Becker: Spine Surgeons Drop Medicare. Pain Surgeons Next?

[drusso]

Spine surgeons weigh Medicare exit amid pay cuts

Declining CMS rates have been a concern among physicians across the board, and spine surgeons are thinking about implications for the future of patient care as

www.beckersspine.com

"For some spine surgeons, dropping Medicare patients entirely was an option that has worked long-term. Ara Deukmedjian, MD, backed out of Medicare more than a decade ago. Medicare patients who still wanted to see him paid out of their pockets, and his practice has remained strong financially."

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[CleanUp]

I’ve dropped Medicare. Haven’t looked back.

Rates have been on the decline for quite some time. Need to increase volume to make up for this. There’s a breaking point to this charade.

I seriously doubt, in my humble opinion, the rates will go up.

The expense to run a practice (malpractice, ancillary staff, EMR, supplies) have not gone down yet the patients want the same amount of time and attention. They want their shots right away. They want to message and call and expect a prompt response.

That is like wanting to go to McDonalds and then wanting a gourmet steak restaurant experience. Ain’t gonna happen. If you wanna cut the line at Disney ya better be prepared to pay for it.

To be fair this is not the patients’ fault. However, they did agree to be covered by Medicare. Medicare doesn’t pay me fair market value or reflect my value. Thus, I do not take Medicare.

Healthcare has changed - not the patients. I empathize with them that suddenly they are being treated different than they were in the last 20-30 years. Such is healthcare though.

There are many people in my neck of the woods that do accept Medicare.

 

[mdo1738]

HOPD based, I love Medicare. Probably would be different if I was PP. Have adapted to their new MBB/RFA nonsense after a couple hiccups. Lots of stuff that either needs no auth or is painless to obtain auth. On the other hand, Medicare Advantage? Nightmare.

My perspective would be different if I were not RVU based.

 

[drusso]

HOPD based, I love Medicare. Probably would be different if I was PP. Have adapted to their new MBB/RFA nonsense after a couple hiccups. Lots of stuff that either needs no auth or is painless to obtain auth. On the other hand, Medicare Advantage? Nightmare.

My perspective would be different if I were not RVU based.

It's almost like there are two kinds of pain doctors...employed/HOPD and independent/private practice....

 

[BobBarker]

Traditional Medicare is great for me in private practice. No auth, can do pretty much any procedure I want, elderly and kind patients, payment about the same as many commercial payors.

 

[Taus]

Traditional Medicare is great for me in private practice. No auth, can do pretty much any procedure I want, elderly and kind patients, payment about the same as many commercial payors.

agree re most of that with traditional Medicare…. Except that’s awful to have Medicare paying similar to your commercial carriers. Why is that?

 

[drusso]

Traditional Medicare is great for me in private practice. No auth, can do pretty much any procedure I want, elderly and kind patients, payment about the same as many commercial payors.

Our commercial payers pay 3X Medicare.

 

[bedrock]

I’ve dropped Medicare. Haven’t looked back.

Rates have been on the decline for quite some time. Need to increase volume to make up for this. There’s a breaking point to this charade.

I seriously doubt, in my humble opinion, the rates will go up.

The expense to run a practice (malpractice, ancillary staff, EMR, supplies) have not gone down yet the patients want the same amount of time and attention. They want their shots right away. They want to message and call and expect a prompt response.

That is like wanting to go to McDonalds and then wanting a gourmet steak restaurant experience. Ain’t gonna happen. If you wanna cut the line at Disney ya better be prepared to pay for it.

To be fair this is not the patients’ fault. However, they did agree to be covered by Medicare. Medicare doesn’t pay me fair market value or reflect my value. Thus, I do not take Medicare.

Healthcare has changed - not the patients. I empathize with them that suddenly they are being treated different than they were in the last 20-30 years. Such is healthcare though.

There are many people in my neck of the woods that do accept Medicare.

Aren’t you in Southern California? A lot of commercial insurance pays close to Medicare rates in SoCal.

 

[BobBarker]

Our commercial payers pay 3X Medicare.

So $300 office visits, $800 epidurals, and $2500 RFA’s? That is a little less than 3x Medicare. Does not seem believable.

 

[SSdoc33]

It's almost like there are two kinds of pain doctors...employed/HOPD and independent/private practice....

It’s almost like there are two kids of pain doctors…… those treat the indigent/those who don’t…..

 

[bedrock]

Our commercial payers pay 3X Medicare.

