Descent of CT surgery

[Taurus]

http://vasculardiseasemanagement.com/article/8077

http://vasculardiseasemanagement.com/article/8080#

Medicare reimbursement for cardiac surgery has seen dramatic reductions since the 1980s. As a result of Medicare reform in the early 1990s, reimbursement for CABG fell by more than 50% compared to reimbursement in the 1980s. In 2002, CABG reimbursement by Medicare had decreased by 38% compared to the 1990s, a trend that has continued over the last 5 years. Residents in cardiothoracic surgery cite dwindling reimbursement rates and limited job selection as the two biggest concerns with the field.

A recent poll of graduates from approved cardiothoracic surgery programs in the U.S. identified significant difficulties in finding suitable job placement. In this report, 16% of those polled did not receive a single job interview, and 80% of those who sought additional training did so as a result of an inability to find a suitable job. Over 80% reported difficulty in finding a job. Importantly, almost one-fourth of those polled would not choose a career in cardiothoracic surgery again, and more than half would not recommend the field to potential trainees.​

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[Blade28]

.
.
. <-- tears running down my cheek

 

[Winged Scapula]

I wanted a sleepy/bored emoticon.

Is there anything new in the article (I only read the first paragraph or two)?

 

[Castro Viejo]

No, just the typical Chicken Little CTS "The Sky is Falling! The Sky is Falling!" kind of article.

I believe that if you train in a tremendous CTS program (a la Duke, Baylor, etc.) you'll be fine. It's just the guys who train in no-one's-heard-of-your-town-let-alone-your-hospital community CTS residency that'll suffer.

 

[Faebinder]

It's okay Blade, the field was malignant anyway.. You would have hated your life.. Go vascular. Seriously, CT surgeons need to start publishing some serious randomized trials to show that their surgeries improve survival over medical management. Otherwise they will never get the primary care referral. (Not to mention they gotta convince the general surgeons to ask questions about that improvement on the boards, otherwise primary care will never know that they SHOULD replace a valve, half the primary care docs have no clue what operations a cardiac surgeon does other than replacing a valve).

 

[Winged Scapula]

It's okay Blade, the field was malignant anyway.. You would have hated your life.. Go vascular.

There IT is!

For some reason I was blind and couldn't find it.

Yeah,

 

[Blade28]

It's okay Blade, the field was malignant anyway.. You would have hated your life.. Go vascular.

But I don't like Vascular. I like CT, remember?

 

[Castro Viejo]

But I don't like Vascular. I like CT, remember?

It doesn't matter what YOU like, all that matters is what matters. You see?

Vascular Surgery! Oh yeah baby!

 

[Blade28]

It doesn't matter what YOU like, all that matters is what matters. You see?

Vascular Surgery! Oh yeah baby!

Then I'm doomed...but I've known this since college.

 

[johnny_blaze]

Then I'm doomed...but I've known this since college.

don't worry mate... u and i will be doomed together. at least we have each other...

I hear a lot of positive things about CT surgery from the consultants over here. I think a lot of it has to do with the fact that a vast majority of consultants will be retiring in the next 10 years and there wont be enough trainees to fill the vacancies (probably due to the fact that you and i are the only two people gunning for the field). I've been told that if you're keen from the beginning and hard working then you shouldn't have a problem. interpret this as you will.

There's a very large trial run in oxford by a professor there called the ART (arterial revascularisation trial) and it involved almost every academic CT centre in the U.K. It focused on the long term outcomes following total arterial revascularisation (no vein grafts). Dunno what the results are like so far but i'll be at the annual U.K cardiothoracic conference in march in 2008, so i might hear something. Perhaps this might shine some light at the end of our tunnel.

 

[Blade28]

don't worry mate... u and i will be doomed together. at least we have each other...

I hear a lot of positive things about CT surgery from the consultants over here. I think a lot of it has to do with the fact that a vast majority of consultants will be retiring in the next 10 years and there wont be enough trainees to fill the vacancies (probably due to the fact that you and i are the only two people gunning for the field). I've been told that if you're keen from the beginning and hard working then you shouldn't have a problem. interpret this as you will.

That's funny...I've been saying the exact same thing for the past 3+ years! (Most CT Surg attendings will retire in the next 5-10 years.)

 

[Castro Viejo]

don't worry mate... u and i will be doomed together. at least we have each other...

