Advanced Procedures Post-Fellowship

[JBM16BYU]

Hi everyone! Just as the title says, if you don’t end up matching at a pain fellowship that has exposure to or teaches you to perform advanced procedures, such as MILD, ISS, BVN ablation, Interspinous fusion, etc, how do you go about learning and getting enough personal practice to add these procedures to your clinical practice?

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[paindoc007]

Cadaver workshops hosted by the companies

 

[gaspasser127]

Hi everyone! Just as the title says, if you don’t end up matching at a pain fellowship that has exposure to or teaches you to perform advanced procedures, such as MILD, ISS, BVN ablation, Interspinous fusion, etc, how do you go about learning and getting enough personal practice to add these procedures to your clinical practice?

If you’re motivated you can learn on your own. Go to cadaver courses and network with other attendings who are younger and may have been in a similar situation as you when they first graduated.

You’d be surprised at how many pain fellowship grads just don’t have any interest in pursuing those advanced procedures or at most will just learn SCS.

No judgement on those folks though. To each their own.

 

[runfastnow]

MILD is very approachable and easy to learn if you are comfortable with CLO views. Rep typically in the room for your first 5-10 cases then PRN.

 

[drrosenrosen]

FYI new Intracept CPT code will pay $220/level for Medicare. That's probably not going to fly since it takes a solid 30 min/level and has to be done at the hospital

 

[drusso]

FYI new Intracept CPT code will pay $220/level for Medicare. That's probably not going to fly since it takes a solid 30 min/level and has to be done at the hospital

How does it pencil for the facility? If you're juicing the Vig on the SOS who cares what the pro-fee is as long as you're turning over the rooms!

The physician pro-fee/RVU is the Hospital's version of the Costco Rotisserie chicken.

 

[Ferrismonk]

Hi everyone! Just as the title says, if you don’t end up matching at a pain fellowship that has exposure to or teaches you to perform advanced procedures, such as MILD, ISS, BVN ablation, Interspinous fusion, etc, how do you go about learning and getting enough personal practice to add these procedures to your clinical practice?

99% of pain docs don't do these fyi.

There are 3 reasons for this.
1. It takes more work to do/learn these procedures.
2. There is always something "new" which often ends up just being a flash in the pan. (i.e. doesn't work or ends up not being covered)
3. You will get paid more per unit time to simply do MBB/RFA/ESI.

That being said, don't worry about training. Learn to steer a needle very well during fellowship and you can learn anything else later either through reading, shadowing, or courses.

 

[bedrock]

FYI new Intracept CPT code will pay $220/level for Medicare. That's probably not going to fly since it takes a solid 30 min/level and has to be done at the hospital

I'm definitely not going to learn this with it paying that badly. Might be worth it for HOPD employed physicians, but still likely not a big earner unless they get a high RVU for this.

I would still refer patients who need it, but I'm not going to learn/perform Intracept.

 

[SSdoc33]

I'm definitely not going to learn this with it paying that badly. Might be worth it for HOPD employed physicians, but still likely not a big earner unless they get a high RVU for this.

I would still refer patients who need it, but I'm not going to learn/perform Intracept.

im still intrigued, but this is moving very slowly. seems like it will become an out-of-pocket for the well heeled type of procedure only.

 

[RoloTomassi]

Pro fee is sad:
64628 - $456.26 (for first two vertebral bodies)
64629 - $213.69 (for each additional)

Facility:
HOPD $12,593
ASC $9420

 

[drusso]

Pro fee is sad:
64628 - $456.26 (for first two vertebral bodies)
64629 - $213.69 (for each additional)

Facility:
HOPD $12,593
ASC $9420

Again, if you're juicing the Vig on SOS facility fee, who cares about the pro-fee? The manufacturer doesn't. They built their whole pricing model on that juicy facility fee, not the provider's piddly pro-fee.

Just show your Admin the juicy $12.5K reimbursement and say, "Pay me." The hospital shouldn't be so greedy with that juicy fee. Three words, "Physician Enterprise Value." Google it.

 

[paindoc007]

And when the feds come after you for the illegal downstream referrals and facility fee kickbacks, you can say “well this dude on SDN talks about SOS and physician enterprise value basically every day. So I thought it was all good”.

 

[drusso]

And when the feds come after you for the illegal downstream referrals and facility fee kickbacks, you can say “well this dude on SDN talks about SOS and physician enterprise value basically every day. So I thought it was all good”.

No one would make it that obvious. But, does it really cost them $12.5K to support that service, or is the Admin hiding the ball? They can pay you whatever they want as long you keep turning the crank for them on the facility fees.

 

[paindoc007]

No one would make it that obvious. But, does it really cost them $12.5K to support that service, or is the Admin hiding the ball? They can pay you whatever they want as long you keep turning the crank for them on the facility fees.

Dude we all agree with you. I’m not defending sos health care costs. It’s absolute insanity.

What I have a problem with is the casualness you keep pushing physician enterprise value, and “get paid what you’re worth”, type of stuff on people.

Whisleblowers are incentivized to “come forward” - doesn’t take a lot. A pissed off administrator doesn’t get the bonus and can whine to the wrong people that the hospital is paying a doctor wrongfully. There are examples of this happening. I’ve sent you one before on a post while back. The corrupt justice dept always wants to make an example out of a greedy doctor

 

[drusso]

Dude we all agree with you. I’m not defending sos health care costs. It’s absolute insanity.

