Describe Ideal Dynamics for IPM MD-MidLevel Team...

[drusso]

The cheese has moved. How will you find it?

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[Ducttape]

thats a nice blue suit the APP is wearing

 

[pmrmd]

Interesting question.

I think extenders can do med refills.

That’s it.

 

[RoloTomassi]

I think post-procedure follow-ups where the plan is laid out works too

Ex:
Start with left L4-S1 TFESI
If radicular pain not adequately improved, L4-5 ILESI
If radicular pain improved but axial pain persists, left L4-S1 MBB
If MBB positive, will repeat then RFA; if negative, L4-S1 Intracept

 

[Agast]

Are we moving to a narrative that seeing an APP is superior to accessing an actual doctor in pain management now?

 

[lobelsteve]

No scenario where this benefits patients over profits.

 

[MitchLevi]

No scenario where this benefits patients over profits.

Dude, come on...

You can't get in to see me without waiting an absurd amount of time. My line to get in is months.

A PA can see you, give you a Toradol IM injxn, send you to PT with Robaxin 500mg BID and have you follow up with me.

 

[drrosenrosen]

Interesting question.

I think extenders can do med refills.

That’s it.

Depends on the state. Midlevels can't prescribe CII in Texas. So if you wanted to set them up to see the med refills (if you prescribe opioids), you're still putting your name to all those prescriptions, and trusting that they're doing everything right. I don't love that model myself

 

[lobelsteve]

Dude, come on...

You can't get in to see me without waiting an absurd amount of time. My line to get in is months.

A PA can see you, give you a Toradol IM injxn, send you to PT with Robaxin 500mg BID and have you follow up with me.

You are entitled to provide inferior care if you choose. Until you are out of a job.
No extenders for me. Or my family.

PCP should have done PT, SMR- mine always do. Patient expected to have imaging done, PT done, non-opiates started.

 

[MitchLevi]

You are entitled to provide inferior care if you choose. Until you are out of a job.
No extenders for me. Or my family.

PCP should have done PT, SMR- mine always do. Patient expected to have imaging done, PT done, non-opiates started.

You didn't address the central issue at hand.

There's only one of me.

 

[Agast]

You didn't address the central issue at hand.

There's only one of me.

Why not hire another You if the wait is truly months?

 

[SSdoc33]

Why not hire another You if the wait is truly months?

i think the implication is that there is only one MitchLevi

 

[drusso]

Are we moving to a narrative that seeing an APP is superior to accessing an actual doctor in pain management now?

This is a hot topic among pain surgeons, KOLs, and Super Partners across the country.

 

[drusso]

Dude, come on...

You can't get in to see me without waiting an absurd amount of time. My line to get in is months.

A PA can see you, give you a Toradol IM injxn, send you to PT with Robaxin 500mg BID and have you follow up with me.

Have you considered Saturday clinics? Patients love them.

 

[lobelsteve]

i think the implication is that there is only one MitchLevi

How does Mitch change a light bulb?
He holds it still and the universe turns around him.

• Chuck Norris (Mitch) makes onions cry.
• Chuck Norris (Mitch) uses pepper spray to spice up his steaks.
• When Chuck Norris (Mitch) wants an egg, he cracks open a chicken.
• Some people like to eat frogs’ legs. Chuck Norris (Mitch) likes to eat lizard legs. Hence, snakes.

 

[SSdoc33]

How does Mitch change a light bulb?
He holds it still and the universe turns around him.

• Chuck Norris (Mitch) makes onions cry.
• Chuck Norris (Mitch) uses pepper spray to spice up his steaks.
• When Chuck Norris (Mitch) wants an egg, he cracks open a chicken.
• Some people like to eat frogs’ legs. Chuck Norris (Mitch) likes to eat lizard legs. Hence, snakes.

mitch doesnt do push ups, he pushes the world down

 

[MitchLevi]

We've had other pain doctors and they never pan out. That's why I now have a PA and will soon hire another pain doctor.

There is a simple math problem that Steve is ignoring, one that isn't limited to my community. There simply isn't enough doctors.

You can say whatever you want about your referral base; you can say your referring physicians do everything perfectly before you get those referrals (we all know that's BS). That's not the situation nationwide.

A well-trained midlevel is more than capable of urgent care visits, nonscheduled follow ups and medication visits. Under certain conditions they can schedule procedures too. If they schedule the wrong one, you cancel it.

We have midlevels in our group that are fantastic. A few are just good enough.

I know several utterly horrendous pain physicians.

 

[MitchLevi]

Have you considered Saturday clinics? Patients love them.

Yeah...I actually have, but I wouldn't do that to my staff.

 

[DOctorJay]

Dude, come on...

You can't get in to see me without waiting an absurd amount of time. My line to get in is months.

A PA can see you, give you a Toradol IM injxn, send you to PT with Robaxin 500mg BID and have you follow up with me.

Does it pencil out financially to miss out on the consult/new patient code if you have the midlevel see them first? I’d assume you give up incident to billing in that situation as well.