True. You can boil each other's pee and drink the distillate when you run out of money to pay your utility bill.

 

[Blade28]

Or I could just do General Surgery bread and butter and take trauma call.



God have mercy.

 

[-Goose-]

Or I could just do General Surgery bread and butter and take trauma call.



God have mercy.

Spent some time recently with a private practice CT surgery group in my home town while I was home for Thanksgiving; watched a robotic mitral valve repair. Pretty damn amazing stuff. Looks literally like a video game.

From what I gathered, all these guys felt that the market would start to correct itself and that the biggest hurdle was getting that first job. One surgeon, who had been employed by the group for 5 years, said "Now I could get a job anywhere I want." They work pretty hard though. One attending said he pushed 70-80 hours a week from all his call (he was the youngest in the group). I guess if you love it, it doesn't matter though.

For other reasons, I decided that CT wasn't for me (patients too sick, I want at least some outpatient procedures). Its an amazing field, though. You gotta think the market will correct itself with the aging baby-boomers, retiring baby-boomer surgeons, decreasing number of graduating CT surgeons, etc.

 

[gasnewby]

don't worry mate... u and i will be doomed together. at least we have each other...

awwww....british love songs.

 

[Taurus]

Just pray you're not in the 16% who can't get a single job interview after completing.

 

[Blade28]

For other reasons, I decided that CT wasn't for me (patients too sick, I want at least some outpatient procedures). Its an amazing field, though. You gotta think the market will correct itself with the aging baby-boomers, retiring baby-boomer surgeons, decreasing number of graduating CT surgeons, etc.

I plan on doing a bunch of pacemakers for quick outpatient procedures. If you're also doing Thoracic, there are tons of sympathectomies to be done.

 

[Celiac Plexus]

I plan on doing a bunch of pacemakers for quick outpatient procedures. If you're also doing Thoracic, there are tons of sympathectomies to be done.

You also will have all of the inpatient consults for chest tube placements! They reimburse almost as much as CABGs do... Pacemakers are a neat outpatient procedure, however depending on the strength of your cts group, in a lot of places the cardiologists do these.

Seriously, what I find interesting about the article is that only a quarter would not choose cts over again, and only half would not recommend the field to general surgery residents. Those guys must really love it. (yes, that's teal).

 

[Blade28]

You also will have all of the inpatient consults for chest tube placements! They reimburse almost as much as CABGs do...

Wow, hadn't realized this!

It always amazes me how much more profitable outpatient procedures and bedside procedures are, compared to big ol' whacks.

 

[DrDude]

I believe that if you train in a tremendous CTS program (a la Duke, Baylor, etc.) you'll be fine. It's just the guys who train in no-one's-heard-of-your-town-let-alone-your-hospital community CTS residency that'll suffer.

That's like saying as long as you went to a "tremendous" med school you'll be fine getting a job but if you went to one no one's heard of then you'll have trouble finding work. Very few people are selected to train at the best CT programs like the ones you mentioned. So if the criteria becomes that you have to train at an elite CT program to land a decent job then you do indeed have to admit CT surgery is on a decline. Before graduates were getting minimum offers starting at about a quarter million per year and up the very first year out of their CT fellowship at any program in the country, and it wasn't unusual for them to be pulling in over a million after a few years in practice. Yeah it was that good.

 

[JosephFaecesMD]

That's like saying as long as you went to a "tremendous" med school you'll be fine getting a job but if you went to one no one's heard of then you'll have trouble finding work. Very few people are selected to train at the best CT programs like the ones you mentioned. So if the criteria becomes that you have to train at an elite CT program to land a decent job then you do indeed have to admit CT surgery is on a decline. Before graduates were getting minimum offers starting at about a quarter million per year and up the very first year out of their CT fellowship at any program in the country, and it wasn't unusual for them to be pulling in over a million after a few years in practice. Yeah it was that good.

I think that once you get into a practice, you are freaking set. They make serious bank. Look at the average salaries... in the 400k range (and thats whats "reported"). Its just that right now getting that first job is difficult.

 

[Castro Viejo]

I plan on doing a bunch of pacemakers for quick outpatient procedures. If you're also doing Thoracic, there are tons of sympathectomies to be done.

I've known quite a few Vascular Surgery-types to do these kind of cases too.

Weird.