What I have a problem with is the casualness you keep pushing physician enterprise value, and “get paid what you’re worth”, type of stuff on people.

Whisleblowers are incentivized to “come forward” - doesn’t take a lot. A pissed off administrator doesn’t get the bonus and can whine to the wrong people that the hospital is paying a doctor wrongfully. There are examples of this happening. I’ve sent you one before on a post while back. The corrupt justice dept always wants to make an example out of a greedy doctor

Not if we change the rules. But, first people need to speak openly about the problem. Physician enterprise value, revenue leak, consolidation, monopoly, steerage of referrals, etc are all real conversations that Admin have with employed MD's all the time. Got to let the light shine in on this stuff.

The only thing doctors can do is ask for a bigger piece of the pie or grow the pie bigger. Nothing wrong with that. Better than just running faster on the treadmill for more RVU pellets.

 

[drrosenrosen]

I'm definitely not going to learn this with it paying that badly. Might be worth it for HOPD employed physicians, but still likely not a big earner unless they get a high RVU for this.

I would still refer patients who need it, but I'm not going to learn/perform Intracept.

Yeah, I'm disappointed, because my partner has been doing them this year, and been very happy with results. I was looking forward to doing them, but between having to book time at the hospital to do them, and basically losing money on the time spent, it's hard to justify

 

[Agast]

I’m willing to do any procedure that works as long as it does not lose money or create unnecessary problems. Reducing pain is how we combat the opioid epidemic. It also encourages word of mouth referrals to friends, families and more referrals from PCPs. Patient goes back and tells their PCP that you helped them when no one else could or knew how, and they remember that kind of thing.

 

[swamprat]

Minutemen, MILD procedure, SCS, endoscopic disc/rhizo - all advanced procedures that pay pretty darn well and in the RIGHT PATIENT can make a world of difference. Notice I did not include vertiflex..

 

[manowar rules]

Minutemen, MILD procedure, SCS, endoscopic disc/rhizo - all advanced procedures that pay pretty darn well and in the RIGHT PATIENT can make a world of difference. Notice I did not include vertiflex..

Why you hatin’ on Vertiflex?

 

[swamprat]

Why you hatin’ on Vertiflex?

Pays poorly and anecdotally I have not had really any great results. In contrast to MILD which pays much better and results have been fantastic. Perhaps my patient selection for vertiflex is poor and the patients I am choosing are too far gone

 

[RoloTomassi]

Minutemen, MILD procedure, SCS, endoscopic disc/rhizo - all advanced procedures that pay pretty darn well and in the RIGHT PATIENT can make a world of difference. Notice I did not include vertiflex..

Good experiences with Minuteman and endoscopic?

 

[Crybaby]

Pays poorly and anecdotally I have not had really any great results. In contrast to MILD which pays much better and results have been fantastic. Perhaps my patient selection for vertiflex is poor and the patients I am choosing are too far gone

Does minute man get you significantly better results than vertiflex?

 

[mid|ine]

I do SCS. I trained for MILD but have never done a case. I wanted to do more advanced procedures. Now Im happy keeping it simple.

 

[swamprat]

Good experiences with Minuteman and endoscopic?

Yeah so if I think vertiflex now I consider minutemen espeically if there is any listhesis. I use a wilson frame when I place it. I have done a few and suprised at the results they have beenn good. Endoscopic too - the rhizos work great and so far have had results working > 1 year out - they say 3-5 but idk?

 

[DrSpine]

And when the feds come after you for the illegal downstream referrals and facility fee kickbacks, you can say “well this dude on SDN talks about SOS and physician enterprise value basically every day. So I thought it was all good”.

Physician Enterprise Value just means that a Physician has a specific worth, and as Physician that should be factored into one's salary with the Hospital if entering employment. Professional Athlete's have enterprise value, and it comes accordingly during contract negotiations. Plus, the kickback should come in the form of a bonus for "productivity." It's essentially what they're doing anyway by encouraging you to do more procedures. Only the bonus should be far higher.

 

[drusso]

Physician Enterprise Value just means that a Physician has a specific worth, and as Physician that should be factored into one's salary with the Hospital if entering employment. Professional Athlete's have enterprise value, and it comes accordingly during contract negotiations. Plus, the kickback should come in the form of a bonus for "productivity." It's essentially what they're doing anyway by encouraging you to do more procedures. Only the bonus should be far higher.

Physician enterprise value is the coin of the realm but the concept is never discussed in medical school or residency. But, the first 3 chapters of any health care finance or accounting book will have it. Still, doctors pretend like it doesn't exist. The bean counters measure and track it explicitly. What do you think the EHR is for? It's a cash register that links every click you make to a chargemaster.

 

[DrSpine]

Physician enterprise value is the coin of the realm but the concept is never discussed in medical school or residency. But, the first 3 chapters of any health care finance or accounting book will have it. Still, doctors pretend like it doesn't exist. The bean counters measure and track it explicitly. What do you think the EHR is for? It's a cash register that links every click you make to a chargemaster.

I wish more Physicians out there had the ability to think and be honest and smart about themselves, their surroundings, and career.