a facet injxn, MBB/RFA, SIJ, hip, etc...

I get the MRI before an epidural of course...In my group, we have 3 MRI machines and you WILL get an MRI if you see a midlevel. Infuriating to me...

75 yo M with 20 years of back pain comes in with golf ball facets and they MRI out the gate...Makes me so angry bc the much older guys in the group love that BS bc they're making money off those ancillary income dollars.

i guess you'd prefer the cancer to metastasize first, then?

and we are not only talking about bony mets

i catch several/year on these "bogus" MRIs.

no MRI for an SIJ, but mbb or esi? yes. always.

 

[clubdeac]

Clinically you are all correct in that we can usually get by without an MRI. However, medicolegally unfortunately we should get MRIs before any and all injections. That is until there's tort reform

 

[SommeRiver]

i guess you'd prefer the cancer to metastasize first, then?

and we are not only talking about bony mets

i catch several/year on these "bogus" MRIs.

no MRI for an SIJ, but mbb or esi? yes. always.

Someone comes in with axial back pain and a concordant XRAY and before you MBB them you always MRI them?

I don't understand that rationale. Do the injection and if they're no better MRI them.

 

[hyperalgesia]

Look at the data for inappropriate imaging and the need for advanced imaging in situations of axial pain. Certainly if anyone has radicular symptoms, stenosis, or "red flags", imaging is indicated. However, even in clear lumbar radiculitis without radiculopathy, you can get by with clinical exam and history if you are going to simply do an injection and the patient is not a surgical candidate as far as an initial treatment plan.

The era of "everyone gets an MRI" is ending, as it should.

Actually, I think MRIs are underutilized from an individual health perspective. In this day and age, they should (and eventually will) be used routinely as an adjunct to a physical exam. What is their benefit to harm ratio?

I have no doubt that if our free market healthcare system was not stunted and suppressed by Medicare and health insurance company monopolies, MRIs would be offered cheaply and recommended routinely.

We have all been offered the kool aid that is "population healthcare". I never drank it...

edit: I'm off my soapbox now. It's really pt dependent for me. I don't get MRIs prior to all axial procedures but I think there's an argument to do so. I had a pt on the schedule for lumbar mbbs when he went to the ER and got admitted for worsening pain. Turns out he had severe discitis with abscess without any neurological/radicular signs. Yikes.

 

[drusso]

Actually, I think MRIs are underutilized from an individual health perspective. In this day and age, they should (and eventually will) be used routinely as an adjunct to a physical exam. What is their benefit to harm ratio?

I have no doubt that if our free market healthcare system was not stunted and suppressed by Medicare and health insurance company monopolies, MRIs would be offered cheaply and recommended routinely.

We have all been offered the kool aid that is "population healthcare". I never drank it...

In-office MRI cash-price is approximately $750 for a knee, hip, or ankle. A little more for a spine segment. Compare that $3000 in hospital HOPD. I keep seeing magnets showing up in Regen Med offices. People like the convenience of getting MRI's at the site of service.

 

[hyperalgesia]

In-office MRI cash-price is approximately $750 for a knee, hip, or ankle. A little more for a spine segment. Compare that $3000 in hospital HOPD. I keep seeing magnets showing up in Regen Med offices. People like the convenience of getting MRI's at the site of service.

Yep, it's a beautiful thing watching the market work outside the scope of the gov/insurance complex. I actually called around my city for the lowest price for a cash ankle MRI. Lowest was $450 on a 3T read by American trained radiologist. Of course, it was outside a hospital setting. Obviously wasn't worth the oxygen to even check with HOPD for their inflated price.

 

[drusso]

Yep, it's a beautiful thing watching the market work outside the scope of the gov/insurance complex. I actually called around my city for the lowest price for a cash ankle MRI. Lowest was $450 on a 3T read by American trained radiologist. Of course, it was outside a hospital setting. Obviously wasn't worth the oxygen to even check with HOPD for their inflated price.

I can't imagine how $3000 MRI's and 60 min HOPD CESI's are going to compete in the age of Healthcare Uber & Lyft unless the Dem's completely Federalize the practice of medicine. Then we will all be getting the equivalent of ACO Federal Crop Subsidies to do nothing and just dole out government-cheese style population health care...

 

[drusso]

I can't imagine how $3000 MRI's and 60 min HOPD CESI's are going to compete in the age of Healthcare Uber & Lyft unless the Dem's completely Federalize the practice of medicine. Then we will all be getting the equivalent of ACO Federal Crop Subsidies to do nothing and just dole out government-cheese style population health care...

 

[SSdoc33]

Someone comes in with axial back pain and a concordant XRAY and before you MBB them you always MRI them?

I don't understand that rationale. Do the injection and if they're no better MRI them.


Ovarian cancer doesnt hurt. Until it's too late. Same with renal, etc.

