Concierge Pain Medicine

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Can't imagine anyone of the mind to employ a concierge pain physician that would also agree to limits on scheduled drugs. Michael Jackson, etc...... That's why they pay them, to get whatever goodies they want.
 
I think it would be difficult to have a concierge practice now, other than being a candyman. But as Obamacare gets implemented and insurance rates soar, especially after the "mandate" gets overturned, things may change. Medicare and Medicaid slashing reimbursement (as they must to stay solvent) along with health insurance cost skyrocketing (with no lifetime caps or pre-existing clauses-this is inevitable), it is a recipe for a resurgent free market fee-for-service model. In the future, we might see a "government health plan" that is substandard and rationed, alongside an independently thriving free market health care system. But where ever we end up, getting there will be excruciating.
 
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People will not pay for specialty services out of pocket. Primary care, yes, specialty, no.

Those that will pay OOP are either so rich that they can buy someone better than you, or more generous with the Rx pad, or they are so whacked out that you don't want them.
 
I personally believe this is a terrible idea, fraught with perils of the legal, financial, and ethical nature. The idea that x dollars per year will buy up to y quantity of pain medications if specified, is simply drug dealing while on the other hand if the amount is not specified and you do not comply with the patient's wishes, they can sue for fraudulant misrepresentation. Ethically...well, don't even go there.
Acute pain patients could probably afford concierge treatments but unless they become chronic, concierge would not be needed. If they are chronic and have no funding or are on medicare or medicaid, it doesn't matter if you want to render concierge services...you cannot legally do this in some cases (Medicare and in some states Medicaid) and they cannot afford it.
 
I do not think this would work for Rx'ing or injections, maybe for OMT/accupuncture type practice.
 
algosdoc said:
I personally believe this is a terrible idea, fraught with perils of the legal, financial, and ethical nature. The idea that x dollars per year will buy up to y quantity of pain medications if specified, is simply drug dealing while on the other hand if the amount is not specified and you do not comply with the patient's wishes, they can sue for fraudulant misrepresentation. Ethically...well, don't even go there.
Acute pain patients could probably afford concierge treatments but unless they become chronic, concierge would not be needed. If they are chronic and have no funding or are on medicare or medicaid, it doesn't matter if you want to render concierge services...you cannot legally do this in some cases (Medicare and in some states Medicaid) and they cannot afford it.
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I completely agree that "concierge" is inappropriate for pain management when it's defined in this way (paying up front for 1 year's worth of service). I'm sort of thinking as concierge just as "personalized service". I think it would be nice if, when someone needs a doctor, they go see their PCP and pay $150 cash. If referral is appropriate, they're sent to a pain specialist with another $150 or so. Maybe they can expect to pay $300 cash for a LESI. The rates could all be determined by the market. Can I be arrested for this kind of talk?
 
hyperalgesia said:
I think it would be difficult to have a concierge practice now, other than being a candyman. But as Obamacare gets implemented and insurance rates soar, especially after the "mandate" gets overturned, things may change. Medicare and Medicaid slashing reimbursement (as they must to stay solvent) along with health insurance cost skyrocketing (with no lifetime caps or pre-existing clauses-this is inevitable), it is a recipe for a resurgent free market fee-for-service model. In the future, we might see a "government health plan" that is substandard and rationed, alongside an independently thriving free market health care system. But where ever we end up, getting there will be excruciating.
Click to expand...

I don't know if concierge medicine has a future, but I agree that fee-for-service will return down the road. People are already paying huge co-pays for routine follow ups. I commonly see $35 dollars for follow up visits. Hell, we don't get paid much more than that. The combination of the mandates and the greedy private insurance companies will drive up the price of coverage so high that people will only be able to afford catastrophic coverage. At that point, all this non-essential care will be cash-driven. People will pay, just ask the 35 chiropractors and dentists in my small town. I'm not saying salaries will rise by any means, but you will be able to let go of your 4 employees who code, bill, and fight with the insurance companies.

"Ray, people will come Ray. They'll come to Iowa for reasons they can't even fathom. They'll turn up your driveway not knowing for sure why they're doing it. They'll arrive at your door as innocent as children, longing for the past. Of course, we won't mind if you look around, you'll say. It's only $20 per person. They'll pass over the money without even thinking about it: for it is money they have and peace they lack... Oh... people will come Ray. People will most definitely come."
 