 

[MitchLevi]

Does it pencil out financially to miss out on the consult/new patient code if you have the midlevel see them first? I’d assume you give up incident to billing in that situation as well.

The most important thing for the practice is the pt gets seen in a reasonable amount of time. Those wait times result in ppl going elsewhere.

 

[DODOCSS]

Does it pencil out financially to miss out on the consult/new patient code if you have the midlevel see them first? I’d assume you give up incident to billing in that situation as well.

could be wrong, but I think you an still bill NP based on specialty designation.

 

[Agast]

We've had other pain doctors and they never pan out. That's why I now have a PA and will soon hire another pain doctor.

I know several utterly horrendous pain physicians.

Why do you think they don’t pan out? Do you think your midlevels are superior to other pain physicians in your area? How so?

 

[Agast]

If given a choice between my mom seeing Tim Deer’s PA and one of you guys, I’d pick one of you 98.9% of the time

 

[lobelsteve]

My mom is seeing no one’s Pa or NP.

 

[RoloTomassi]

If given a choice between my mom seeing Tim Deer’s PA and one of you guys, I’d pick one of you 98.9% of the time

Do tell who's responsible for that 1.1%

 

[wendalltwolf]

Do tell who's responsible for that 1.1%

Probably me, I start EMGs with max stim and duration to not waste time.

 

[callmeanesthesia]

My area has lost 4 pain doctors since I started 4 years ago, and added none. Payor mix sucks, and the only way I’m profitable is on volume which means using PAs to see patients. Patients who only want to see the doctor are welcome, they’ll just have to wait 2 months for their new patient appointment, which is a bummer if they have an acute disc herniation or compression fracture. Or they can see my PA next week, and he can grab me if needed. It’s hard to recruit to our area - I remember getting a mailer in intern year for the job I took after fellowship. Took the group five years to recruit a pain doc.

 

[nvrsumr]

Well regarded practice near me has 2 docs and 9 mid levels.

 

[lmsanscafe]

My area has lost 4 pain doctors since I started 4 years ago, and added none. Payor mix sucks, and the only way I’m profitable is on volume which means using PAs to see patients. Patients who only want to see the doctor are welcome, they’ll just have to wait 2 months for their new patient appointment, which is a bummer if they have an acute disc herniation or compression fracture. Or they can see my PA next week, and he can grab me if needed. It’s hard to recruit to our area - I remember getting a mailer in intern year for the job I took after fellowship. Took the group five years to recruit a pain doc.

Which area is this if you don’t mind me asking?

 

[MitchLevi]

Why do you think they don’t pan out? Do you think your midlevels are superior to other pain physicians in your area? How so?

Too long to type on my phone.

Last doctor in our group I knew by reputation prior to his coming on board. I was actually thrilled bc it meant I'd finally have someone to help me out. He was a catastrophic disappointment.

He was slow, limited, overwhelmingly difficult to work with and largely FoS.

We need you to see 25-30 per day, and he couldn't do 20. Our other guy is the same.

 

[MitchLevi]

My mom is seeing no one’s Pa or NP.

...but what about the math problem Steve? There aren't enough pain doctors.

The US Healthcare system cannot survive without midlevels.

Why is your mother so special she can't see a PA for an initial visit, urgent visit, procedure follow up or med management visit?

 

[Ferrismonk]

I agree with Mitch. A midlevel/APP is good for following algorithm medicine. The patient does not need a doctor to confirm the efficacy of a MBB and document the 10 pages the insurance company requires for the next step.

First diagnosis? Change in management? Unusual finding on MRI? Complex case? See the doc. Routine gabapentin refills or scheduling repeat TFESI which worked great 6 months ago? APP.

 

[Agast]

I agree with Mitch. A midlevel/APP is good for following algorithm medicine. The patient does not need a doctor to confirm the efficacy of a MBB and document the 10 pages the insurance company requires for the next step.

First diagnosis? Change in management? Unusual finding on MRI? Complex case? See the doc. Routine gabapentin refills or scheduling repeat TFESI which worked great 6 months ago? APP.

I’ve said this before, but your APPs can’t tell when a patient needs change in management or have flipped into becoming more complex. I’ve had a number of patients pass through my clinic that already have a pain doctor, but they only see the PA who never bothered to ask them how things are going with the rest of their body. So I’m suddenly being consulted on their neck or their hip and because I’m a nice person I will gently re-direct them to their pain doctor and explain how we do the same thing.

 

[callmeanesthesia]

Which area is this if you don’t mind me asking?

Northern California (the part that tends to be on fire all the time, not the nice part).

 

[MitchLevi]

The enemy of good is perfect, and while midlevels aren't perfect they absolutely play a role.

 

[lobelsteve]

...but what about the math problem Steve? There aren't enough pain doctors.

The US Healthcare system cannot survive without midlevels.

Why is your mother so special she can't see a PA for an initial visit, urgent visit, procedure follow up or med management visit?

