Curious about pain medicine practice

[CECC110]

Hello,

I'm a student interested in pursuing pain and had a few questions to ask, if anyone would be so kind to give their insight of any/all of the below!

-What is the typical practice of an academic pain physician, and how does it differ from a private doc?
-Is it possible to strike a good balance between doing procedures and medical pain management?
-Could anyone elaborate on what medical pain management exactly entails? I've had brief exposure to procedural pain via epidurals/SCS, but am curious about the other side - as a student, typically I've only seen attendings consult in the context of "patient continuously complains about pain, let's see what pain mgmt can do about it." Is it as cut and dry as relieving pain through optimization of medication regimens and trying to avoid drug addictions?
-What are some other ways of practicing pain beyond procedures or hospital-based work, and is it feasible to craft your career in a way you can practice in various settings/contexts?
-How do you envision the role of a pain management physician who is training in the next 5-10 years to be different than those who are practicing now, particularly in the face of the opioid epidemic?

Thank you!

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[Ducttape]

apparently, there is no role for academic pain physicians - the only real pain doc is a private practice doc that serves as a needle jockey.

or so ive been told.




ok, sarcasm off. if you are interested in an academic career, then the focus is on teaching, clinical work, and research, not necessarily in that order. research money is a little tight right now, according to my colleagues in academic medicine, but its still out there.

cutting edge technology needs to be explored. there is still a wide open field on neuromodulation, both with stim, DRG stim, and with neuromodulation via medication. there are more research in the various opioid receptors. when marijuana is made legal (not in the next 4 years, of course), there will be a wide open field of cannabinoid research. if one were to perform a double blinded prospective study demonstrating clinically significant benefit for PRP or stem cell, one's career is made.

 

[101N]

-Is it possible to strike a good balance between doing procedures and medical pain management?

This is a real problem. In most settings we are paid on a wRVU scale which incentivizes us to do procedures
whether or not they improve a patient's function or reduce their opioid use. Conversely, if you talk to your IM &
FM colleagues they will tell you that what THEY need is help with are the working-aged, but often not working,
patients with obvious psych/social/affective/existential suffering. Proceduralizing these folks will increase your
wRVU's but it also creates iatrogenic harm by reinforcing the patient's psychological pathology: "See it's not in my
head! My pain doctor said I have: discogenic, facetogenic, CRPS, TOS, SIJDF, ... pain". Press-Ganey scores also
incentivize ignoring obvious, overwhelming, psychological comorbidity as patient's don't like the elephant in
the exam room being pointed out.

If you are ethical I'd look long and hard prior to going into pain medicine unless you are ready to innovate, and
make less than MGMA 50th percentile.

 

[Disciple]

Conversely, if you talk to your IM &
FM colleagues they will tell you that what THEY need is help with are the working-aged, but often not working,
patients with obvious psych/social/affective/existential suffering.

I think all of us need help with those patients as well haha..

I thought your premise was that due to their personality types, development, life experiences, etc. they could not be helped.

If that's the case, I'm not sure pain management doctors are more equipped to "help" these patients than any other doctor.

 

[drusso]

Hello,

I'm a student interested in pursuing pain and had a few questions to ask, if anyone would be so kind to give their insight of any/all of the below!

-What is the typical practice of an academic pain physician, and how does it differ from a private doc?
-Is it possible to strike a good balance between doing procedures and medical pain management?
-Could anyone elaborate on what medical pain management exactly entails? I've had brief exposure to procedural pain via epidurals/SCS, but am curious about the other side - as a student, typically I've only seen attendings consult in the context of "patient continuously complains about pain, let's see what pain mgmt can do about it." Is it as cut and dry as relieving pain through optimization of medication regimens and trying to avoid drug addictions?
-What are some other ways of practicing pain beyond procedures or hospital-based work, and is it feasible to craft your career in a way you can practice in various settings/contexts?
-How do you envision the role of a pain management physician who is training in the next 5-10 years to be different than those who are practicing now, particularly in the face of the opioid epidemic?

Thank you!

The future is hard to predict...

Ten years ago, I wrote this:

20 Questions: David Russo, DO [Pain Medicine and Physiatry] - Student Doctor Network

"Where do you see your specialty in 10 years?"

I think the indications for neuromodulation and spinal cord stimulation are going to increase. I think that surgical approaches to pain management are going to become more refined, especially with respect to peripheral nerve disorders. New neuropathic drugs and analgesics are on the horizon. There is an emerging appreciation of the psychoneuroendocrinology of pain and its treatment. I hope that the field has the fortitude to stay true to its roots and remain broad and comprehensive and not attempt to over-simplify things. When it comes to pain, I like the expression, “For every complex problem, there is a solution that is simple, neat, and completely wrong.” Some speculate that pain medicine could become its own specialty, but I think that field is fed and nourished by its multidisciplinary make-up."