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knoxdoc said:
"Ray, people will come Ray. They'll come to Iowa for reasons they can't even fathom. "
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They will come because they are starving and that's where the food is. Not that I'm pessimistic or anything.
 
If a pain physician wants to offer procedures for a reasonable cash price then there should be nothing wrong with that concept, if it can be done within the confines of state and federal laws. Medicare patients pose a problem...unless you have opted out of Medicare, you cannot charge them your own fee schedule. If you are listed on the Medicaid provider list, even if you don't take any new Medicaid, you cannot charge your own fee schedule or balance bill. But otherwise, staying clear of insurer contracts, you would probably be able to perform the services for cash, providing of course you had any patients that were willing to cough up the money for such services.
 
algosdoc said:
If you are listed on the Medicaid provider list, even if you don't take any new Medicaid, you cannot charge your own fee schedule or balance bill.
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There are likely state-to-state differences. Many, many moons ago, in Texas, I was told by Medicaid that there were no circumstances under which I could charge a Medicaid patient cash. If I saw them, I must bill Medicaid. If it was a non-covered service, I had to eat it. ABNs did not count.

Here in Illinois, I am told by our billing department that it is the same with the excpetion possibly of "experimental" therapies, such as PRP. But we won't try it on Medicaid (or here it is usually Ill Dept of Public Aid) as we stand to lose too much money.
 
specepic said:
Off topic but most food grown there is animal feed.
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Not sure I buy that since Iowa is a major producer of soybeans and corn, which are undoubtedly suitable for human consumption. It's also a major livestock producer.

Beef, poultry, pork, eggs, cheese, butter, and milk - all based on animals that eat grain. Not to mention the use of grain-based feed for commercial fish farms.
 
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Mister Mxyzptlk said:
Not sure I buy that since Iowa is a major producer of soybeans and corn, which are undoubtedly suitable for human consumption. It's also a major livestock producer.

Beef, poultry, pork, eggs, cheese, butter, and milk - all based on animals that eat grain. Not to mention the use of grain-based feed for commercial fish farms.
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Feed corn is not the corn you and I eat, the vast majority of Iowa corn is feed corn. Not sure about feed vs. other type soybeans. Not a farmer, just someone who has lived in the midwest quite a bit and talked to a lot of farmers.

The animals we can eat, although in the context of food shortages, direct consumption of produce from land, rather than feeding it to livestock, is more efficient

Iowa farming, as it stands, is designed to feed animals>people.

0.02
 
in my state i cannot bill medicaid patients even if i were non-par w/ medicaid... in fact, if a medicaid patient paid me cash without telling me they are medicaid, legally (once i find out they are medicaid), I would have to refund the patient and bill medicaid... now if i am non-par w/ medicaid I cannot bill medicaid... which means: self-pay/cash patients who are (secretly) medicaid patients, will have to (legally) get a refund check from me and i would have to eat the cost of the visit since medicaid would not pay me since i am out of network with medicaid....

who comes up with these rules???

of course, we can go cash based... however, our competitors will jump at the chance to gobble up market share while we wait for those w/ cash to show up...

concierge pain medicine? = drug dealer (plain and simple).
 
The only concierge aspect of my practice is when I make reservations for the patient to go somewhere else.
 
Hmmm. Maybe getting closer to patient acceptance of paying cash. One of my patients today was talking about her "naturopath" doctor. $500 per office visit. Not including the supplements, etc. She switched naturopaths, because the other one charged even more. Of course it is all out-of-pocket. I won't even get half that for the epidural I just performed...
 
Mister Mxyzptlk said:
The only concierge aspect of my practice is when I make reservations for the patient to go somewhere else.
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ha! good one.

I have seen these naturopaths set up practice around me as well. In fact one of the scrub techs in the surgery center was married to one. SHe is now going through a divorce. She states that he was pulling in over 300 grand per YEAR!
 
Yes, naturopathic scam artists will always beat out legitimate pain physicians in cash payments. Anything insurance will pay for, even at a lowly rate, becomes an expectation by the patient. Those things that insurance will not pay for become accepted by the patient as an out of pocket expenditure.
 