MRI helps me determine disc vs facet (sometimes), helps me catch cancers, helps determine acuity of compression fractures, helps me find annular tears, and protects me legally.

MRI before any spine injection

 

[SommeRiver]

I hear all that but the delay to MRI by doing an MBB (and the intervention most likely to help) is minimal, with the potential upside of helping significantly and saving healthcare money.

I have pts call my staff to report their pain diary the day after the MBB. So if it looks like a classic back pain pt with huge facets in an elderly pt (the example I'm using), the odds of discogenic pain being the Dx are low, and the odds of it being cancer are far lower.

Fractures you see on the XRAY, and if they have abrupt onset back pain and a fracture on your screening XRAY go ahead and MRI them but that's clearly not what I'm talking about...

 

[Ducttape]

nice graph drusso.

do you want doctors to essentially accept Medicaid payments? because those are what are closest to "actual" cost.

fwiw, you do know that roughly 57% of Americans have less than $1000 saved? 39% have zero saved. that $750 is roughly a weeks salary for half of all Americans....

 

[lonelobo]

nice graph drusso.

do you want doctors to essentially accept Medicaid payments? because those are what are closest to "actual" cost.

fwiw, you do know that roughly 57% of Americans have less than $1000 saved? 39% have zero saved. that $750 is roughly a weeks salary for half of all Americans....

"let them eat cake"

 

[SSdoc33]

I hear all that but the delay to MRI by doing an MBB (and the intervention most likely to help) is minimal, with the potential upside of helping significantly and saving healthcare money.

I have pts call my staff to report their pain diary the day after the MBB. So if it looks like a classic back pain pt with huge facets in an elderly pt (the example I'm using), the odds of discogenic pain being the Dx are low, and the odds of it being cancer are far lower.

Fractures you see on the XRAY, and if they have abrupt onset back pain and a fracture on your screening XRAY go ahead and MRI them but that's clearly not what I'm talking about...

i dont care about saving health care spending. i care about saving my patients lives. the risk of detecting a cancer is relatively low, but i still catch 3-5/year at least. you usually miss these on xrays, and sometimes the MBB/RF will help cancer-related pain. you'd be delaying the diagnosis at this point. i can see your side of the issue, but i just disagree with it. at least right now, i dont care how much health care expenditures there may be with this approach

 

[deleted993114]

i dont care about saving health care spending. i care about saving my patients lives. the risk of detecting a cancer is relatively low, but i still catch 3-5/year at least. you usually miss these on xrays, and sometimes the MBB/RF will help cancer-related pain. you'd be delaying the diagnosis at this point. i can see your side of the issue, but i just disagree with it. at least right now, i dont care how much health care expenditures there may be with this approach

You will be forced to change your views, as you will be identified as a high cost provider and will get "squeezed" in a quality environment. Rather than relying upon anecdotal information, which we all have, one will be forced to rely upon what the literature suggests for imaging.

Keep in mind that there is only one "bucket" of money for imaging or certain classes of specialists among insurers. If one is blowing money needlessly, there will be less funds for legitimate purposes.

I find your views very peculiar for one who supports a single payer system which will most certainly demand a fairly scaled back, "cheap" means of managing patients. You say that you "don't care" about costs; you will care when it starts to cost you personally with a lower and lower salary.

Also., what cancer pain are you treating with rf? I am not aware of any pain from mets that would use our rf medial branch treatments for pain, as mets tend to encompass vertebral bodies, which would not be amendable to such treatments.

 

[SSdoc33]

You will be forced to change your views, as you will be identified as a high cost provider and will get "squeezed" in a quality environment. Rather than relying upon anecdotal information, which we all have, one will be forced to rely upon what the literature suggests for imaging.

Keep in mind that there is only one "bucket" of money for imaging or certain classes of specialists among insurers. If one is blowing money needlessly, there will be less funds for legitimate purposes.

I find your views very peculiar for one who supports a single payer system which will most certainly demand a fairly scaled back, "cheap" means of managing patients. You say that you "don't care" about costs; you will care when it starts to cost you personally with a lower and lower salary.

Also., what cancer pain are you treating with rf? I am not aware of any pain from mets that would use our rf medial branch treatments for pain, as mets tend to encompass vertebral bodies, which would not be amendable to such treatments.

listen, oh learned one, i dont support single payer. your assumptions are wrong.

secondly, how many times have your had a mbb last longer than you'd think? how many times did it work when you think it shouldnt have (disc pain)? i cant always explain pain relief, but it doest follow the textbooks, thats for sure.

when the time comes that quality measures determine how i practice, then i may change. until then, ill keep saving lives and giving my patients the best treatment available.

 

[SommeRiver]

Target audiences though right? An 85 yo is less likely to have discogenic pain.

 

[SSdoc33]

Target audiences though right? An 85 yo is less likely to have discogenic pain.

And more likely to have cancer