That was before the full magnitude of the opioid epidemic came to light, the massively distorting market forces of the ACA, and organized medicine's abdication of its duty to protect the primacy of the patient-physician relationship in policy and political matters. Overall, I'd score my "prediction" like this:

+1 for neuromodulation
0 for psychoneuroimmunology
0 for new analgesics
0 for pain becoming its own specialty
0 for recognition & support of multi-disciplinary care (no one pays for it)

Consulting my crystal ball, I offer the following predictions for the field of pain medicine for the next 10 years:

I think that patient access to pain management becomes severely restricted--essentially no access for patients with government payor insurance and limited access for patients with commercial insurance products. For the self-insured and wealthy, pain management is available (mostly procedural care but also medical and behavioral) as a direct care/concierge service--aka "aesthetic medicine for the altered comfort crowd." Most pain specialists function as gate-keepers, medical/program directors, or "opioid compliance officer" in health systems (mostly supervising NP's & behavioralists managing legacy opioid patients), but some are able to stay independent by doing a variety of work (consulting, medico-legal & direct service). Payors espouse the virtues of interdisciplinary care but there is no payment for the service commensurate to the risk and intensity of the work. Indications for neuromodulation grow as technical advances make the therapy more flexible for a variety of indications. Grant funding for academic pain specialists remains very tight. Restrictive rules governing industry/academic relationships chills innovation in the field.

My practical advice is that you train in a core pain specialty--anesthesia, neurology, psych, or PM&R--and find a mentor. Complete an ACGME-accredited fellowship at a reputable academic center. Focus on a niche pain condition that most practitioners despise--pelvic pain would be a good one--and become the "go-to-person" for it in your community or program. Get good practical training in addiction--better yet, get certified in both pain and addiction.

 

[DrCommonSense]

-Is it possible to strike a good balance between doing procedures and medical pain management?

This is a real problem. In most settings we are paid on a wRVU scale which incentivizes us to do procedures
whether or not they improve a patient's function or reduce their opioid use. Conversely, if you talk to your IM &
FM colleagues they will tell you that what THEY need is help with are the working-aged, but often not working,
patients with obvious psych/social/affective/existential suffering. Proceduralizing these folks will increase your
wRVU's but it also creates iatrogenic harm by reinforcing the patient's psychological pathology: "See it's not in my
head! My pain doctor said I have: discogenic, facetogenic, CRPS, TOS, SIJDF, ... pain". Press-Ganey scores also
incentivize ignoring obvious, overwhelming, psychological comorbidity as patient's don't like the elephant in
the exam room being pointed out.

If you are ethical I'd look long and hard prior to going into pain medicine unless you are ready to innovate, and
make less than MGMA 50th percentile.

The same argument can be made about interventional cardiology, neurosurgery, orthopedics, etc. Basically any field that is pay for procedure is going to have that issue and will have a "hard time being ethical" given the incentive structures.

Kind've like the Suboxone pimps who will give Suboxone to anyone as long as they have the cash without a care for the long term addiction outcomes of their patients, especially when the money runs out.

You think the Sub pimps are watching their patients 5 or 10 years later to see if they dont overdose after their cash runs out and they can't afford their treatment anymore?

 

[Ducttape]

all your talk about suboxone pimps is distracting from the fact that the vast majority of opioid prescriptions are for the "usual" drugs of (oxy, vicodin, etc).

we currently have huge problems with opioid pimps.

and as you make arguments about pay for procedure, dont forget "injection pimps".

 

[nvrsumr]

What is an injection pimp? If there is no quid pro quo for narcs then no different than a gi doc doing scopes all day

 

[101N]

What is an injection pimp? If there is no quid pro quo for narcs then no different than a gi doc doing scopes all day

Your an injection pimp if:

You're PA/NP is writing Rx's and bouncing the patient back to you for injections.
You're an injection pimp if your PA/NP is in the top 10% of opioid prescribers for their specialty in your state for Medicare
You're an injection pimp if you're an injectionist and you- or your PA - orders UDS on every visit
You're an injection pimp if you fire patients when their workers comp converts to medicare/caid
You're an injection pimp if your referral base consists of workers comp attorneys
You're an injection pimp if you don't screen for co-morbid psych ds in your cohort and the results don't change your injection plan
You're an injection pimp if your position is all pain is nociceptive
You're an injection pimp if all of the arrows in your quiver are interventional
You're an injection pimp if you worship Bogduk
You're probably an injection pimp if you belong to either SIS or ASIPP

capiche?