Because mom. Others can do as they please. Having reviewed files for disability, WC, the government, and referrals into my practice: I realize becoming a doctor is not equal to becoming an NP or PA. Education, experience, training. Unmatched. Then add in what other specialties have done to devalue medicine. Not for me, not for my family. My post-procedures are seen by me if it is surgical. If MBB, phone call. If ESI, go exercise. Unclogs the office so I can see my 25-32 every day.

 

[MitchLevi]

Because mom. Others can do as they please. Having reviewed files for disability, WC, the government, and referrals into my practice: I realize becoming a doctor is not equal to becoming an NP or PA. Education, experience, training. Unmatched. Then add in what other specialties have done to devalue medicine. Not for me, not for my family. My post-procedures are seen by me if it is surgical. If MBB, phone call. If ESI, go exercise. Unclogs the office so I can see my 25-32 every day.

That's great, and you're operating in an ideal situation that you've spent yrs building.

...but the math problem still exists friend.

 

[lobelsteve]

That's great, and you're operating in an ideal situation that you've spent yrs building.

...but the math problem still exists friend.

 

[SSdoc33]

Too long to type on my phone.

Last doctor in our group I knew by reputation prior to his coming on board. I was actually thrilled bc it meant I'd finally have someone to help me out. He was a catastrophic disappointment.

He was slow, limited, overwhelmingly difficult to work with and largely FoS.

We need you to see 25-30 per day, and he couldn't do 20. Our other guy is the same.

correct me if i'm wrong, and im just throwing this out there, but you MAY not be the easier coworker, mitch

 

[SSdoc33]

the issue with APPs is that there really is no such thing as "algorithm" medicine. every patient is different and nuanced. APPs (and roger chou, for that matter) love little flow charts and algorithms. but they dont exist in real world medicine. there is always a little tangent that doesnt follow that straight line on a chart.

that being said, i do sometimes use APPs for patients that A. take up way too much of my time, B. have a language barrier that necessitates a translator , C. I don't like D. i have no patience for E. smell really bad, F. are likely to no-show or G. are middle eastern

as far as G, is concerned, that is sort of a joke. sort of. im middle eastern myself, and i find those patients to be some of the neediest

if you take that group of patients as a whole, most of them end up being medicaid.

i do realize that I am talking out of both sides of my mouth here. i accept that APP care is suboptimal, but i also accept mitch's premise about the math.

 

[PainApp2021]

Probably me, I start EMGs with max stim and duration to not waste time.

Go big or go home

 

[MitchLevi]

correct me if i'm wrong, and im just throwing this out there, but you MAY not be the easier coworker, mitch

I'm never in the same building. We're spread out over 12 locations. Also, you do what you want. No one hangs over your head about anything.

 

[nvrsumr]

Opposite problem by me. There are plenty of pain docs. Every local pain doc still seems to need a mid level even if they are still doing gas on the side to make ends meet….

 

[Status Sciaticus]

thats a nice blue suit the APP is wearing

Why not hire another You if the wait is truly months?

 

[bedrock]

Opposite problem by me. There are plenty of pain docs. Every local pain doc still seems to need a mid level even if they are still doing gas on the side to make ends meet….

Even if only doing pain half time, they’ll still make more $ utilizing a PA for some visits, and making $$ doing gas the other half of their time .

Maybe they are block jocks, I don’t know, but there is definitely some wasted time each day that can be handled by a PA.

Not sure about a full time PA though for a part time pain doc.
I’m busy AF, but I can’t see a PA competently handling more than 1/3 of my patient visits.

 

[nvrsumr]

I’m not anti midlevel. Just don’t buy there aren’t enough pain docs in attractive metro areas. Lots of docs have a big staff for reasons other than need. To each their own and I hope they are killing it. Won’t change what’s in my cup.

 

[bedrock]

I’m not anti midlevel. Just don’t buy there aren’t enough pain docs in attractive metro areas.

Agree. There are plenty of well qualified physician medical specialists in every attractive metro in the country.

BFE is a different story.

 

[kstarm]

I think there is a role. Like physicians (plumbers, electricians, everyone) some are really good and some are not. I think the amount of supervision makes a big difference. We had an NP that was really good and for issues unrelated to the practice she left. To Urology. She had never done Urology before, outside of exposure in her training, but was expected to be the new urology midlevel. When I think about sending patients, or family to a specialist I get concerned if they are seeing a midlevel as it seems that it is a bit more a roll of the dice. That person could be great with a ton of experience, or they could have recently transferred from a completely unrelated field. To Agast's point how is someone who has very little experience able to determine if something concerning is going on. With close physician supervision I think you can mitigate this, but at least in the pain world around me the private practice midlevels do everything and the docs just sit in the procedure room all day.

 

[drpainfree]

Dude, come on...

You can't get in to see me without waiting an absurd amount of time. My line to get in is months.

A PA can see you, give you a Toradol IM injxn, send you to PT with Robaxin 500mg BID and have you follow up with me.

come to see me, physicians are my VIP patients, and pain physicians specially. Because one day I might need you to see me, fast-track! PA, com'on, get out of here, will you let you PA see your mom, your wife...maybe mother-in-law!

 

[drpainfree]

Why not hire another You if the wait is truly months?

money, money, money,