 

[Castro Viejo]

That's like saying as long as you went to a "tremendous" med school you'll be fine getting a job but if you went to one no one's heard of then you'll have trouble finding work. Very few people are selected to train at the best CT programs like the ones you mentioned. So if the criteria becomes that you have to train at an elite CT program to land a decent job then you do indeed have to admit CT surgery is on a decline. Before graduates were getting minimum offers starting at about a quarter million per year and up the very first year out of their CT fellowship at any program in the country, and it wasn't unusual for them to be pulling in over a million after a few years in practice. Yeah it was that good.

I never said CTS wasn't on the decline, but it's like anything else in the world, right? The ones considered at the higher end of the spectrum, the guys who trained at the leading institutions for this kind of thing, are relatively protected and sought after. The guys who trained in the middle-of-nowhere places have more trouble finding a job.

It's the same with law school grads...

Business schools grads...

College grads...

And, heck, probably even med school grads. If I went to the Gonzaga University School of Medicine I'd probably have a much more difficult time getting an integrated PRS spot than if I had gone to Harvard Medical School.

You can't honestly tell me a CTS trained outta Newark-Beth Israel Hospital in New Jersey is going to have the same chances of landing a job as a CTS trained at Duke or Baylor.

 

[DrDude]

I never said CTS wasn't on the decline, but it's like anything else in the world, right? The ones considered at the higher end of the spectrum, the guys who trained at the leading institutions for this kind of thing, are relatively protected and sought after. The guys who trained in the middle-of-nowhere places have more trouble finding a job.

It's the same with law school grads...

Business schools grads...

College grads...

And, heck, probably even med school grads. If I went to the Gonzaga University School of Medicine I'd probably have a much more difficult time getting an integrated PRS spot than if I had gone to Harvard Medical School.

You can't honestly tell me a CTS trained outta Newark-Beth Israel Hospital in New Jersey is going to have the same chances of landing a job as a CTS trained at Duke or Baylor.

I realize what you're saying. I also agree that in today's "market" (in lieu of a better word) the CT grad coming out of a elite program is WAY ahead in terms of employment than someone coming out a lesser name program. My point was that it wasn't like this before. Before a grad from any CT program in the country was all but assured an excellent job immediately upon completion of their fellowship. Which is of course one of the reasons why CTS was one the most competetive fellowships to obtain back then.

 

[Castro Viejo]

My point was that it wasn't like this before. Before a grad from any CT program in the country was all but assured an excellent job immediately upon completion of their fellowship. Which is of course one of the reasons why CTS was one the most competetive fellowships to obtain back then.

Yeah... One of the CTS staff here gave up PRS back in the day because of the lucrative opportunities in CTS and because he just plain "liked it more." I'm sure it was mostly the cash. Anyway, nowadays, he walks around the place and bangs his head on the walls, muttering, "What did I do? WHAT DID I DO???"

Who knows? Perhaps one day Trauma/SCC will be the shiznit and will draw in $urgical opportunitie$ that'll make us all kick ourselves for not doing it too.

(Yeah right...)

 

[Blade28]

Who knows? Perhaps one day Trauma/SCC will be the shiznit and will draw in $urgical opportunitie$ that'll make us all kick ourselves for not doing it too.

(Yeah right...)

I doubt it.

 

[johnny_blaze]

If I went to the Gonzaga University School of Medicine I'd probably have a much more difficult time getting an integrated PRS spot than if I had gone to Harvard Medical School.

hey dont diss Gonzaga... i went there! And so did my sister.. and now she's the best dang GP in all of Roanoke Rapids! Gooooooo Bulldogs!

But i do agree with you. Those who had it good from the start are gonna have a much easier time getting a CT consultant job. The "old boy" mentality exists in my neck of the woods aswell. I've realised from speaking to almost every med student / junior resident in my generation that i am the ONLY person actually considering CTS. I don't believe that the same problems that exist for trainees now will be present in the next 10 years.

 

[mitchconnie]

I believe that if you train in a tremendous CTS program (a la Duke, Baylor, etc.) you'll be fine. It's just the guys who train in no-one's-heard-of-your-town-let-alone-your-hospital community CTS residency that'll suffer.

