ACOs and bundled payments

[deleted993114]

Ugh. Rather than spouting off the same crap, why dont you add to the conversation and post an article defending your point. I'll do your homework for you once I finish putting out some fires over here

As I said before- your practice of ordering MRIs for back pain is opposed to the balance of every published article in the medical literature describing indications for MRI. I already posted articles describing indications for MRI. However, as you are entrenched in your beliefs and will never change, you simply did not read them. One of those key articles is Chou's article in Lancet. However, you presume to know more than the balance of the medical literature and thus will ignore everything it says.

It is truly shocking that you do not understand this. We had a list of 20 "must read" articles for every fellow in pain management, seven of which involved indications for imaging.

Even if you want to do an epidural, there is no improvement in outcomes for patients that get an MRI and those who do not:

Effect of MRI on treatment results or decision making in patients with lumbosacral radiculopathy referred for epidural steroid injections: a multicenter, randomized controlled trial.
Cohen SP1, Gupta A, Strassels SA, Christo PJ, Erdek MA, Griffith SR, Kurihara C, Buckenmaier CC 3rd, Cornblath D, Vu TN.
Author information
1Department of Anesthesiology, Johns Hopkins Schoolof Medicine, Baltimore, MD, USA. [email protected]
Erratum in

• Arch Intern Med. 2012 Apr 23;172(8):673.

Abstract
BACKGROUND:
Studies have shown that radiologic imaging does not improve outcomes in most patients with back pain, though guidelines endorse it before epidural steroid injections (ESIs). The objective of this study was to determine whether magnetic resonance imaging (MRI) improves outcomes or affects decision making in patients with lumbosacral radiculopathy referred for ESI.
METHODS:
In this multicenter randomized study, the treating physician in group 1 patients was blinded to the MRI results, while the physician for group 2 patients decided on treatment after reviewing the MRI findings. In group 1 subjects, an independent physician proposed a treatment plan after reviewing the MRI, which was compared with the treatment the patient received.
RESULTS:
Slightly lower leg pain scores were noted in the group 2 at 1 month compared with MRI-blinded patients in group 1 (mean scores, 3.6 vs 4.4) (P = .12). No differences were observed in pain scores or function at 3 months. Overall, the proportion of patients who experienced a positive outcome was similar at all time points (35.4% at 3 months in group 1 vs 40.7% in group 2). Among subjects in group 1 who received a different injection than that proposed by the independent physician, scores for both leg pain (4.8 vs 2.4) (P = .01) and function (38.7 vs 28.2) (P = .04) were inferior to patients whose injection correlated with imaging. Collectively, 6.8% of patients did not (group 2) or would not have (group 1) received an ESI after the MRI was reviewed.
CONCLUSION:
Magnetic resonance imaging does not improve outcomes in patients who are clinical candidates for ESI and has only a minor effect on decision making. Trial Registration clinicaltrials.gov Identifier: NCT00826124.

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[SSdoc33]

As I said before- your practice of ordering MRIs for back pain is opposed to the balance of every published article in the medical literature describing indications for MRI. I already posted articles describing indications for MRI. However, as you are entrenched in your beliefs and will never change, you simply did not read them. One of those key articles is Chou's article in Lancet. However, you presume to know more than the balance of the medical literature and thus will ignore everything it says.

It is truly shocking that you do not understand this. We had a list of 20 "must read" articles for every fellow in pain management, seven of which involved indications for imaging.

Even if you want to do an epidural, there is no improvement in outcomes for patients that get an MRI and those who do not:

Effect of MRI on treatment results or decision making in patients with lumbosacral radiculopathy referred for epidural steroid injections: a multicenter, randomized controlled trial.
Cohen SP1, Gupta A, Strassels SA, Christo PJ, Erdek MA, Griffith SR, Kurihara C, Buckenmaier CC 3rd, Cornblath D, Vu TN.
Author information
1Department of Anesthesiology, Johns Hopkins Schoolof Medicine, Baltimore, MD, USA. [email protected]
Erratum in

• Arch Intern Med. 2012 Apr 23;172(8):673.

Abstract
BACKGROUND:
Studies have shown that radiologic imaging does not improve outcomes in most patients with back pain, though guidelines endorse it before epidural steroid injections (ESIs). The objective of this study was to determine whether magnetic resonance imaging (MRI) improves outcomes or affects decision making in patients with lumbosacral radiculopathy referred for ESI.
METHODS:
In this multicenter randomized study, the treating physician in group 1 patients was blinded to the MRI results, while the physician for group 2 patients decided on treatment after reviewing the MRI findings. In group 1 subjects, an independent physician proposed a treatment plan after reviewing the MRI, which was compared with the treatment the patient received.
RESULTS:
Slightly lower leg pain scores were noted in the group 2 at 1 month compared with MRI-blinded patients in group 1 (mean scores, 3.6 vs 4.4) (P = .12). No differences were observed in pain scores or function at 3 months. Overall, the proportion of patients who experienced a positive outcome was similar at all time points (35.4% at 3 months in group 1 vs 40.7% in group 2). Among subjects in group 1 who received a different injection than that proposed by the independent physician, scores for both leg pain (4.8 vs 2.4) (P = .01) and function (38.7 vs 28.2) (P = .04) were inferior to patients whose injection correlated with imaging. Collectively, 6.8% of patients did not (group 2) or would not have (group 1) received an ESI after the MRI was reviewed.
CONCLUSION:
Magnetic resonance imaging does not improve outcomes in patients who are clinical candidates for ESI and has only a minor effect on decision making. Trial Registration clinicaltrials.gov Identifier: NCT00826124.