Pain_doc said:
Hmmm. Maybe getting closer to patient acceptance of paying cash. One of my patients today was talking about her "naturopath" doctor. $500 per office visit. Not including the supplements, etc. She switched naturopaths, because the other one charged even more. Of course it is all out-of-pocket. I won't even get half that for the epidural I just performed...
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I see this all of the time. They pay $5000 to the chiropractor for the decompression machine therapy and then complain when they have a $20 copay for me!
 
mid|ine said:
I see this all of the time. They pay $5000 to the chiropractor for the decompression machine therapy and then complain when they have a $20 copay for me!
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Because they have nothing left since they went to the chiro first...

If i told a patient, "I want you to come in here 5x/week for 3 weeks, then 3x/week x 8 weeks, then 2x/week for 12 weeks, then 1 x/week for 16 weeks, and I want you to pay it all up front. Oh and it won't be covered by insurance," they would look at me like I was from another planet and go find someone else.

Yet I've seen chiros and naturopaths do it all the time and people line up for them.

I sometimes want to restart my old solo practice, complete with counselor and PT, and make it a cash-only pain practice. No opioids whatsoever. You can come in as many times as you want - and much of the time I would see them and defer to PT or counselor depending on the current problem. I'll do as many injections as you want, within medical standards. PT and counseling will see you as much as they need to. $5K/person per year. Pay the PT and counselor $50K each. Minimal office staff.
 
I think people naturally think if it costs money, it must be good. This guy I heard about (actually a patient told me about him) charges $1000 cash for a LESI. Patients just assume he does a much better LESI than all the inferior docs who have to accept insurance because they are not as skilled. We are really being taken for a ride by insurance companies and Medicare. Under $100 for a medical procedure? It's unbelieveable.
 
I'm an MSIII, and I was half considering doing pmr and pain.

I would have liked to have worked for a hospital and had some degree of fee for service private practice, treating sports med / rehab / pain / omm...



You guys are trying to say fee for service pain management is unethical?


Am I misunderstanding something? I understand it has the potential to dance a fine line but as long as you are actually legitimate... How is this unethical?
 
DannMann99 said:
You guys are trying to say fee for service pain management is unethical?
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No one is saying that. Some just have concerns about patients paying up front, well in advance, for services that may be inappropriate to deliver. For example; I pay you $5000 for this year's worth of pain care. Now I tell you that nothing works except oxycodone. "And damn it, I already paid for it!"
 
The only way to remove money from ethics of pain medicine is for the pain physician to be straight salary with no bonuses or financial incentives (ala Mayo and many other academics). Outside of academics, this is very rare.
 
the problem with straight salary is that the physicians become less productive, take less risk and eventually the employer (hospital) will be dis-enchanted w/ the physician because he/she is know a net-loss to the hospital

there are local neurosurgeons who became employees: all of a sudden - they limit their day to 20 patients per day, will only operate on urgent/emergent cases, have cut way back on their elective cases (ie: they will operate on a very healthy, straight-forward disc herniation). I have never met surgeons who were less inclined to operate...

now maybe that is a good thing, but medical care would become a quagmire if all physicians were turned into bureaucrats.

on the flip side, ideally you would pay based on outcomes... however, the only specialties who would do well are orthopods (because they fix broken bones that heal). Specialties that have a lot of non-compliant chronic illness patients will have a lot of difficulty showing improved outcomes (ie: diabetes/COPD/low back pain/depression) in a way that is measurable short term for reimbursement.

the best solution?

just have CRNAs/NPs/PAs manage all of these problems because they will fix all of our healthcare problems...
 
Tenesma said:
the problem with straight salary is that the physicians become less productive, take less risk and eventually the employer (hospital) will be dis-enchanted w/ the physician because he/she is know a net-loss to the hospital

there are local neurosurgeons who became employees: all of a sudden - they limit their day to 20 patients per day, will only operate on urgent/emergent cases, have cut way back on their elective cases (ie: they will operate on a very healthy, straight-forward disc herniation). I have never met surgeons who were less inclined to operate...

now maybe that is a good thing, but medical care would become a quagmire if all physicians were turned into bureaucrats.

on the flip side, ideally you would pay based on outcomes... however, the only specialties who would do well are orthopods (because they fix broken bones that heal). Specialties that have a lot of non-compliant chronic illness patients will have a lot of difficulty showing improved outcomes (ie: diabetes/COPD/low back pain/depression) in a way that is measurable short term for reimbursement.

the best solution?

just have CRNAs/NPs/PAs manage all of these problems because they will fix all of our healthcare problems...
Click to expand...