I highly doubt most of your commercial payors pay 3x medicare.

I suspect you have can get 3x medicare from a random legacy UHC or Aetna patient, but I'm sure the bulk of commercial insurance including BCBS of oregon does not pay 3x medicare.

 

[bedrock]

It’s almost like there are two kids of pain doctors…… those treat the indigent/those who don’t…..

It is......... like almost like there are two kinds of pain doctors.

Private practice pain docs who have their payment rates cut every year while their staff/equipment costs go up and so have to make rational decisions to keep their practices viable……

And there are HOPD employed/adjacent docs who treat the indigent and then arrogantly claim it is because they are superior doctors/human beings, while in reality they can only do this because of the ridiculous SOS difference between HOPD and PP.

 

[RoloTomassi]

I highly doubt most of your commercial payors pay 3x medicare.

I suspect you have can get 3x medicare from a random legacy UHC or Aetna patient, but I'm sure the bulk of commercial insurance including BCBS of oregon does not pay 3x medicare.

Some of the bigger practices in my area with more bargaining power have commercial rates at that range. A lot of hospital systems have good rates and you can get those rates my joining their clinically integrated network if you agree to do a certain number of cases at their hospital. We are a smaller practice but hired a consultant to do our negotiations who got us pretty good rates.

I recently stopped taking new Medicare patients. Keeping the existing ones that just need repeat procedures periodically.

 

[nvrsumr]

All the ortho groups in my town are under one umbrella group and my understanding is they have great contracts. I’d still be surprised at even 2x medicare

 

[MitchLevi]

Medicare is better for me vs some payers for some things.

I love Medicare. I don’t need permission for anything.

 

[CleanUp]

I have no problem waiting longer if the payout is remarkably higher.

I have no need to get paid right away.

Peanuts are still peanuts even if they’re delivered right away.

 

[powermd]

I have no problem waiting longer if the payout is remarkably higher.

I have no need to get paid right away.

Peanuts are still peanuts even if they’re delivered right away.

Sounds like you are mainly PI. True?

 

[Dr. Ice]

It is......... like almost like there are two kinds of pain doctors.

Private practice pain docs who have their payment rates cut every year while their staff/equipment costs go up and so have to make rational decisions to keep their practices viable……

And there are HOPD employed/adjacent docs who treat the indigent and then arrogantly claim it is because they are superior doctors/human beings, while in reality they can only do this because of the ridiculous SOS difference between HOPD and PP.

I treat the indigent in private practice…

 

[CleanUp]

Sounds like you are mainly PI. True?

No

 

[SSdoc33]

It is......... like almost like there are two kinds of pain doctors.

Private practice pain docs who have their payment rates cut every year while their staff/equipment costs go up and so have to make rational decisions to keep their practices viable……

And there are HOPD employed/adjacent docs who treat the indigent and then arrogantly claim it is because they are superior doctors/human beings, while in reality they can only do this because of the ridiculous SOS difference between HOPD and PP.

thats true, and i accept that PP generally does not and should not treat the indigent. we shouldnt work for free or for pennies on the dollar.

but you (mainly talking at drusso here) dont get to have your cake and eat it, too. you bitch about SOS (d), but then punt difficult cases, medicaid, and probably a lot of ACA exchange patients to HOPD.

nothing about being a superior human being, that came out of nowhere. but you do need to acknowledge that you are only treating those with the means to have representative medical insurance.

SOS (d) is not going anywhere. the gap shouldnt be as big as it is, but hospitals should get subsidized for all of the free care/barely paid care they provide

 

[drusso]

thats true, and i accept that PP generally does not and should not treat the indigent. we shouldnt work for free or for pennies on the dollar.

but you (mainly talking at drusso here) dont get to have your cake and eat it, too. you bitch about SOS (d), but then punt difficult cases, medicaid, and probably a lot of ACA exchange patients to HOPD.

nothing about being a superior human being, that came out of nowhere. but you do need to acknowledge that you are only treating those with the means to have representative medical insurance.

SOS (d) is not going anywhere. the gap shouldnt be as big as it is, but hospitals should get subsidized for all of the free care/barely paid care they provide

I don't punt any cases to HOPD doctors.

 

[SSdoc33]

I don't punt any cases to HOPD doctors.

some do. some that are flintstone's fans.....

 

[Ducttape]

I don't punt any cases to HOPD doctors.

refusing to see or limiting Medicare/Medicaid panels are common mechanisms of limiting access.

entirely appropriate for a PP to do so, but it does imply limiting these patients, who then turn to HOPD doctors.

