Adding obesity medicine to a busy practice

[callmeanesthesia]

Hi all, I figured IM is the best group of people to ask about how to go about this, and maybe point me in the direction of pre-made resources so I’m not reinventing the wheel. I’m a busy interventional pain doctor (anesthesia primary specialty) in a relatively rural, medically underserved area. PCPs are hard to come by, and obviously overworked. My practice is, admittedly, a bit of a block shop (heavy on injections), but I still like to pretend I’m a real doctor when I get the chance.

I have a lot of patients where obesity is a major contributor to their pain, and I’d like to help them with it. I had a lady yesterday who seemed quite surprised by the advice to add some non-starch vegetables to her diet. Maybe she’ll even listen. If I’m going to do it, I want to do it right. I’m in the process of doing the CMEs for a board certification in obesity medicine. But, I’m in private practice and my income comes from doing lots of injections, so if I’m going to avoid losing money on this, I need to make it efficient, with thorough intake and screening forms, order sets, and standard patient education handouts, and delegate as much as possible. I’m considering hiring an RN (or even better, an LCSW, who could bill separately for their services) to do the bulk of the patient education and counseling. If I can find the right person, I’ll hire a PA or NP to do most of the follow ups as well. I’m not looking to dabble in compounded meds or make a bunch of money on this, just filling an unmet need in the community.

For anyone who has added obesity medicine to an already busy practice, can you give me some pointers?

Thank you in advance!

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[DrMetal]

Hi all, I figured IM is the best group of people to ask about how to go about this, and maybe point me in the direction of pre-made resources so I’m not reinventing the wheel. I’m a busy interventional pain doctor (anesthesia primary specialty) in a relatively rural, medically underserved area. PCPs are hard to come by, and obviously overworked. My practice is, admittedly, a bit of a block shop (heavy on injections), but I still like to pretend I’m a real doctor when I get the chance.

I have a lot of patients where obesity is a major contributor to their pain, and I’d like to help them with it. I had a lady yesterday who seemed quite surprised by the advice to add some non-starch vegetables to her diet. Maybe she’ll even listen. If I’m going to do it, I want to do it right. I’m in the process of doing the CMEs for a board certification in obesity medicine. But, I’m in private practice and my income comes from doing lots of injections, so if I’m going to avoid losing money on this, I need to make it efficient, with thorough intake and screening forms, order sets, and standard patient education handouts, and delegate as much as possible. I’m considering hiring an RN (or even better, an LCSW, who could bill separately for their services) to do the bulk of the patient education and counseling. If I can find the right person, I’ll hire a PA or NP to do most of the follow ups as well. I’m not looking to dabble in compounded meds or make a bunch of money on this, just filling an unmet need in the community.

For anyone who has added obesity medicine to an already busy practice, can you give me some pointers?

Thank you in advance!

Are you willing to pass out scripts for GLP1 agonists? That's what 'obesity' medicine has succumb to. Nobody cares about 'non-starch vegetables'.

 

[callmeanesthesia]

Are you willing to pass out scripts for GLP1 agonists? That's what 'obesity' medicine has succumb to. Nobody cares about 'non-starch vegetables'.

Absolutely. I’ve had patients who have made great lifestyle changes while on GLP-1s. A1C under control, weight down 20% or more, and with that, the inflammation in their body is less and their pain is less. Trouble is, GLP-1s are a lot of work in terms to getting them covered, and helping patients titrate them effectively so they don’t wash out due to GI side effects.

I haven’t started writing for them yet, but I’ve had several long conversations with patients during procedures, and written down some recommendations for them to talk to their PCP. For example, a patient who wanted it for weight loss but didn’t have diabetes, but did have sleep apnea so should be able to qualify for tirzepatide. Also wrote down a few apps for him to start tracking his calories, and gave him a PT Rx to start a home exercise program.

 

[chessknt]

Absolutely. I’ve had patients who have made great lifestyle changes while on GLP-1s. A1C under control, weight down 20% or more, and with that, the inflammation in their body is less and their pain is less. Trouble is, GLP-1s are a lot of work in terms to getting them covered, and helping patients titrate them effectively so they don’t wash out due to GI side effects.