Either Baylor isn't all that tremendous, or the problems are more extensive than you think. When I was at Baylor, the CT program was in big trouble. Fellows couldn't find jobs and were doing second fellowships, or just plain dropping out of the program. I don't even think that the original Baylor College of Medicine (Debakey) program is even accredited. Check out their web-site which clearly states that it is not an accredited program and graduates can't sit for the boards.

http://www.debakeydepartmentofsurgery.org/home/content.cfm?menu_id=8

I think that the Texas Heart (Cooley) program is still up and running.

 

[Celiac Plexus]

Wow, hadn't realized this!

It always amazes me how much more profitable outpatient procedures and bedside procedures are, compared to big ol' whacks.

Actually I was kidding. However, if you consider that it takes about 5 minutes to place a chest tube, and it takes about 2-3 hours to do a CABG, the reimbursements for chest tubes is probably more per unit time.

 

[Castro Viejo]

hey dont diss Gonzaga... i went there! And so did my sister.. and now she's the best dang GP in all of Roanoke Rapids! Gooooooo Bulldogs!

They're quite an NCAA force, from my understaging! Go Zag! (Made the last part up...)

I've realised from speaking to almost every med student / junior resident in my generation that i am the ONLY person actually considering CTS. I don't believe that the same problems that exist for trainees now will be present in the next 10 years.

I agree. Ultimately CTS will wise up and start taking down things that rightfully belong to them. Once they get the hang of sliding endografts into the thoracic aorta some boob somewhere will start doing the same for coronaries.

Just stay outta the periphery or I'll take you guys down with my bare hands!

 

[Castro Viejo]

Either Baylor isn't all that tremendous, or the problems are more extensive than you think. When I was at Baylor, the CT program was in big trouble. Fellows couldn't find jobs and were doing second fellowships, or just plain dropping out of the program. I don't even think that the original Baylor College of Medicine (Debakey) program is even accredited. Check out their web-site which clearly states that it is not an accredited program and graduates can't sit for the boards.

http://www.debakeydepartmentofsurgery.org/home/content.cfm?menu_id=8

I think that the Texas Heart (Cooley) program is still up and running.

According to the ACGME the DeBakey program is on probation. Wonder what happened.

There are two other Texas Heart programs, both of which have continued accreditation.

Silly Thoracic Surgeons...

 

[Blade28]

Actually I was kidding. However, if you consider that it takes about 5 minutes to place a chest tube, and it takes about 2-3 hours to do a CABG, the reimbursements for chest tubes is probably more per unit time.

Yeah it's probably close, in terms of reimbursement per minute.

 

[johnny_blaze]

They're quite an NCAA force, from my understaging! Go Zag! (Made the last part up...)

hahah i didn't actually thing Gonzaga was a real school until i googled it... that's right... i googled it!

i seriously thought u were making it up.

 

[DrDude]

I don't believe that the same problems that exist for trainees now will be present in the next 10 years.

That's what a lot of trainees believed 10 years ago too.

 

[droliver]

I don't even think that the original Baylor College of Medicine (Debakey) program is even accredited. Check out their web-site which clearly states that it is not an accredited program and graduates can't sit for the boards.http://www.debakeydepartmentofsurgery.org/home/content.cfm?menu_id=8
I think that the Texas Heart (Cooley) program is still up and running.

You're confusing the fellowship at Baylor with the CTVS residency program they run(here) I believe. While the term fellow gets used in laymans terms to describe anything after your general surgery training, for CTVS and traditional Plastic Surgery programs you're still technically residents to the RRC. Ther are many "fellowships" in different things that don't make you board-eligible in anything per se.

 

[Castro Viejo]

You're confusing the fellowship at Baylor with the CTVS residency program they run(here) I believe. While the term fellow gets used in laymans terms to describe anything after your general surgery training, for CTVS and traditional Plastic Surgery programs you're still technically residents to the RRC. Ther are many "fellowships" in different things that don't make you board-eligible in anything per se.

I have no idea which one is on probation, but here are the three programs associated with Texas Heart. Anyone confused as I am? Why does Cooley have two programs? These are all Thoracic Residencies.