I was hoping you would post the Cohen article. Now it seems you are advocating for ESIs without an MRI. It is becoming very easy to see how you raked in all that money over the years. Every patient who walked in your door got an injection without a work-up.

There are so many flaws in this article, i don't even know where to begin.

The Cohen article aside, BY YOUR OWN words, you said that imaging is indicated after 3 months of conservative care. "imaging" is pretty vague, but since we have been discussing MRIs, then that is what i assume you meant. if that is indeed the case, then i havent ordered a single MRI that you woulnd't "approve" of, and your whole argument is trash.


Am i understanding you correctly in saying that as long as you have axial pain and no red flags, then an MRI is not indicated. is that your position?

 

[deleted993114]

I was hoping you would post the Cohen article. Now it seems you are advocating for ESIs without an MRI. It is becoming very easy to see how you raked in all that money over the years. Every patient who walked in your door got an injection without a work-up.

There are so many flaws in this article, i don't even know where to begin.

The Cohen article aside, BY YOUR OWN words, you said that imaging is indicated after 3 months of conservative care. "imaging" is pretty vague, but since we have been discussing MRIs, then that is what i assume you meant. if that is indeed the case, then i havent ordered a single MRI that you woulnd't "approve" of, and your whole argument is trash.


Am i understanding you correctly in saying that as long as you have axial pain and no red flags, then an MRI is not indicated. is that your position?

MRI is not indicated for the initial three months of low back pain in the absence of red flags. That is what the guidelines say. MANY practices are extending that to six months, as there is NO EVIDENCE for improved care (in fact, a lot of evidence for worse care) with the addition of an MRI for back pain.

There is no hope for you, as you will continue to order imaging for back pain. This is why such behaviors have to be changed through involuntary means, as evidence in the literature is never enough for many people. Like it or not, you will be forced to abandon your ordering inappropriate MRIs, as ACOs will identify you as a high cost provider and you will no longer be a part of their panel. That is an economic reality that you will face, one way or another.

I guess Paul Dreyfus and Jim Weinstein are just idiots and you know more than them? Arrogance runs deep in the pain community.

The literature shows that over ordering MRIs for back leads to WORSE CARE, not better. So despite your thinking you are "helping" patients with over ordering imaging, you are actually providing worse care and potential harm.

Not to be insulting, but did you actually undergo a formal fellowship for pain? In a fellowship, they would have had these issues as required reading and as a routine part of training regarding when one orders imaging (and when one does not).

 

[SSdoc33]

MRI is not indicated for the initial three months of low back pain in the absence of red flags. That is what the guidelines say. MANY practices are extending that to six months, as there is NO EVIDENCE for improved care (in fact, a lot of evidence for worse care) with the addition of an MRI for back pain.

There is no hope for you, as you will continue to order imaging for back pain. This is why such behaviors have to be changed through involuntary means, as evidence in the literature is never enough for many people. Like it or not, you will be forced to abandon your ordering inappropriate MRIs, as ACOs will identify you as a high cost provider and you will no longer be a part of their panel. That is an economic reality that you will face, one way or another.

I guess Paul Dreyfus and Jim Weinstein are just idiots and you know more than them? Arrogance runs deep in the pain community.

as someone else once said on this board "I am not the beast you seek to slay". im not the guy getting too many MRIs. you seem to have a vendetta against me when I am ONLY arguing for an MRI before a MBB. i never get an MRI for axial back pain before 3 months. you have created a scenario in your head about me based on other threads.

 

[10KHertz]

We don’t have medical malpractice controllers or tribunals in this country. In spite of the aforementioned convincing literature, most of us over prescribe imaging studies. And I’m okay with that... change the system and I’ll change my practice patterns.

also I want an MRI prior to MBBs or any axial spinal pain that is subacute or chronic in nature .

good conversation.

 

[Dr. Ice]

Most Cigna plans require and updated MRI every year for an ESI approval, regardless of outcomes.

More and more BCBS plans (many variations per state) require yearly repeat Mbbs even if a RFA lasts over a year.

We have no say in the matter really....Why argue.

Exactly

 

[hyperalgesia]

I'll take an MRI before mbbs and I'm happy to pay cash. Then I'll take a full body MRI just to get a baseline for any future issues.

 

[10KHertz]

I'll take an MRI before mbbs and I'm happy to pay cash. Then I'll take a full body MRI just to get a baseline for any future issues.

Get a CT coronary calcium score while you’re at it... muy importante. And not covered usually.

 

[hyperalgesia]

Get a CT coronary calcium score while you’re at it... muy importante. And not covered usually.

Sounds radioactive... When they can do with U/S...

 

[deleted993114]

I'll take an MRI before mbbs and I'm happy to pay cash. Then I'll take a full body MRI just to get a baseline for any future issues.

Agreed- Why not get whole body MRIs every 2-3 months? That way if anyone gets a tumor anywhere on their body, it can be detected in the first two months. Also, you could watch the progression of your discs naturally degenerate over time and create a wall montage, visually documenting your own aging.

Someone at a party may want to know the precise dimensions of your liver; with your scans, you could immediately answer with up to date data.

PS- to SSdoc who seems to be obsessed over my past income- I had 12-15 new patients every day; MOST of my patients were sent specifically by our neurosurgeons (4), physiatrists (3), and orthopedists (10) specifically for injections which they had already worked up.