 

[callmeanesthesia]

I don't punt any cases to HOPD doctors.

Did you mash up Lobel and Gollum for your new profile pic?

 

[lobelsteve]

Did you mash up Lobel and Gollum for your new profile pic?

My ears are bigger

 

[nvrsumr]

I get referred Medicaid patients weekly from the academic hospital near me. From their outpatient np clinics that bill a facility fee …

 

[nvrsumr]

In fairness not certain if all the clinics charge a facility fee. It’s up to a year wait for an epidural so patients complain enough to eventually get referred out

Thankfully the U hospital built a gorgeous new building for their pain surgeon and other the other specialists who dont see caid in the swankiest part of town. Love my tax dollars getting funneled to my direct competitors.

From where I sit hopd pain docs have cush jobs with great pay in very nice new suburban hospitals.

 

[Dr. Ice]

The hopd guys by me have 5 page long notes that say nothing, mostly templated hospital mumbo jumbo that gets them a higher bill for saying nothing and having no plan

 

[bedrock]

In fairness not certain if all the clinics charge a facility fee. It’s up to a year wait for an epidural so patients complain enough to eventually get referred out

Thankfully the U hospital built a gorgeous new building for their pain surgeon and other the other spacialists who dont see caid in the swankiest part of town. Love my tax dollars getting funneled to my direct competitors.

From where I sit hopd pain docs have cush jobs with great pay in very nice new suburban hospitals.

Don’t want to hurt you but if it takes a year to get an ESI, it sounds like U hospital needs to hire several pain physicians (not surgeons ..)

 

[nvrsumr]

A year for Medicaid patients.

 

[bedrock]

A year for Medicaid patients.

So the federal tax shelter non profit university hospital, with all kinds of federal grants, has a quota on procedures going to Medicaid patients vs procedures on patients with commercial insurance ??

 

[Status Sciaticus]

how are yall turning away medicare patients? The majority of pain patients I've come across are on some form of medicare. I'm surprised that the volume lost by dropping medicare is easily replaced by commercial and/or PI. Maybe I'm missing something?

 

[Ducttape]

how are yall turning away medicare patients? The majority of pain patients I've come across are on some form of medicare. I'm surprised that the volume lost by dropping medicare is easily replaced by commercial and/or PI. Maybe I'm missing something?

im guessing location has a role in this.

From where I sit hopd pain docs have cush jobs with great pay in very nice new suburban hospitals.

grass is always greener on the other side of the fence.

 

[Dr. Ice]

From where I’m at, it seems pretty cush. They don’t see high volume, and have no real plan most of the time.

I see nj health which is basically Obamacare nonsense Medicaid in this state. We only see it because no other ortho private practice takes it so we have decent contracts, probably better than some commercial payors, but no hospital employed doc around me can whine to me that they see “tough indigent patients” cause we essentially have the same payor mix.

 

[SSdoc33]

The hopd guys by me have 5 page long notes that say nothing, mostly templated hospital mumbo jumbo that gets them a higher bill for saying nothing and having no plan

that is not exclusive to HOPD, btw

 

[CleanUp]

I think it is quite sad how we are arguing private practice versus HOPD when in reality insurance is looking to chop every single one of us. The enemy is not the physician across the street.

To those who are asking how this could be done it is simply a matter of focusing on the other side of the equation – the expenses. You have to think like a business owner and not a clinician. You have to break the idea of increasing volume. It does not work every where. It does not work for everyone. And that’s OK.

It is certainly not as easy as it seems. I completely agree that it is a niche.

 

[Ducttape]

that is correct.

and there are issues on this side of the fence too. from this side, PP looks appealing...

 

[cowboydoc]

I get referred Medicaid patients weekly from the academic hospital near me. From their outpatient np clinics that bill a facility fee …

Now, that's some BS!

 

[swamprat]

I have this one insurance (and also one patient) that pays insane like 10x medicare rates.

Example - office visit follow up ~$400, in office epidural ~$3000, professional fee on discectomy from ASC $7500. Love to get more of these patients - its a weird name insurance from like some local city job.

 

[Gauss]

I get referred Medicaid patients weekly from the academic hospital near me. From their outpatient np clinics that bill a facility fee …

Fee for service, straight MCaid or Managed Mcaid? Seeing more and more Managed MCaid not contracting with state university hospital systems. Most managed Mcaid reimburses better than FFS, but FFS auths are usually easier to get