 

[lobelsteve]

Your an injection pimp if:

You're PA/NP is writing Rx's and bouncing the patient back to you for injections.
You're an injection pimp if your PA/NP is in the top 10% of opioid prescribers for their specialty in your state for Medicare
You're an injection pimp if you're an injectionist and you- or your PA - orders UDS on every visit
You're an injection pimp if you fire patients when their workers comp converts to medicare/caid
You're an injection pimp if your referral base consists of workers comp attorneys
You're an injection pimp if you don't screen for co-morbid psych ds in your cohort and the results don't change your injection plan
You're an injection pimp if your position is all pain is nociceptive
You're an injection pimp if all of the arrows in your quiver are interventional
You're an injection pimp if you worship Bogduk
You're probably an injection pimp if you belong to either SIS or ASIPP

capiche?

Im 2 for 10 on your list. Would set criteria 4/10 or more.

Luv me some Nik

 

[Ducttape]

ill add a few more:

you are an injection pimp:
- if you still do series of 3
- if you discharge patients if they "fail" series of 3, cause you have nothing else to offer
- if you have to ask your midlevel how to write a referral to PT/OT/pain psychology, or have never written one before
- if 4 out of 5 days are spent in the procedure room, especially if you are actively figuring out how to make that 5 out of 5 days
- if you never see a patient outside the procedure room (im not sure this would include the set up at Kaiser, though)
- really, you are an injection pimp if you are top 5% for wRVU
- if you do a stim or other intensive procedure, regardless of the success, and then you send the patient to a different pain doc "to write the meds"

(that last one is particularly galling to me, and yes it has happened a number of times to me)

 

[DrCommonSense]

all your talk about suboxone pimps is distracting from the fact that the vast majority of opioid prescriptions are for the "usual" drugs of (oxy, vicodin, etc).

we currently have huge problems with opioid pimps.

and as you make arguments about pay for procedure, dont forget "injection pimps".

Ok that makes the SUboxone pimps ok then because there are pill mills?

Logic is lost on me

 

[DrCommonSense]

Your an injection pimp if:

You're PA/NP is writing Rx's and bouncing the patient back to you for injections.
You're an injection pimp if your PA/NP is in the top 10% of opioid prescribers for their specialty in your state for Medicare
You're an injection pimp if you're an injectionist and you- or your PA - orders UDS on every visit
You're an injection pimp if you fire patients when their workers comp converts to medicare/caid
You're an injection pimp if your referral base consists of workers comp attorneys
You're an injection pimp if you don't screen for co-morbid psych ds in your cohort and the results don't change your injection plan
You're an injection pimp if your position is all pain is nociceptive
You're an injection pimp if all of the arrows in your quiver are interventional
You're an injection pimp if you worship Bogduk
You're probably an injection pimp if you belong to either SIS or ASIPP

capiche?

Being in the top 10% of prescribers and ordering UDS constantly is more consistent with pills mills than injections mills.

By the last two positions, you are probably a Suboxone pimp if you worship PROP or their pimp leaders that want to make big money off Suboxone treatment.

Maybe you should read the reviews of how PROP Suboxone pimps treat their employees as well on Glassdoor or their opinion their pimp CEO.

Addiction Treatment With a Dark Side

The Coming ‘Economic Bonanza’ in Addiction Treatment

 

[DrCommonSense]

ill add a few more:

you are an injection pimp:
- if you still do series of 3
- if you discharge patients if they "fail" series of 3, cause you have nothing else to offer
- if you have to ask your midlevel how to write a referral to PT/OT/pain psychology, or have never written one before
- if 4 out of 5 days are spent in the procedure room, especially if you are actively figuring out how to make that 5 out of 5 days
- if you never see a patient outside the procedure room (im not sure this would include the set up at Kaiser, though)
- really, you are an injection pimp if you are top 5% for wRVU
- if you do a stim or other intensive procedure, regardless of the success, and then you send the patient to a different pain doc "to write the meds"

(that last one is particularly galling to me, and yes it has happened a number of times to me)

This I agree with.

 

[DrCommonSense]

all your talk about suboxone pimps is distracting from the fact that the vast majority of opioid prescriptions are for the "usual" drugs of (oxy, vicodin, etc).

we currently have huge problems with opioid pimps.

and as you make arguments about pay for procedure, dont forget "injection pimps".

Also, what makes you think we won't have another opioid crisis once the PROP pimps start doling out Suboxone in the future for all the "addicts"?

Why Are So Many Suboxone Patients Buying the Drug on the Street?