Don't count other people's money- it will make you old. If I had to do it all over again, I would have preferred to be less busy and had more time off; that was not possible as the single provider for the group.

 

[Ducttape]

Oddly enough, this entire conversation would probably be moot if MRI scans were not so expensive.

 

[SSdoc33]

Agreed- Why not get whole body MRIs every 2-3 months? That way if anyone gets a tumor anywhere on their body, it can be detected in the first two months. Also, you could watch the progression of your discs naturally degenerate over time and create a wall montage, visually documenting your own aging.

Someone at a party may want to know the precise dimensions of your liver; with your scans, you could immediately answer with up to date data.

PS- to SSdoc who seems to be obsessed over my past income- I had 12-15 new patients every day; MOST of my patients were sent specifically by our neurosurgeons (4), physiatrists (3), and orthopedists (10) specifically for injections which they had already worked up.

Don't count other people's money- it will make you old. If I had to do it all over again, I would have preferred to be less busy and had more time off; that was not possible as the single provider for the group.

look, you keep trying to justify your income. i can see how a busy pain guy in the early 2000s with a heavy commercial base can pull in that much. and i was pretty much just trying to get a reaction from you b/c i you do seem to be pretty conservative with this stuff. again, i think it is great that you made so much, but i just find it odd that you would post how much money you made. why would anyone do that on a board like this?

 

[10KHertz]

Oddly enough, this entire conversation would probably be moot if MRI scans were not so expensive.

Remember when l I’m

Oddly enough, this entire conversation would probably be moot if MRI scans were not so expensive.

True.
Remember when NIH went after mammography and PSA screening? Those tests are cheap. They tried to scrap them so as to reduce/control/deter subsequent surgical procedures(ie lumpectomies, prostate biopsies). That’s why insurance companies are denying spine MRIs , which as someone mentioned previously, are getting much cheaper (esp cash based).
Nothing is transparent in medicine ...

 

[hyperalgesia]

True.
Remember when NIH went after mammography and PSA screening? Those tests are cheap. They tried to scrap them so as to reduce/control/deter subsequent surgical procedures(ie lumpectomies, prostate biopsies). That’s why insurance companies are denying spine MRIs , which as someone mentioned previously, are getting much cheaper (esp cash based).
Nothing is transparent in medicine ...

At one point Medicare felt that ASCs were costing too much because there were too many of them. Their response was to MANDATE implementation of a CON (certificate of need) system in every state. It turnd out that that monopolies are NOT actually conducive to a competitive free market. Medicare has since removed the CON requirements but many states still have theirs, with all of the crooked lobby support you would expect with a crony capitalist system.

 

[deleted993114]

look, you keep trying to justify your income. i can see how a busy pain guy in the early 2000s with a heavy commercial base can pull in that much. and i was pretty much just trying to get a reaction from you b/c i you do seem to be pretty conservative with this stuff. again, i think it is great that you made so much, but i just find it odd that you would post how much money you made. why would anyone do that on a board like this?

It was a description of a practice that one would think (myself included) to be undesirable. However, MANY pain docs are searching for such practices and want to make that much. Having experienced such a practice, I would strongly suggest that it is not worth it and one should seek to work at a slower pace for less money. There are a couple of providers in my town who currently have such a practice- I do not envy them, nor should anyone.

Back to imaging- Whether one likes it or not, imaging has been identified as a major source of waste in the literature and by ACOs. In an ACO/quality environment, people should be aware of that and take measures to reduce unnecessary imaging. Why is that important?

1. It is better medical practice- over ordering MRIs leads to unnecessary procedures and worse care.

2. Excessive MRIs are expensive. Money will be diverted from necessary treatments to pay for the unnecessary ones. If we want to continue to have indicated and effective imaging and treatments paid for, we need to be the ones to cut unnecessary treatments.

3. Providers who over order imaging will be identified as "high cost providers" by ACOs and insurers. Such providers will be targeted to divert patient referrals in order to control costs. So there self interest involved here as well.

4, Be a part of the solution, rather than the problem. Pain providers can lead the way in controlling costs and be an important and integral part of quality based programs. Take the initiative and provide solutions- in that way, pain medicine can continue and thrive as a specialty.

 

[lonelobo]

4, Be a part of the solution, rather than the problem. Pain providers can lead the way in controlling costs and be an important and integral part of quality based programs. Take the initiative and provide solutions- in that way, pain medicine can continue and thrive as a specialty.

that is funny

 

[jsaul]

It was a description of a practice that one would think (myself included) to be undesirable. However, MANY pain docs are searching for such practices and want to make that much. Having experienced such a practice, I would strongly suggest that it is not worth it and one should seek to work at a slower pace for less money. There are a couple of providers in my town who currently have such a practice- I do not envy them, nor should anyone.

Back to imaging- Whether one likes it or not, imaging has been identified as a major source of waste in the literature and by ACOs. In an ACO/quality environment, people should be aware of that and take measures to reduce unnecessary imaging. Why is that important?

1. It is better medical practice- over ordering MRIs leads to unnecessary procedures and worse care.

2. Excessive MRIs are expensive. Money will be diverted from necessary treatments to pay for the unnecessary ones. If we want to continue to have indicated and effective imaging and treatments paid for, we need to be the ones to cut unnecessary treatments.