I haven’t started writing for them yet, but I’ve had several long conversations with patients during procedures, and written down some recommendations for them to talk to their PCP. For example, a patient who wanted it for weight loss but didn’t have diabetes, but did have sleep apnea so should be able to qualify for tirzepatide. Also wrote down a few apps for him to start tracking his calories, and gave him a PT Rx to start a home exercise program.

Now imagine having that conversation but only getting paid a paltry E/M code instead of whatever astronomical facility fee your procedure pays but using just as much of your time plus all the uncompensated time appealing denials and answering calls about side effects from medications...

Just keep doing blocks on people while it still gets paid for, you can take an obesity fellowship or something later once your specialty dies and join the ranks of the E/M peons who get paid Walmart wages to perform cognitive (ie pretend) medicine.

 

[callmeanesthesia]

Now imagine having that conversation but only getting paid a paltry E/M code instead of whatever astronomical facility fee your procedure pays but using just as much of your time plus all the uncompensated time appealing denials and answering calls about side effects from medications...

Just keep doing blocks on people while it still gets paid for, you can take an obesity fellowship or something later once your specialty dies and join the ranks of the E/M peons who get paid Walmart wages to perform cognitive (ie pretend) medicine.

That’s why I want a mid level or LCSW to do most of the talking. And yes, a follow up pays about half what an epidural does and takes longer. On the other hand, if I have that conversation while doing a procedure, it’s a separately identifiable E&M service. I just have to write a little note and I can bill for it on top of the procedure, with a 25 modifier. Then if I can get my handouts and templates in order like I described, I can give them intake paperwork and lab orders before they leave, and at follow up review that data and give them a prescription.

 

[DrMetal]

That’s why I want a mid level or LCSW

You don't even that. Hire a secretary to manage your orders, buy the materials, a peptide synthesizer, and a gas chromatograph (to confirm purity). < $250K, small business loan, cheaper than running a micro-brewery.

Everyone's "Breaking Bad" with these GLP1 agonists.

 

[chessknt]

That’s why I want a mid level or LCSW to do most of the talking. And yes, a follow up pays about half what an epidural does and takes longer. On the other hand, if I have that conversation while doing a procedure, it’s a separately identifiable E&M service. I just have to write a little note and I can bill for it on top of the procedure, with a 25 modifier. Then if I can get my handouts and templates in order like I described, I can give them intake paperwork and lab orders before they leave, and at follow up review that data and give them a prescription.

How good are you at E/M billing really though and is it worth it? I could easily imagine an audit if suddenly your E/M billing shoots up on completely unrelated procedures. You should look in to the placeb... err I mean SGB injections for cash instead. That is what the pain guy does in my area and he clears multiple millions a year selling it for literally every medical condition in existence.

Makes no sense trying to monetize obesity education-our broken ass ****ty medical system places almost 0 value on this service and $$$$$ on doing things to people regardless of indication or efficacy. You are in a specialty that can massively capitalize on this and since you are trying to monetize things you should monetize that.

 

[callmeanesthesia]

How good are you at E/M billing really though and is it worth it? I could easily imagine an audit if suddenly your E/M billing shoots up on completely unrelated procedures. You should look in to the placeb... err I mean SGB injections for cash instead. That is what the pain guy does in my area and he clears multiple millions a year selling it for literally every medical condition in existence.

Makes no sense trying to monetize obesity education-our broken ass ****ty medical system places almost 0 value on this service and $$$$$ on doing things to people regardless of indication or efficacy. You are in a specialty that can massively capitalize on this and since you are trying to monetize things you should monetize that.

Not in it to make more money. Just trying not to lose money, while providing a service I think could really help my patients. I think I’m pretty good at billing and coding. Blue Cross basically doesn’t pay for 25 modifier but these will be mostly Medicare/Medicaid patients anyway (we have a unique Medicaid carrier in our area that pays better than Medicare when you include the specialist incentives)

If that’s what’s going on around you, I can see why you’d be cynical about pain docs. I don’t really like doing stellate blocks, or cash pay services in general. Not a good enough salesman.