Texas Heart Institute Program [4604821093]
Denton A. Cooley, MD
Program Director and Department Chair
Original Accreditation Date:
Accreditation Status: Continued Full Accreditation
Accreditation Effective Date: July 9, 2004
Accredited Program Length: 2 years

Texas Heart Institute/Baylor College of Medicine Program [4604813124]
Denton A. Cooley, MD
Director, Thoracic Surgery Residency Program
Original Accreditation Date: July 1, 2007
Accreditation Status: Initial Accreditation
Accreditation Effective Date: July 1, 2007
Accredited Length: 3 years

Baylor College of Medicine Program [4604821092]
Joseph S. Coselli, MD
Director Thoracic Surgery Residency
Original Accreditation Date: July 2, 1956
Accreditation Status: Probation
Accreditation Effective Date: January 13, 2006
Accredited Length: 2 years

 

[ESU_MD]

Why does Cooley have two programs?

Probably since he is the ultimate badass

Actually, the THI and Baylor programs merged to one program. The solo THI/ Baylor programs will phase out as the current residents graduate

 

[raidenxp2005]

A POINT TO ALL U GUYS HERE ON THE FORUM IS THAT WE DON'T KNOW WHAT THE FUTURE HAS IN STORE FOR CTS ....... THOUGH FOR MY CHRISTMAS WISH IS TO HAVE MORE VALVULAR DISEASES AND MORE CAD's.....meaning more obesity.......

YES, THIS IS WHAT WE ALL WISH FOR ..... THIS IS WHAT WE NEED TO WORK ON..... BUT GUYS, I GUESS WE ALL HAVE TO WAIT AND PRAY FOR MORE WENDY'S, KFC's, CANCER, ETC. TO COME ALONG ..... LET'S JUST WAIT FOR THE NEXT 10 YEARS AND SEE WHAT HAPPENS

TRAINING IS NOT A PROBLEM....GETTING PATIENTS AND UPDATED MEDICAL GUIDELINES (ie Cardiology) are our biggest herdle

 

[gasnewby]

ever heard of caps lock?

 

[Celiac Plexus]

A POINT TO ALL U GUYS HERE ON THE FORUM IS THAT WE DON'T KNOW WHAT THE FUTURE HAS IN STORE FOR CTS ....... THOUGH FOR MY CHRISTMAS WISH IS TO HAVE MORE VALVULAR DISEASES AND MORE CAD's.....meaning more obesity.......

YES, THIS IS WHAT WE ALL WISH FOR ..... THIS IS WHAT WE NEED TO WORK ON..... BUT GUYS, I GUESS WE ALL HAVE TO WAIT AND PRAY FOR MORE WENDY'S, KFC's, CANCER, ETC. TO COME ALONG ..... LET'S JUST WAIT FOR THE NEXT 10 YEARS AND SEE WHAT HAPPENS

TRAINING IS NOT A PROBLEM....GETTING PATIENTS AND UPDATED MEDICAL GUIDELINES (ie Cardiology) are our biggest herdle

A useful tip for the holiday season: alternate each glass of egg nog with a glass of water.

 

[Castro Viejo]

A POINT TO ALL U GUYS HERE ON THE FORUM IS THAT WE DON'T KNOW WHAT THE FUTURE HAS IN STORE FOR CTS ....... THOUGH FOR MY CHRISTMAS WISH IS TO HAVE MORE VALVULAR DISEASES AND MORE CAD's.....meaning more obesity.......

YES, THIS IS WHAT WE ALL WISH FOR ..... THIS IS WHAT WE NEED TO WORK ON..... BUT GUYS, I GUESS WE ALL HAVE TO WAIT AND PRAY FOR MORE WENDY'S, KFC's, CANCER, ETC. TO COME ALONG ..... LET'S JUST WAIT FOR THE NEXT 10 YEARS AND SEE WHAT HAPPENS

TRAINING IS NOT A PROBLEM....GETTING PATIENTS AND UPDATED MEDICAL GUIDELINES (ie Cardiology) are our biggest herdle

Yeah, dude... That's a bit of a rant there.

Here's to disulfram!

 

[gasnewby]

TRAINING IS NOT A PROBLEM....GETTING PATIENTS AND UPDATED MEDICAL GUIDELINES (ie Cardiology) are our biggest herdle

i know, what does this even mean? CT surgery is declining from a lack of updated medical guidelines?

on a completely off-topic note,
i am laughing my ASS off right now. they called a rapid response to the medical floor near my call room. i immediately hear the thundering footsteps of medicine residents, who foolishly run to codes. and a big 'thump,' followed by "who left that chuck on the floor?!" HA HA HA HA.

 

[labst]

Vascular Surgery! Oh yeah baby!