3. Providers who over order imaging will be identified as "high cost providers" by ACOs and insurers. Such providers will be targeted to divert patient referrals in order to control costs. So there self interest involved here as well.

4, Be a part of the solution, rather than the problem. Pain providers can lead the way in controlling costs and be an important and integral part of quality based programs. Take the initiative and provide solutions- in that way, pain medicine can continue and thrive as a specialty.

if your practice was "undesirable" and you were the "sole provider" then why did you not push to get another pain physician in your group for all those years you were too busy? I am sure that could have been easily done but it wasn't. no offense, Just asking

 

[hyperalgesia]

ACO/quality

You group these things as if they are somehow compatible. Are you considering a job in healthcare administrative policy?

 

[deleted993114]

You group these things as if they are somehow compatible. Are you considering a job in healthcare administrative policy?

For God sake no! I hate that stuff! I like nuts and bolts clinical medicine; however, understanding the goals and mechanism of the ACO/quality system is important for all of us. Why? Understand the economic forces that will be shaping all of medicine and learn to adapt, such that we can still do the clinical medicine we like. Those guys are very clever and are working on things all the time that are not necessarily in our best interest, particularly like the "ACO trap" where they get groups to "bet" a higher and higher risk percentage on commercial contracts (not medicare) until they get on the wrong side of the contract and end up being owned by the insurer for nothing. Whoever came up with that one is pretty damn smart- kind of evil- but smart. Have you noticed that there are commercial insurers that now own medical practices? Also, many practices are looking to form "equity partnerships" with the insurers- selling 49% to them so that the insurer has a financial stake in their preservation.

There is no way in hell that I would ever be a "suit" in medicine. I am far from politically correct and would be unhappy in such a role and probably fired the first week. If you saw me at a meeting, you would mistake me for Carl from "Slingblade" and would think I was some mentally challenged guy who got lost and ended up there by mistake. I speak slowly and with an accent, and dress like a rube, so I exude stupidity.

We have a good gig in clinical medicine- I think one occasionally needs to step back and ask ourselves why we went into this in the first place. However, we have to adapt to the current economic climate and find ways to be a source of solutions in such a system, or risk being swept away.

 

[Dr. Ice]

Oddly enough, this entire conversation would probably be moot if MRI scans were not so expensive.

$250 for outpatient mri where I’m from..$3k hopd..just saying. I’ve actually had patients do this after they and I play the insurance denial merrigoround..

 

[Dr. Ice]

For God sake no! I hate that stuff! I like nuts and bolts clinical medicine; however, understanding the goals and mechanism of the ACO/quality system is important for all of us. Why? Understand the economic forces that will be shaping all of medicine and learn to adapt, such that we can still do the clinical medicine we like. Those guys are very clever and are working on things all the time that are not necessarily in our best interest, particularly like the "ACO trap" where they get groups to "bet" a higher and higher risk percentage on commercial contracts (not medicare) until they get on the wrong side of the contract and end up being owned by the insurer for nothing. Whoever came up with that one is pretty damn smart- kind of evil- but smart. Have you noticed that there are commercial insurers that now own medical practices? Also, many practices are looking to form "equity partnerships" with the insurers- selling 49% to them so that the insurer has a financial stake in their preservation.

There is no way in hell that I would ever be a "suit" in medicine. I am far from politically correct and would be unhappy in such a role and probably fired the first week. If you saw me at a meeting, you would mistake me for Carl from "Slingblade" and would think I was some mentally challenged guy who got lost and ended up there by mistake. I speak slowly and with an accent, and dress like a rube, so I exude stupidity.

We have a good gig in clinical medicine- I think one occasionally needs to step back and ask ourselves why we went into this in the first place. However, we have to adapt to the current economic climate and find ways to be a source of solutions in such a system, or risk being swept away.

If the aco’s want me to save money, stop denying my axial procedures without an mri and for Godsake stop demanding a structured bs pt program for 6 weeks at $40-50 per visit cost to patient. If you can give me a timeline for when this bs will end then maybe I’ll stop ordering MRIs so I don’t have to do some stupid peer to peer nonsense so I can treat the patient

 

[10KHertz]

If the aco’s want me to save money, stop denying my axial procedures without an mri and for Godsake stop demanding a structured bs pt program for 6 weeks at $40-50 per visit cost to patient. If you can give me a timeline for when this bs will end then maybe I’ll stop ordering MRIs so I don’t have to do some stupid peer to peer nonsense so I can treat the patient

But the OB/GYN peer to peer was so insightful this week...

 

[deleted993114]

If the aco’s want me to save money, stop denying my axial procedures without an mri and for Godsake stop demanding a structured bs pt program for 6 weeks at $40-50 per visit cost to patient. If you can give me a timeline for when this bs will end then maybe I’ll stop ordering MRIs so I don’t have to do some stupid peer to peer nonsense so I can treat the patient

First of all, I am not in charge of any ACO program. Secondly, the insurance companies are somewhat "behind the curve" in value contracts; most insurers, obviously, do have aco plans, but many are new to that game. I actually had a pain reviewer demand that I get an MRI before lumbar intra-articular facet injections on some 80 year old several weeks ago (it was a medicare supplement plan). Of course, that is absurd and directly opposite of what the literature is suggesting. I am sure that if they have not, your large local primary care groups will try to set guidelines and inform you of their goals.

Any transition to practices that are more in line with best practice and the literature sometimes takes time. Keep in mind that Blue Cross purchases these BS suggestions from MacKesson, who sometimes are not in line with reality.