Do you honestly think some Suboxone pimps like PROP will solve this crisis by doling out another slightly less addictive substance for "addicts" as long as they have the cash (after which they get booted onto the street) that is traded among prisoners/addicts on the street to get high to prevent them from getting on further heroin/fentanyl in the future?

Cool story bro

 

[drusso]

You're probably an injection pimp if you belong to either SIS or ASIPP

capiche?

What if you belong to both?

 

[nvrsumr]

Seems to be a lot of ways to qualify as an injection pimp...

Other than the usual envious disparagement of those more financially more successful than oneself really just the same old pills for pokes issue. If never give pills then not a pimp.

It’s ok not to do a full psych work up prior to a knee injection on the patient with medial compartment oa and point tenderness. Spine can be the same if physician is selective.

I have no sympathy for the bottom feeder physicians with no option but these terrible opioid dump practices. Pull yourselves up by your bootstraps and show some grit. Might rub off on ur patients.

Capiche

 

[Ducttape]

Injection pimps don’t have to trade pills for shots to do harm. They are only interested in financial renumeration and raping the system.

These are not “selective” physicians. These are the ones that are making CMS want to make rule changes to decrease costs... charging for epidurograms; multiple injections concurrently; epidurals without any imaging; recurrent injections when none of them work; firing patients if they refuse injections; things like that.

FYI comm you clearly have not talked to any addicts who have used “bupe”. They Do Not want bupe. They want something else but will settle for bupe if they can’t get anything else, so they don’t have the shakes.

And that drug has in multiple studies been shown to have a mechanism of action that significantly reduces overdose risk.

The opioid crisis is not about who is taking the drugs. It’s about the people dying from the drugs.

 

[DrCommonSense]

Injection pimps don’t have to trade pills for shots to do harm. They are only interested in financial renumeration and raping the system.

These are not “selective” physicians. These are the ones that are making CMS want to make rule changes to decrease costs... charging for epidurograms; multiple injections concurrently; epidurals without any imaging; recurrent injections when none of them work; firing patients if they refuse injections; things like that.

FYI comm you clearly have not talked to any addicts who have used “bupe”. They Do Not want bupe. They want something else but will settle for bupe if they can’t get anything else, so they don’t have the shakes.

And that drug has in multiple studies been shown to have a mechanism of action that significantly reduces overdose risk.

The opioid crisis is not about who is taking the drugs. It’s about the people dying from the drugs.

I agree with that abuse situation.

I disagree that patients aren't abusing bupe. Sure they want "stronger" stuff but they will abuse bupe if offered over others if desperate. This has been shown in the prisons as well.

 

[DrCommonSense]

Seems to be a lot of ways to qualify as an injection pimp...

Other than the usual envious disparagement of those more financially more successful than oneself really just the same old pills for pokes issue. If never give pills then not a pimp.

It’s ok not to do a full psych work up prior to a knee injection on the patient with medial compartment oa and point tenderness. Spine can be the same if physician is selective.

I have no sympathy for the bottom feeder physicians with no option but these terrible opioid dump practices. Pull yourselves up by your bootstraps and show some grit. Might rub off on ur patients.

Capiche

The disparagement is usually a function of Suboxone pimps that want to make a quick buck on a Sub for cash practice without having to work hard doing anything else in pain management.

The problem is the Sub for cash pimps have literally no other solutions for pain control outside of:

1) Take some Sub for cash due to Opioid "Abuse" or pain in general.
2) Go see my therapist and will it all away and go do some exercise

So really outside of just giving everyone Sub, they offer no solutions.

 

[244913]

The disparagement is usually a function of Suboxone pimps that want to make a quick buck on a Sub for cash practice without having to work hard doing anything else in pain management.

The problem is the Sub for cash pimps have literally no other solutions for pain control outside of:

1) Take some Sub for cash due to Opioid "Abuse" or pain in general.
2) Go see my therapist and will it all away and go do some exercise

So really outside of just giving everyone Sub, they offer no solutions.

They need to remove cash from the suboxone equation.

Allow it to be prescribed for chronic pain, not just opioid use disorder (or opioid dependence as the backdoor)
Get it covered universally by Medicaid, Medicare.

In my state, you can prescribe suboxone for "chronic pain" per a board of medicine emergency injunction but most Medicaid plans won't even cover it.

Having suboxone in your back pocket would make weaning patients a lot more tolerable. If they fail the taper, are on > 250 MME or just plain unwilling, offer a transition to bupe.

- ex 61N

 

[101N]

They need to remove cash from the suboxone equation.