Correct me if I am wrong. But a recent review from Britain does not support any medical benefit with 'outcomes based' health system and reinbursement. The rates of HTN, DM, CAD are unchanged, and so will LBP outcomes. Actually, it appears your are likely to have better cardiac outcomes in Poland compared to Britain and other countries using outcomes based approaches.
 
Ah, but the academics supplement their income in other ways....testifying against other physicians and advertising their services to do so, seminars and external pain courses, etc.
 
i didn't say that the outcomes/medical benefits would be there with an "outcomes" based system.... but intuitively the reimbursement model would be a more ethical model (as long as doctors can't discharge all of their non-compliant, or non-improving patients)
 
if i was paid a straight salary with no bonus, i would do the absolute minimum acceptable amount of work.
 
my point exactly - as humans we will always either
1) do the bare minimum if no incentives - that's why collectivism/communism fails
2) do as much as possible if there are tangible incentives - that's why capitalism succeeds.
 
The only thing worse than paying doctors to do things is paying doctors not to do things.

I spent 8 years in academics. There was NO incentive to work. At 3 pm when the call team came in the attendings were sitting there like birds on a wire waiting to be relieved.

OTOH, once I went into private practice it was very different. It's 3 pm and an orthopod asks if you can stay and do a fractured hip. Of course I can!

If I ran an academic department I'd pay everyone 100% of collections as a baseline. Then we subtract billing services and administrative costs. You want an office? We'll deduct the rent. You want a secretary? Fine, but we'll deduct that too. You want a "lab" day? No problem, just remember you're not producing any income on that day, which goes to your bottom line. Eight weeks vacation? If we can accommodate it, no problem but it's w/o pay.

Next thing you know attendings would be down at the billing department screaming about days in A/R and non-contractual write-offs.
 
I believe the free market, without all the buffers like Medicare, fiscal intermediaries, insurance companies, etc, is the least of all evils. The closer we get back to the original fee-for-service, the better off we'll be.
The patient must invest in his own care. He has to directly interact with the person taking his money and to evaluate the results of his care. When the money goes into some large organization, gets processed and distributed to partners and eventually disbursed to the provider in the form of a "production incentive, this is also suboptimal. The arguments against capitalism could be used for every aspect of our society. It's not perfect. It's just better than anything else.
 
While I agree with this in principle, be careful what you wish for. Medical fees would deflate faster than Pamela Anderson's boobs in an entirely free-market system. Not many people have the disposable income to pay for a SCS system, an MRI, or even an RFL.

What's more realistic would be a system where insurance or Medicare would pay a set amount but without a cap on balance billing. So if you can find a doctor who will do your SCS for what insurance pays, good for you. Otherwise, you'll have to pay what the market dictates. If people are beating down the door to see you, you will be able to charge a premium over what insurance covers. If you're the new boy on the block you might accept insurance to build your practice.

Another system might be that the patient pays a set percentage, which will induce them to shop around for the best fees.

Whatever form it takes, the patient has to have some skin in the game so they "directly interact with the person taking his money and to evaluate the results of his care" as hyperalgesia says.

The worst situation right now is the disconnect on drug prices. This "everything's $20 for a 30 day supply" is lunacy.
 
My point was simply that physician financial incentives cause ethical problems, and the only way around that is to not have any financial incentives. That's how the public would like it - docs to have absolutely no financial interest in their health care. However, few docs will work that way.

I think, however, on further reflection, it could actually cause as much harm this way.

When I was a resident we had an other resident who was a practicing orthopod in England before coming to the states. He said they would do a maximum of 2-3 surgery cases /day, 2-3 x/week. The rest of the time was minimal clinic as socializing. Late morning arrivals, early afternoon departures for the doctors. This was due to a combination of rationing of healthcare due to socialized medicine and straight salary for the docs. No one cared - do you work, go home. You need a new hip? Sure, give us 6 - 9 months and we'll be able to do it. Don't like that? Go talk to your magistrate.

My ideal medical system for America - A national health care plan is available to everyone. $3000 deductible/ year, with subsidies for the poor. everyone gets a health savings account to put pre-tax money into for this purpose, and it can roleover year-to-year. Employers can then offer to pay into the HSAs in lieu of offering health insurance. It would be cheaper for all parties. Private insurances could be used as supplements or in place of the national health care, for those who wish to purchase them, or employers to offer as incentives.