We all try to pattern our practice over what is indicated by the literature, but also by what is practical. I agree that "peer-to-peer" phone calls are a terrible waste of clinic time, yet this is the world that the insurers have created and we are forced to use.

 

[Dr. Ice]

First of all, I am not in charge of any ACO program. Secondly, the insurance companies are somewhat "behind the curve" in value contracts. I actually had a pain reviewer demand that I get an MRI before lumbar intra-articular facet injections on some 80 year old several weeks ago (it was a medicare supplement plan). Of course, that is absurd and directly opposite of what the literature is suggesting. I am sure that if they have not, your large local primary care groups will try to set guidelines and inform you of their goals.

Any transition to practices that are more in line with best practice and the literature sometimes takes time. Keep in mind that Blue Cross purchases these BS suggestions from MacKesson, who sometimes are not in line with reality.

We all try to pattern our practice over what is indicated by the literature, but also by what is practical. I agree that "peer-to-peer" phone calls are a terrible waste of clinic time, yet this is the world that the insurers have created and we are forced to use.

They are behind the curve because they inevitably want to deny care. I get it. Isn’t thats why Liz and bern are popular candidates? A big fu to insurance companies..and full taxation to cover cost. We are gonna eventually live in a situation where the government will bleed money to cover health care cost because lawyers will not be regulated and no tort reform because the party trying to create a nanny state are made up of lawyers who couldn’t make it in the private sector large law firms with insane billable hours...

 

[hyperalgesia]

Any transition to practices that are more in line with best practice and the literature sometimes takes time. Keep in mind that Blue Cross purchases these BS suggestions from MacKesson, who sometimes are not in line with reality.

What if the literature is written by people who want what's best for our society, and not what's best for the patient sitting in front of you?

Does this literature define what is "best practice" and what is "appropriate" for your patient?

 

[Ducttape]

I find it interesting that you are concerned, hawkeye, about ACOs not approving MRI scans that cost $250-3000, even as many of us daily ask for authorization for $40,000 spinal cord stim implants.

as a side note, in terms of open info, im struggling to find out how much it is cash pay for MILD or Vertiflex...

 

[SSdoc33]

this entire conversation may soon be moot:

‘Quantum leap’: Researchers develop ‘intelligent’ new material for quicker, cheaper MRIs

If such technology is made available commercially, it could revolutionize magnetic resonance imaging, noted Stephan Anderson, a Boston Medical Center radiologist and BU School of Medicine professor of radiology.

www.radiologybusiness.com

 

[SommeRiver]

I find it interesting that you are concerned, hawkeye, about ACOs not approving MRI scans that cost $250-3000, even as many of us daily ask for authorization for $40,000 spinal cord stim implants.

as a side note, in terms of open info, im struggling to find out how much it is cash pay for MILD or Vertiflex...

Surely you're capable of seeing the difference in MRI ordering and SCS.

 

[SSdoc33]

They are behind the curve because they inevitably want to deny care. I get it. Isn’t thats why Liz and bern are popular candidates? A big fu to insurance companies..and full taxation to cover cost. We are gonna eventually live in a situation where the government will bleed money to cover health care cost because lawyers will not be regulated and no tort reform because the party trying to create a nanny state are made up of lawyers who couldn’t make it in the private sector large law firms with insane billable hours...

its is not clear which side you are mad at here. it looks like both.....

 

[deleted993114]

if your practice was "undesirable" and you were the "sole provider" then why did you not push to get another pain physician in your group for all those years you were too busy? I am sure that could have been easily done but it wasn't. no offense, Just asking

I am pretty darn quick and could see a ton of patients. However, we were only ever scheduled out "full" a max of two weeks. The rule of thumb is 6 weeks out to get another guy. Not all of our own partners were "loyal" in referring patients, as it was more of a confederation than a union.

Secondly, despite being a partner in a large group, I asked for duplicate space to get another guy and just make half as much money. The space was denied (despite me being the one paying for it). I was told that pain was not a priority, despite a consultant coming through and saying we needed another provider.

Lastly, the CEO (our employee) hated my guts and wanted to make my life miserable. With bladder CA, I leased my own bathroom, as I had to take a leak every 10 minutes. He moved in 18 admin staff next to me who constantly occupied my bathroom, so I would have to take a leak in the trashcan in my office. I would obstruct about every other week and have to get a foley with bladder bag (I would go back to work). With the 1/2 hour delay in getting that done, they would bitch me out for having to have patients wait. It was hell- the last thing he was going to do is help me get a partner to make my life better. Oddly, the guy is now fired for hostile work environment, sexual harassment, and embezzling. The guy hated me as I knew he was stealing and wanted him fired (no audit for 25 years).

Now they have two new guys out of fellowship and combined they cannot do the same amount of work I did by myself and the clinic is losing money every day. Wayyyyyyy too much overhead.

 

[deleted993114]

its is not clear which side you are mad at here. it looks like both.....

I'm not "mad" at either side. I am just an indian (not a chief) trying to adapt to a changing environment. I understand the forces behind quality contracts and know that I cannot change those things, so one must just accept it as reality and adapt.

 

[deleted993114]

I find it interesting that you are concerned, hawkeye, about ACOs not approving MRI scans that cost $250-3000, even as many of us daily ask for authorization for $40,000 spinal cord stim implants.

as a side note, in terms of open info, im struggling to find out how much it is cash pay for MILD or Vertiflex...