Allow it to be prescribed for chronic pain, not just opioid use disorder (or opioid dependence as the backdoor)
Get it covered universally by Medicaid, Medicare.

In my state, you can prescribe suboxone for "chronic pain" per a board of medicine emergency injunction but most Medicaid plans won't even cover it.

Having suboxone in your back pocket would make weaning patients a lot more tolerable. If they fail the taper, are on > 250 MME or just plain unwilling, offer a transition to bupe.

- ex 61N

Agree with most all you've said. However, I think we do everyone involved a disservice when/if we Rx buprenorphine for addiction but call it
chronic non-cancer pain. This just continues the charade of the last 30yrs. Instead I think we need to be reducing the activation energy of all prescribers
for making the diagnosis of opioid use disorder, and then treating it.

SAMHSA estimates that there are about 2.5M opioid addicts in the US. By contrast, a conservative estimate of the number of chronic non-cancer
pain patients on opioids is probably 10x that amount. A recent meta-analysis of COT patients pegs misuse at 25%, ie, 5M. We need to be actively
winnowing the ranks of COT-receiving patients and converting those 5M - usually high dose, non-working - to buprenorphine for OUD. Time to
take the cat out of the bag.

 

[Timeoutofmind]

Can I prescribe suboxone for "chronic pain" in the state of WI?

 

[DrCommonSense]

They need to remove cash from the suboxone equation.

Allow it to be prescribed for chronic pain, not just opioid use disorder (or opioid dependence as the backdoor)
Get it covered universally by Medicaid, Medicare.

In my state, you can prescribe suboxone for "chronic pain" per a board of medicine emergency injunction but most Medicaid plans won't even cover it.

Having suboxone in your back pocket would make weaning patients a lot more tolerable. If they fail the taper, are on > 250 MME or just plain unwilling, offer a transition to bupe.

- ex 61N

Even when its covered by Medicaid there is no money doing a Suboxone induction for Medicaid office visit rates.

You also have Butrans and Belbuca for chronic pain patients with a bup component, so you don't need Suboxone for them.

That is why the Suboxone pimps like PROP will charge pay for play service unless they get special funding from the state way above office visit rates.

The big money in pimping the "addicts" is hitting them with huge cash fees for the dollar dollar.

You think the boys at PROP are doing this to be a pauper?

You think these pimps would be as excited in "helping addicts" if it was for working at Medicaid OV rates mostly?

Dont be naive.

Little Andy at PROP/Phoenix house ain't working for Medicaid rates. I wouldn't doubt he makes 1+ million/year as leader of Phoenix house for his "service" to the "addicts"

 

[epidural man]

ill add a few more:

you are an injection pimp:

- if you discharge patients if they "fail" series of 3, cause you have nothing else to offer

I did this as a resident rotating through the pain clinic - I think the patient had had ESI, RFA, probably SI-Joint, maybe something else - then I sent him back to PCM.

Attending yelled at me and said - "We ALWAYS have something we can offer."

I don't think he was being literal - but his point was well taken and remembered. We have better tools and better understanding then anyone else out there and so they are better off getting education, encouragement, advice, etc - from us then anyone else. We do have many more things to offer than just injections. (That takes time though...)

 

[244913]

Even when its covered by Medicaid there is no money doing a Suboxone induction for Medicaid office visit rates.

You also have Butrans and Belbuca for chronic pain patients with a bup component, so you don't need Suboxone for them.

That is why the Suboxone pimps like PROP will charge pay for play service unless they get special funding from the state way above office visit rates.

The big money in pimping the "addicts" is hitting them with huge cash fees for the dollar dollar.

You think the boys at PROP are doing this to be a pauper?

You think these pimps would be as excited in "helping addicts" if it was for working at Medicaid OV rates mostly?

Dont be naive.

Little Andy at PROP/Phoenix house ain't working for Medicaid rates. I wouldn't doubt he makes 1+ million/year as leader of Phoenix house for his "service" to the "addicts"

The highest dose butrans patch equates to what, 2 mg of suboxone? Belbuca never gets covered either

I can't speak for "the boys" at PROP. All I know is, in my current job as a hospital employed pain physician, I am stuck seeing a ton of medicaid and medicare, and I need solutions.

Whether in office induction pays or doesn't pay is immaterial to me. I'm salaried. What I want is a way to safely transition the disasters dumped on my doorstep by the profligate prescribers of yesteryear.

I need a better solution then a forced, inevitably unsuccessful (in 90% of cases) taper off high dose (>200 MME) opioids for these patients, who then go to the street. I've seen bupe work wonders and it is a hell of a lot safer than taking high dose opiates.