Although, if you were being honest, that banana would be lying in bed with his left leg gone and his right leg an AKA, lolz. COLORECTAL FTW!!!

 

[Castro Viejo]

i immediately hear the thundering footsteps of medicine residents, who foolishly run to codes. and a big 'thump,' followed by "who left that chuck on the floor?!" HA HA HA HA.

 

[Blade28]

No point running to codes - you'll only save around 20 seconds, plus you arrive at the patient's room tachycardic and out of breath.

 

[johnny_blaze]

A POINT TO ALL U GUYS HERE ON THE FORUM IS THAT WE DON'T KNOW WHAT THE FUTURE HAS IN STORE FOR CTS ....... THOUGH FOR MY CHRISTMAS WISH IS TO HAVE MORE VALVULAR DISEASES AND MORE CAD's.....meaning more obesity.......

YES, THIS IS WHAT WE ALL WISH FOR ..... THIS IS WHAT WE NEED TO WORK ON..... BUT GUYS, I GUESS WE ALL HAVE TO WAIT AND PRAY FOR MORE WENDY'S, KFC's, CANCER, ETC. TO COME ALONG ..... LET'S JUST WAIT FOR THE NEXT 10 YEARS AND SEE WHAT HAPPENS

TRAINING IS NOT A PROBLEM....GETTING PATIENTS AND UPDATED MEDICAL GUIDELINES (ie Cardiology) are our biggest herdle

RAAAA!!! HULK SMASH PUNY CARDIOLOGISTS! MAKE BETTER FOR CT SURGERY!!!

dude, is this the first time you've used a keyboard?

 

[raidenxp2005]

better guidelines from medical practitioners means less work for the CT Surgeon

who knows maybe a by-pass might be a relic or a procedure u read in the Smithsonian archieves

lets just see how many old timers don't like seeing their doctors and wait until things get worse

CTS's may become a pheonix of the modern day

 

[Misterioso]

How many times are we gonna go 'round about cardiac surgery being a diminishing field til you guys get the message? It's NOT gonna get better in 10, 20, 100 years in terms of job prospects. You're gonna need fewer surgeons to do the fewer procedures...there's not enough to go around for everyone like before. But I guess CT fellowships need idiots who don't listen to reason to sign up and do the grunt work under the pipe dream that it'll all get better by the time they're finished training.

 

[GSresident]

Its an amazing field, though. You gotta think the market will correct itself with the aging baby-boomers, retiring baby-boomer surgeons, decreasing number of graduating CT surgeons, etc.

If medicine truly existed in a free market it probably would correct itself. The problem is that CTS isn't part of a free market.

If I was an insurance company executive my goal would be to collect premiums and not pay out any benefits. What most insurance companies do is just reject every claim that comes across the desk figuring that the physician will get sick of making 30 phone calls to collect the $150 for a hernia repair. Most times that works. For a lot of procedures insurance plans will require a 'pre-approval'. Most of those get rejected the first time and you have to keep jumping through hoops to get it approved. Most offices have to hire an extra person just to deal with this kind of B.S.

It used to be that the insurance companies would just not cover things end of story. But they started looking like the bad guy so now they are in the process of reducing the reimbursements so much that surgeons won't do the procedures. That way they can make the surgeon look like the bad guy for not wanting to do a 4-6 hour whipple and the aftercare for $900.

Now that the insurance companies and 'Ole Uncle Sugar' know that you will put up with that crap you guys are stuck.

 

[Playmakur42]

What most insurance companies do is just reject every claim that comes across the desk figuring that the physician will get sick of making 30 phone calls to collect the $150 for a hernia repair. Most offices have to hire an extra person just to deal with this kind of B.S.

Now that the insurance companies and 'Ole Uncle Sugar' know that you will put up with that crap you guys are stuck.

In my non-medical business experience, I've noticed that most businesses where money is exchanged before the service is rendered have less issues w/ payment (obviously).

Have any groups of surgeons in a geographical area gotten together and demanded that the patient pay the surgeons fee upfront & then allow the patient to chase the insurance companies for the reimbursement? Maybe I'm wrong, but I think most people would be able to put $500 for a gallbladder removal on a credit card until the insurance reimburses them. It would be a pain in the a** explaining to the patient why business is being done this way, but probably better than calling the insurance company 30 times to get paid.