Stim implants, if chosen carefully, save money after 2.5 years compared to "usual care".

I am a pretty conservative guy and try NOT to do stims (even though I like them) due to cost and I also would not want one in me if I could avoid it. Unfortunately, I was kind of the "stim guy" for a big area, so I actually had a large number of patients who were good candidates (failed everything else) sent to me for stims, and I was the cheapest guy to get the implants done.

We order far, far more MRIs than we do stim implants, thus the volume adds up. In recognition of this, quality plans have targeted advanced imaging to cut waste.

Again, I am not on the "side" of these ACOs- I am just advocating that docs understand these forces and try to adapt in a changing environment and try to practice in the most cost effective way possible. I am ALWAYS a physician advocate; the only legal stuff I do as well is always for defense.

 

[SSdoc33]

I'm not "mad" at either side. I am just an indian (not a chief) trying to adapt to a changing environment. I understand the forces behind quality contracts and know that I cannot change those things, so one must just accept it as reality and adapt.

i was talking to dr. ice

 

[Ducttape]

Surely you're capable of seeing the difference in MRI ordering and SCS.

from a purely cost containment standpoint, both can lead to significant amounts of money. from an ACO standpoint, that is a primary driver of healthcare economics.

doesn't matter what you think will be helpful. that is a different discussion. (fwiw, the SCS would be preceded by at least 1 MRI)

 

[SommeRiver]

If every pt with axial back pain got an MRI you'd spend quite a bit more money than what is spent on SCS.

 

[deleted993114]

If every pt with axial back pain got an MRI you'd spend quite a bit more money than what is spent on SCS.

Even with indicated MRIs, there is far, far more money expended on MRIs of the spine than stims. There is a reason that advanced imaging is a "target" of ACOs, while (currently) stims are not.

 

[lobelsteve]

MRI leads to further care.

 

[SommeRiver]

MRI gives every physician in pain the excuse to do an epidural considering the ubiquity of asymptomatic stenosis.

Pt with back and buttock pain and facet arthropathy off an XRAY should get care based off the XRAY alone, and if it fails go get your MRI.

Also the rates of MRI orders increase significantly in practices that own the MRI. We own 3, and we get bonuses based off ancillary income. The PAs order them immediately. Pain = MRI. It makes me so angry.

 

[clubdeac]

But honestly guys, if you got a 55+ y/o with axial low back pain that refers into one or both hips who’s failed 6 weeks of PT and is in your office asking for help, who isn’t going to order an MRI? And then if this is positive for either a posterolateral disc or facet arthropathy, who isn’t going to order a procedure? This scenario probably accounts for 3/4th of my patients. I only save 1/4th of them an MRI by waiting until they’ve completed 6 weeks of PT

 

[hyperalgesia]

But honestly guys, if you got a 55+ y/o with axial low back pain that refers into one or both hips who’s failed 6 weeks of PT and is in your office asking for help, who isn’t going to order an MRI? And then if this is positive for either a posterolateral disc or facet arthropathy, who isn’t going to order a procedure? This scenario probably accounts for 3/4th of my patients. I only save 1/4th of them an MRI by waiting until they’ve completed 6 weeks of PT

I'm making a lot of assumptions about the history and presentation but assuming that all suggests the perfect MBB candidate, I would present both MRI and procedure options to the pt. The MRI will be very low yield in this case but I understand why a pt would want it. If the pt asks what I would do, I'd get the MRI.

 

[10KHertz]

I'm making a lot of assumptions about the history and presentation but assuming that all suggests the perfect MBB candidate, I would present both MRI and procedure options to the pt. The MRI will be very low yield in this case but I understand why a pt would want it. If the pt asks what I would do, I'd get the MRI.

Ezekiel Emanuel, a health policy guy, would say just give him a TCA (no red flags)...

 

[Ferrismonk]

But honestly guys, if you got a 55+ y/o with axial low back pain that refers into one or both hips who’s failed 6 weeks of PT and is in your office asking for help, who isn’t going to order an MRI? And then if this is positive for either a posterolateral disc or facet arthropathy, who isn’t going to order a procedure? This scenario probably accounts for 3/4th of my patients. I only save 1/4th of them an MRI by waiting until they’ve completed 6 weeks of PT

I don't. If axial low back "radiating" to b/l hips, in my experience it's usually SI. If exam correlates, I do SI with no imaging. For axial pain, I want an Xray. I only order MRI if there is radiation past the knee or radiation is accompanied by numbness/tingling/electrical feelings or red flags of course.

 

[deleted993114]

But honestly guys, if you got a 55+ y/o with axial low back pain that refers into one or both hips who’s failed 6 weeks of PT and is in your office asking for help, who isn’t going to order an MRI? And then if this is positive for either a posterolateral disc or facet arthropathy, who isn’t going to order a procedure? This scenario probably accounts for 3/4th of my patients. I only save 1/4th of them an MRI by waiting until they’ve completed 6 weeks of PT

That is a sclerotome for L4/L5. I would order imaging for that patient, as you said they DO have radiating pain to the legs, so it is possible that they have L4/L5 stenosis, for which surgery is superior to conservative care. So if they had symptoms of neurogenic claudication, then yes- I would order imaging. If just back pain- No.

If it was just back pain (no previous surgery and no red flags) then no- no MRI. The guidelines for BACK pain suggest advanced imaging IF symptoms 6-12 weeks in duration. MANY are advocating far less imaging even in that group, as the "yield" for any pathology that will change your treatment plan is about zero, AND it leads to more unnecessary procedures and imaging.