Harm reduction. That is the name of the game.

Again, remove cash from the equation. Open the floodgates for Bupe prescribing and get all hands on deck to deal with this disaster.

The people who really need Bupe are generally not the ones who can afford to pay out of pocket for it.

- ex 61N

 

[drusso]

Whether in office induction pays or doesn't pay is immaterial to me. I'm salaried. What I want is a way to safely transition the disasters dumped on my doorstep by the profligate prescribers of yesteryear.

- ex 61N

If it weren't for the site of service payment differential that your employer receives, you wouldn't be so sanguine...

 

[244913]

Can I prescribe suboxone for "chronic pain" in the state of WI?

Probably. But good luck getting it covered. Requires about 3 prior authorizations and often a peer to peer. Medicaid demands that patient have ongoing counseling.

All the insurers assume that suboxone = addiction and treat it as such

- ex 61N

 

[244913]

If it weren't for the site of service payment differential that your employer receives, you wouldn't be so sanguine...

What would you do in my situation? What percentage of your practice is Medicaid or Indigent?

Are you routinely seeing Medicaid patients on high dose opioids and tapering them down or off? Do you screen them out so they never get an appointment with you? Do you punt them to the local hospital system after injecting them?

The PP vs. Hospital employed thing is played out

As pain Physicians we should mutually support each other to dig ourselves out of this hole.

- ex 61N

 

[101N]

What would you do in my situation? What percentage of your practice is Medicaid or Indigent?

Are you routinely seeing Medicaid patients on high dose opioids and tapering them down or off? Do you screen them out so they never get an appointment with you? Do you punt them to the local hospital system after injecting them?

The PP vs. Hospital employed thing is played out

As pain Physicians we should mutually support each other to dig ourselves out of this hole.

- ex 61N

PM sent. I can help.

 

[drusso]

What would you do in my situation? What percentage of your practice is Medicaid or Indigent?

Are you routinely seeing Medicaid patients on high dose opioids and tapering them down or off? Do you screen them out so they never get an appointment with you? Do you punt them to the local hospital system after injecting them?

The PP vs. Hospital employed thing is played out

As pain Physicians we should mutually support each other to dig ourselves out of this hole.

- ex 61N

If I were you, I'd get out.

Our group sees Medicaid at a loss as a courtesy to referring providers because we're not subsidized by HOPD, wrap-around, and SOSdf payments. In fact, our behavioral health clinicians are paid 1/3 of what they would be paid in a community mental health setting or primary care/medical homes.

We can't get *ANY* injections, RF, or stim paid for Medicaid patients. It's not on the menu for them. The Obama-era ACA/ACO and Medicaid movements were boondoggles for large physician employers and left pretty much everyone else with scraps. Despite the fact that no one at our Federally Qualified Health Center has an x-number or training in addiction medicine (and we have dual board certified pain/addiction specialists) we still can't get anywhere near the same payment that the hospital employed physicians get for the same (or better) level of E&M service.

Hospital-salaried physicians opining about medical payment policies usually have little idea how the real sausage is made. Try sitting down and negotiating with payers and get back to me.

 

[lobelsteve]

If I were you, I'd get out.

Our group sees Medicaid at a loss as a courtesy to referring providers because we're not subsidized by HOPD, wrap-around, and SOSdf payments. In fact, our behavioral health clinicians are paid 1/3 of what they would be paid in a community mental health setting or primary care/medical homes.

We can't get *ANY* injections, RF, or stim paid for Medicaid patients. It's not on the menu for them. The Obama-era ACA/ACO and Medicaid movements were boondoggles for large physician employers and left pretty much everyone else with scraps. Despite the fact that no one at our Federally Qualified Health Center has an x-number or training in addiction medicine (and we have dual board certified pain/addiction specialists) we still can't get anywhere near the same payment that the hospital employed physicians get for the same (or better) level of E&M service.

Hospital-salaried physicians opining about medical payment policies usually have little idea how the real sausage is made. Try sitting down and negotiating with payers and get back to me.

Maybe you need a change of scenery? You crow about hospital employed docs and complain about SOS and your practice always losing money. Ever think of leaving myspace and going to diaspora, or at least facebook?

 

[drusso]

Maybe you need a change of scenery? You crow about hospital employed docs and complain about SOS and your practice always losing money. Ever think of leaving myspace and going to diaspora, or at least facebook?

Medicaid block grants, site neutral payment, direct care, and sanctions against nominally non-profit physician employers are the policy solutions. ASIPP will lead on these.

 

[drusso]

My practice right now is about 60% Medicaid and Indigent, 25% Medicare, and the rest commercial.