The craziest thing about this country is tying your health insurance to your job. Just when you need it most - catostrophic illness or injury, you lose your job since you cant work, and therefore lose your insurance.
 
Mister Mxyzptlk said:
While I agree with this in principle, be careful what you wish for. Medical fees would deflate faster than Pamela Anderson's boobs in an entirely free-market system. Not many people have the disposable income to pay for a SCS system, an MRI, or even an RFL.

What's more realistic would be a system where insurance or Medicare would pay a set amount but without a cap on balance billing. So if you can find a doctor who will do your SCS for what insurance pays, good for you. Otherwise, you'll have to pay what the market dictates. If people are beating down the door to see you, you will be able to charge a premium over what insurance covers. If you're the new boy on the block you might accept insurance to build your practice.

Another system might be that the patient pays a set percentage, which will induce them to shop around for the best fees.

Whatever form it takes, the patient has to have some skin in the game so they "directly interact with the person taking his money and to evaluate the results of his care" as hyperalgesia says.

The worst situation right now is the disconnect on drug prices. This "everything's $20 for a 30 day supply" is lunacy.
Click to expand...

It's funny how patients don't have disposable income for their health care, but they DO have disposable income for important things like iphones with $100+/month cell phone bills, ipads, $200 jeans, $40,000 SUVs, etc etc. It's not that people don't have it... it's that they'd rather give it to their local mall.
 
You have to understand that we are seeing the prime example of moving towards the "original fee for service" --- with the huge growth in high-deductible plans, the insurance companies are making some of their biggest profits in a long time (look at recent quarterly statements).... because patients are consuming less health-care...

a patient is a lot more likely to get an ESI for $50 co-insurance versus $800 cash....

most of the practices in my area have seen a drop-off in volume in the last 4 months, specifically because of the soaring numbers of high-deductible plans.

you are absolutely right - patients will not come in for health care, not pursue diagnostics/treatments when the price >$100....

diagnosis/treatment is very different from a tangible good like cigarettes/plasma TV/cadicallac escalade.....
 
I think of it this way - there are things you want and things you need, some are both or neither.

If you want it, and need it, like food, shelter and clothing, you will pay for it.

If you want it, but don't need it, like SUV's, vacations, iPads, you will pay way more than you should for them.

If you don't want it, and don't need it, you don't worry about it.

If you don't want it, but need it, you want other people to pay for it - police, fire dept, health care, etc.
 
PMR - sounds like you have been reading Rumsfeld's memoirs.
 
Tenesma said:
You have to understand that we are seeing the prime example of moving towards the "original fee for service" --- with the huge growth in high-deductible plans, the insurance companies are making some of their biggest profits in a long time (look at recent quarterly statements).... because patients are consuming less health-care...

a patient is a lot more likely to get an ESI for $50 co-insurance versus $800 cash....
Click to expand...

True, but in an insidious way and from the wrong direction. These patients already paid for their healthcare in the form of insurance premiums. They invested in a healthcare plan and are now at the insurance company's mercy. The company now has the liberty of implying that this particular procedure is not appropriate by manipulating the co-pay and coverage. Insurance companies will not gracefully disappear from the scene. But if we can stop encouraging insurance on a national level and certainly stop this insane employer-based insurance model, and the "mandate" that makes a mockery of our constitution by institutionalizing this parasite into our democracy, I think free enterprise will succeed. Healthcare providers and hospitals are guilty of promoting the present system by gouging "self-pays", giving patients the impression that they were saved by their insurance company. By charging $800 for a LESI that is self-pay, vs $100 for a LESI that is BCBS, we deserve to only serve BCBS.
 
If you want it, and need it, like food, shelter and clothing, you will pay for it but you will have less money to spend on things you want but don't need.

If you want it, but don't need it, like SUV's, vacations, iPads, you will pay what the market will bear. If the prices of food, clothing, and shelter go up then people have less disposable income so demand for SUV's and iPads will drop, as will the prices for same


If you don't want it, but need it, you want other people to pay for it - police, fire dept, health care, etc. Unfortunately you are the "other people" and if you don't pay for it both your property and personal freedom will be at risk.
 
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