You don't need an MRI to do a lumbar epidural, facet blocks, or medial branch test blocks. If you really, really think that somehow imaging might help (the literature says otherwise), you will be able to see disc degen and facet arthritis on a very cheap plain x-ray.

I really don't know what you guys are hoping to find on an MRI for BACK PAIN that would alter your treatment plan. MOST of the pathology on lumbar MRIs is incidental and has nothing to do with the patient's pain. Further, 60% of patients with NO PAIN will have abnormalities on their MRIs. Should we treat them?

 

[Ferrismonk]

That is a sclerotome for L4/L5. I would order imaging for that patient, as you said they DO have radiating pain to the legs, so it is possible that they have L4/L5 stenosis, for which surgery is superior to conservative care. So if they had symptoms of neurogenic claudication, then yes- I would order imaging. If just back pain- No.

If it was just back pain (no previous surgery and no red flags) then no- no MRI. The guidelines for BACK pain suggest advanced imaging IF symptoms 6-12 weeks in duration. MANY are advocating far less imaging even in that group, as the "yield" for any pathology that will change your treatment plan is about zero, AND it leads to more unnecessary procedures and imaging.

You don't need an MRI to do a lumbar epidural, facet blocks, or medial branch test blocks. If you really, really think that somehow imaging might help (the literature says otherwise), you will be able to see disc degen and facet arthritis on a very cheap plain x-ray.

I really don't know what you guys are hoping to find on an MRI for BACK PAIN that would alter your treatment plan. MOST of the pathology on lumbar MRIs is incidental and has nothing to do with the patient's pain. Further, 60% of patients with NO PAIN will have abnormalities on their MRIs. Should we treat them?

I largely agree with you, with the caveat that you can't see discs on Xray (just disc space narrowing) and that lumbar epidurals aren't indicated for back pain or stenosis without radiculopathy.

 

[Ducttape]

you actually do need an MRI to do an epidural injection:

https://www.evicore.com/-/media/files/evicore/clinical-guidelines/solution/msk--advance/healthplan/highmark/pain-and-joint/01_hmk-cmm-200_v102019_eff03012019_pub101518.pdf

CMM-200.4: Indications: Epidural Steroid Injections (Transforaminal, Interlaminar, or Caudal)

An initial trial when there is evidence of symptomatic spinal stenosis and ALL of the following criteria are met: 
 Diagnostic evaluation has ruled out other potential causes of pain
 MRI or CT with or without Myelography within the past twelve (12) months demonstrates moderate to severe spinal stenosis at the level to be treated
 Significant functional limitations resulting in diminished quality of life and impaired, age-appropriate activities of daily living.
 Failure of at least four (4) weeks of conservative treatment (e.g., exercise physical methods including physical therapy and/or chiropractic care, NSAIDS, and/or muscle relaxants

 

[Ducttape]

from my standpoint, that means that MRI is required prior to epidural injections.

to be fair, CMMS states:

Indications for Coverage:

1. Suspected radicular pain
2. Neurogenic claudication
3. Post Laminectomy Syndrome
4. Low back pain with one of the following: substantial imaging abnormalities such as a central disc herniation, severe degenerative disc disease, high grade annular tears, the presence of osteophytes, facet hypertrophy and lateral disc herniation, or any other imaging abnormalities that result in either foraminal or central spinal canal stenosis. For a patient with low back pain only, a simple disc bulge or minor annular tear/ fissure is insufficient to justify performance of a LESI, unless other indications in this section are present. In the case of foraminal stenosis, the injections should only be repeated or continued as long as the patient responds to or shows significant improvement after the injection. Lack of response to additional injections in the face of foraminal stenosis may indicate end stage foraminal stenosis for which epidural injections may no longer be of value and therefore not medically reasonable and necessary.
5. Documented Visual Analog Scale (VAS) for pain or Numeric Pain Rating Scale (NPRS) ≥ 3/10 (moderate to severe pain) with functional impairment in activities of daily living (ADLs).
6. Failure of at least four weeks of non-surgical, non-injection care. All appropriate non-surgical, non-injection treatments should be considered along with a rationale for interventional treatment. Exceptions to waiting 4 weeks since the onset of pain before receiving an LESI exist, but circumstances should be clearly documented in the medical record. These would include, but are not limited to:

• At least moderate pain with significant functional loss at work and/or home.
• Severe pain unresponsive to outpatient medical management.
• Unable to tolerate non-surgical, non-injection care due to co-existing medical condition(s).
• Prior successful LESI for same specific condition.

Imaging Requirements:

1. Minimum criteria: Plain films to rule out fracture, potential malignancies, etc.
2. Advanced imaging (MRI, CT) may be appropriate prior to performing a LESI.

Key note is that there is, by CMMS, no specific requirement for MRI.

 

[hyperalgesia]

Ezekiel Emanuel, a health policy guy, would say just give him a TCA (no red flags)...

Him and Jonathan "Americans are stupid" Gruber. I don't want these guys anywhere near my patients.