Honest question- if there was a favorable SOS differential, and injections reimbursed better etc. etc. would you prefer your practice to be majority Medicaid and indigent?

Would you like to take these patients on and wean them down off ridiculous opioid regimens- often started by PP guys who injected them up and down and sideways when they actually had paying insurance?

Since it's just about the money..

- ex 61N

I don't think that it is good for communities that Medicaid patients are kept in medical ghettos. I already see those patients within in the limits that my group can afford to do so. It's relationship based. If a PCP picks up the phone and says, "I need your help. I'm in over my head." I'll help. And, I think that no one should practice pain medicine without an X-number and some fundamental understanding of addiction treatment. But, I don't think that it is fair that some providers are perked/subsidized to do the same work that others do...

 

[Dr. Ice]

I can't comment too much on actual "Caid." However I can comment on a very similar demographic..the low income exchange kind. Very very similar to caid. I can tell you this..because of the abundant saturation of where I am..my payor mix consists of 40% of these people. Our contract with this payor is not bad. I don't have actual percentage of Medicare figures but it's decent. Despite this, I am constantly looking for ways to minimize the number of them I see on any given day and often times its a losing struggle. It is an enormous mental and emotional drain despite what the "bottom line" may be for me. Some of them are very hard working people who have just been screwed by the system and I do my best to try to help them but most of them have too many compounding psychological issues to ever really get better. Despite the financials, I would not nor cannot possibly see more than I already am. In this way I understand how a hospital employee may feel but as I don't get a SOSD it would not be apples or apples...

 

[PapaDosh]

The highest dose butrans patch equates to what, 2 mg of suboxone? Belbuca never gets covered either

Highest dose of Butrans 20 is equivalent to 300 mcg of Belbuca, so pretty far from 2 mg of suboxone. Highest dose of Belbuca is 900 mcg twice a day which is getting close to 2 mg of suboxone barring bioavailability. I am able to get belbuca and butrans covered via Medicaid in NJ and DE so long as the patient has failed Tramadol ER which is not a high barrier for most patients who have seen pain medicine prior.

 

[DOctorJay]

I wouldn't mind getting patients to fail Tramadol ER but I routinely get denials back stating patients need to fail morphine ER, fentanyl, and methadone. I'm trying to avoid harm by using Butrans, it makes no sense to trial these other agents.

 

[Ducttape]

The option - to eliminate SOS differential would have the net effect of trapping these patients in a situation worse than a ghetto. These are the patients at greatest risk for addiction and diversion. Without some physicians and to see these patients, they would most probably turn to their PCP for the only pain treatment they know of and that the primaries feel “comfortable” prescribing - ie narcotics. The amount of prescribing by primary providers is indisputable.

I can agree with limiting SOS differential for injections/shots, but eliminating them for Medicaid would essentially force hospital based patients to also abandon Medicaid.

And the thing is, taking care of a Medicaid patient is not the same as taking care of a private insurance patient. You know that. The additional comorbidities aboubd, and the psychological illnesses are much more than your acute radic in a working individual. 10 min is sufficient for the latter patient; same 10 min will cover only the first page of diagnoses in a typical Medicaid patient (or the same time as to connect to an interpreter)

 

[DrCommonSense]

The highest dose butrans patch equates to what, 2 mg of suboxone? Belbuca never gets covered either

I can't speak for "the boys" at PROP. All I know is, in my current job as a hospital employed pain physician, I am stuck seeing a ton of medicaid and medicare, and I need solutions.

Whether in office induction pays or doesn't pay is immaterial to me. I'm salaried. What I want is a way to safely transition the disasters dumped on my doorstep by the profligate prescribers of yesteryear.

I need a better solution then a forced, inevitably unsuccessful (in 90% of cases) taper off high dose (>200 MME) opioids for these patients, who then go to the street. I've seen bupe work wonders and it is a hell of a lot safer than taking high dose opiates.

Harm reduction. That is the name of the game.

Again, remove cash from the equation. Open the floodgates for Bupe prescribing and get all hands on deck to deal with this disaster.

The people who really need Bupe are generally not the ones who can afford to pay out of pocket for it.

- ex 61N

How long do you have to prescribe Bupe to a patient before they become "free of addiction"? Seems like the FEW "addict" patients that are "successfully" transitioned stay on this for life or they will get right onto heroin/fentanyl once it's stopped.

What do you do with the many patients that claim an "allergy to bupe" or "it doesn't work doc, im in a ton of pain and need to go back onto the other medications"?

its not as simple as you say since I have transitioned many patients over to Butrans from other ridiculous narcotic regimens done by outside physicians (mostly PCPs).