 

[deleted993114]

you actually do need an MRI to do an epidural injection:

https://www.evicore.com/-/media/files/evicore/clinical-guidelines/solution/msk--advance/healthplan/highmark/pain-and-joint/01_hmk-cmm-200_v102019_eff03012019_pub101518.pdf

CMM-200.4: Indications: Epidural Steroid Injections (Transforaminal, Interlaminar, or Caudal)

An initial trial when there is evidence of symptomatic spinal stenosis and ALL of the following criteria are met: 
 Diagnostic evaluation has ruled out other potential causes of pain
 MRI or CT with or without Myelography within the past twelve (12) months demonstrates moderate to severe spinal stenosis at the level to be treated
 Significant functional limitations resulting in diminished quality of life and impaired, age-appropriate activities of daily living.
 Failure of at least four (4) weeks of conservative treatment (e.g., exercise physical methods including physical therapy and/or chiropractic care, NSAIDS, and/or muscle relaxants

Actually, you don't:

Effect of MRI on treatment results or decision making in patients with lumbosacral radiculopathy referred for epidural steroid injections: a multicenter, randomized controlled trial.
Cohen SP1, Gupta A, Strassels SA, Christo PJ, Erdek MA, Griffith SR, Kurihara C, Buckenmaier CC 3rd, Cornblath D, Vu TN.
Author information
1Department of Anesthesiology, Johns Hopkins Schoolof Medicine, Baltimore, MD, USA. [email protected]
Erratum in

• Arch Intern Med. 2012 Apr 23;172(8):673.

Abstract
BACKGROUND:
Studies have shown that radiologic imaging does not improve outcomes in most patients with back pain, though guidelines endorse it before epidural steroid injections (ESIs). The objective of this study was to determine whether magnetic resonance imaging (MRI) improves outcomes or affects decision making in patients with lumbosacral radiculopathy referred for ESI.
METHODS:
In this multicenter randomized study, the treating physician in group 1 patients was blinded to the MRI results, while the physician for group 2 patients decided on treatment after reviewing the MRI findings. In group 1 subjects, an independent physician proposed a treatment plan after reviewing the MRI, which was compared with the treatment the patient received.
RESULTS:
Slightly lower leg pain scores were noted in the group 2 at 1 month compared with MRI-blinded patients in group 1 (mean scores, 3.6 vs 4.4) (P = .12). No differences were observed in pain scores or function at 3 months. Overall, the proportion of patients who experienced a positive outcome was similar at all time points (35.4% at 3 months in group 1 vs 40.7% in group 2). Among subjects in group 1 who received a different injection than that proposed by the independent physician, scores for both leg pain (4.8 vs 2.4) (P = .01) and function (38.7 vs 28.2) (P = .04) were inferior to patients whose injection correlated with imaging. Collectively, 6.8% of patients did not (group 2) or would not have (group 1) received an ESI after the MRI was reviewed.
CONCLUSION:
Magnetic resonance imaging does not improve outcomes in patients who are clinical candidates for ESI and has only a minor effect on decision making. Trial Registration clinicaltrials.gov Identifier: NCT00826124.

 

[lonelobo]

Actually, you don't:

Effect of MRI on treatment results or decision making in patients with lumbosacral radiculopathy referred for epidural steroid injections: a multicenter, randomized controlled trial.
Cohen SP1, Gupta A, Strassels SA, Christo PJ, Erdek MA, Griffith SR, Kurihara C, Buckenmaier CC 3rd, Cornblath D, Vu TN.
Author information
1Department of Anesthesiology, Johns Hopkins Schoolof Medicine, Baltimore, MD, USA. [email protected]
Erratum in

• Arch Intern Med. 2012 Apr 23;172(8):673.

Abstract
BACKGROUND:
Studies have shown that radiologic imaging does not improve outcomes in most patients with back pain, though guidelines endorse it before epidural steroid injections (ESIs). The objective of this study was to determine whether magnetic resonance imaging (MRI) improves outcomes or affects decision making in patients with lumbosacral radiculopathy referred for ESI.
METHODS:
In this multicenter randomized study, the treating physician in group 1 patients was blinded to the MRI results, while the physician for group 2 patients decided on treatment after reviewing the MRI findings. In group 1 subjects, an independent physician proposed a treatment plan after reviewing the MRI, which was compared with the treatment the patient received.
RESULTS:
Slightly lower leg pain scores were noted in the group 2 at 1 month compared with MRI-blinded patients in group 1 (mean scores, 3.6 vs 4.4) (P = .12). No differences were observed in pain scores or function at 3 months. Overall, the proportion of patients who experienced a positive outcome was similar at all time points (35.4% at 3 months in group 1 vs 40.7% in group 2). Among subjects in group 1 who received a different injection than that proposed by the independent physician, scores for both leg pain (4.8 vs 2.4) (P = .01) and function (38.7 vs 28.2) (P = .04) were inferior to patients whose injection correlated with imaging. Collectively, 6.8% of patients did not (group 2) or would not have (group 1) received an ESI after the MRI was reviewed.
CONCLUSION:
Magnetic resonance imaging does not improve outcomes in patients who are clinical candidates for ESI and has only a minor effect on decision making. Trial Registration clinicaltrials.gov Identifier: NCT00826124.

So what percentage of your ESI's are you performing a year without MRI or CT scan?

 

[clubdeac]

I've seen my fair share of patients with severe stenosis that have only axial lbp without neurogenic claudication. Their back pain is worse with extension, prolonged standing and walking. Universally these guys have not responded consistently to facet interventions as one would expect (b/c that's what I initially targeted in my first 7-8 years in practice). Had I not obtained the MRI, I would have had no idea that they had severe multifactorial stenosis. In addition, doing an interlaminar at a level of severe stenosis could cause more harm than good.