MANY of these patients either claim an allergy to the medication, claim it doesn't cover their pain, even abuse the patch by attempting to suck it down, etc.

When you try to force the Bupe onto MOST of these patients, MOST will become belligerent and leave your practice anyway in a very angry state if you don't put them back on their old medications.

Its not like you just have this smooth transition. Most end up discharged anyway or very very unsatisfied with constant arguments/appeals towards going back to their old medications (that is if they have good UDS findings that remain).

These Medcaid patients will also make a scene if you don't put them back onto the same medications they got before in a very LOUD manner that will often scare away other legitimate patients that don't want to come to an office that has constant craziness.

 

[DrCommonSense]

My practice right now is about 60% Medicaid and Indigent, 25% Medicare, and the rest commercial.

Honest question- if there was a favorable SOS differential, and injections reimbursed better etc. etc. would you prefer your practice to be majority Medicaid and indigent?

Would you like to take these patients on and wean them down off ridiculous opioid regimens- often started by PP guys who injected them up and down and sideways when they actually had paying insurance?

Since it's just about the money..

- ex 61N

Most high dosage narcotic patients are started by PCPs as noted in the Ohio report posted with only 3% prescribed by Pain Physicians of ALL stripes.

The vast majority of my Medicaid disasters were started by PCPs. So yeah its not fun having to dig myself out of someone else's disaster for zero renumeration and mostly a hostile patient that can't do "PT because it hurts, already has a psychologist, doesn't like needs, is allergic to every non narcotic medication, etc"

 

[244913]

How long do you have to prescribe Bupe to a patient before they become "free of addiction"? Seems like the FEW "addict" patients that are "successfully" transitioned stay on this for life or they will get right onto heroin/fentanyl once it's stopped.

What do you do with the many patients that claim an "allergy to bupe" or "it doesn't work doc, im in a ton of pain and need to go back onto the other medications"?

its not as simple as you say since I have transitioned many patients over to Butrans from other ridiculous narcotic regimens done by outside physicians (mostly PCPs).

MANY of these patients either claim an allergy to the medication, claim it doesn't cover their pain, even abuse the patch by attempting to suck it down, etc.

When you try to force the Bupe onto MOST of these patients, MOST will become belligerent and leave your practice anyway in a very angry state if you don't put them back on their old medications.

Its not like you just have this smooth transition. Most end up discharged anyway or very very unsatisfied with constant arguments/appeals towards going back to their old medications (that is if they have good UDS findings that remain).

These Medcaid patients will also make a scene if you don't put them back onto the same medications they got before in a very LOUD manner that will often scare away other legitimate patients that don't want to come to an office that has constant craziness.

Butrans or buprenorphine? Butrans patches have such a low equivalent MME dosage that it is a drop in the bucket.

The patients I have seen transitioned onto suboxone (8-24 mg daily) seem to do very well. Their pain is controlled and their mental state is much better.

Yes, they do probably need to stay on it for life. These are addicts. That's why the govt. needs to open the floodgates and allow widespread prescribing of suboxone. The govt insurance carriers need to cover it for chronic pain, not just opioid use disorder.

PCP's can all get x-waivered and transition their own patients on high MME doses. Surgical NP's and PA's can do the same.

I believe this is the only pragmatic solution for this lost generation created by the out of control opioid prescribing of the 1990's-2010. They need something, and I would rather that "something" be suboxone rather than 240 percocet a month, or heroin.

- ex 61N

 

[DrCommonSense]

Butrans or buprenorphine? Butrans patches have such a low equivalent MME dosage that it is a drop in the bucket.

The patients I have seen transitioned onto suboxone (8-24 mg daily) seem to do very well. Their pain is controlled and their mental state is much better.

Yes, they do probably need to stay on it for life. These are addicts. That's why the govt. needs to open the floodgates and allow widespread prescribing of suboxone. The govt insurance carriers need to cover it for chronic pain, not just opioid use disorder.

PCP's can all get x-waivered and transition their own patients on high MME doses. Surgical NP's and PA's can do the same.

I believe this is the only pragmatic solution for this lost generation created by the out of control opioid prescribing of the 1990's-2010. They need something, and I would rather that "something" be suboxone rather than 240 percocet a month, or heroin.

- ex 61N

I've seen plenty of people do well on Butrans as well just not the good majority of patients who want Oxycontin or some stronger meds.

Patients will endure staying on Suboxone if they can't get anything else but will often supplement it with heroin/illegal pills or some other medication if they have to.

Don't kid yourself. The good majority will fail Suboxone treatment over the long term either by bad UDS findings and/or using other medications illegally.