ECT Reimbursement

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beezley

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Finishing residency in June. Have an all OP gig, employed, salary, benefits, etc. There is no one doing new ECT cases in town, only someone who does maintenance. A little freaked about not having this option for patients without sending them 2-4 hours away.

I loathe having to be at the hospital at 630am 3 days/week to do ECTs prior to doing my full clinic but it is a service that could be useful to the community. Obviously the treatments don't take that long but you have to the pre-procedure notes and stuff. How much would doing this add in terms of reimbursement if you averaged 2-3 ECTs 3x weekly and then were in your full clinic by 830-9am? Think I'd have to end clinic early those days and maybe be done by 4 or so. Plus there would have to be some mechanism to evaluate patients for ECT which would take time also.

THoughts?

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Is that what insurance reimburses or medicare? Does anyone have more specifics on the reimbursements?? thanks
 
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You push a button three times a week...

With paperwork and evals and such I'd assume there's a hell of a lot more legwork to be done than pushing the button. Somebody correct me if I'm wrong, but I'd assume for each 'button-pressing session' there's about and hour of miscellaneous work to complete.
 
$100-$200. Medicare on the lower end and insurance on the upper end. If you have mostly insurance patients and you're seeing 3 per hour that's $600/hour. Not exactly chump change. Key is to find the facility, nurses, and anesthesiologist willing to play along.
 
With paperwork and evals and such I'd assume there's a hell of a lot more legwork to be done than pushing the button. Somebody correct me if I'm wrong, but I'd assume for each 'button-pressing session' there's about and hour of miscellaneous work to complete.

It's maybe an hour or so per series to evaluate, consent, and schedule a patient. But after that, not so much.

$100-$200. Medicare on the lower end and insurance on the upper end. If you have mostly insurance patients and you're seeing 3 per hour that's $600/hour. Not exactly chump change. Key is to find the facility, nurses, and anesthesiologist willing to play along.

So what are you going to do with the other 30 or so hours in your work week? Nobody I know does ECT all day, every day.
 
Well for that hour, but there is probably an hour of paperwork crap to go along with those 3 treatments. Not sure how evals for ECT would work either but that is probably separate as they would be admitted to the hospital for the eval.

Although I'm nervous about going somewhere where it isn't offered I'm not sure I want to get to the hospital that early 3x weekly. Call me crazy....
 
Seems it would fit better with another inpatient gig. It would be hard to fit into an OP gig, which is what I am going to be doing. The evals specifically I am thinking, but I guess it could be done.
 
Seems it would fit better with another inpatient gig. It would be hard to fit into an OP gig, which is what I am going to be doing. The evals specifically I am thinking, but I guess it could be done.

It could be done, but it sounds like you'd pretty much have to build the program up from scratch--which is frightening for most of us.
 
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I agree frightening. I will get there and settle down and see the lay of the land, then we'll see.
 
The doctor at my program who does ECT told us he makes only $68 per session and is very concerned about it's future desirability among the next generation of psychiatrists. He can't find any recent graduates from my program to inherit his ECT practice. I was like $68 only? You're kidding right?
 
It was cool to see tx resistant depression go into remission. The job felt like such a grind though. Fortunately the anesthesiologist was funny and interactive with us.
 
People are giving dollar amounts here but many or most of us are on some sort of RVU system. The RVU value is 2.5 RVU's per ECT.

Another thing to take into account is that the 2.5 RVU is for the 10-15 mins or whatever in the PACU with the patient. People were talking above about all the extra incidentals that the ECT reimbursement wouldn't cover, hidden costs, etc. The pre-ECT workup is billed as an OP office visit or IP followup. There's no separate pre-ECT billing code, nor are you expected to 'absorb' the cost of seeing the patient for consultation or evaluation whether IP or OP. You still get to bill the consultation. The time hangups or "hidden costs" in my eyes are pretty minimal--documentation, waiting for anesthesia, etc, all of which are pretty minimal. ECT went very slowly in my residency because we had different anesthesia folks each time, procedure wasn't streamlined, but it moves faster in private practice world by far.

No one (or almost no one) makes their living doing 100% ECT as was pointed out. But there are tremendous variations in scale. The OP was envisioning doing 6-9 treatments per week on her own select patients, out of frustration with lack of ECT available in her community. Many people do more. In my community it's very specialized--very few psychaitrists do it, and the 2-3 that do it, do it a lot.

One psychiatrist here can do 5-6 per hour right now, 6 days per week That's with a good "program" established: Anesthesia folks who are really on board, RN's etc who do it a lot and can do it quickly, move from one to the next as quickly as possible. Documentation requirements are fairly minimal--print a pad of checksheets up with a place for the patient sticker, just note seizure duration, meds used, complications, etc. This is a procedure note, not a SOAP note, can skip the typical verbosity of psych. really minimal time I think.

Obviously with a big enough catchment area and enough support / willingness from anesthesia / hospital admin, you could scale even higher. For comparison, at 5 ECT's per day, 6 days per week, 50 weeks per year, that's exceeding my base outpatient salary just with ECT alone.

Can anyone in the ECT world comment on the feasibility of getting it done at an outpatient surgicenter? At my multispecialty group, they don't want to do it in the PACU because it's not very profitable for them vs. other procedures. But they won't let it be done in the surgicenter because there's allegedly a Medicare rule that any procedure done in a surgicenter has to involved cutting or the potential to cut. (seriously). This makes no sense to me--anyone ever heard of that?
 
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People are giving dollar amounts here but many or most of us are on some sort of RVU system. The RVU value is 2.5 RVU's per ECT.

It's just easier to talk about cold hard cash. :)

2.5 RVU's is relative to your geographic location. The 2012 conversion factor is 34.0376.

Total RVU x conversion factor = $85 at your geographic location.
 
Well I'm not ruling it out but yes I would be building from ground up so I think I ought to figure out first how to be a new attending in a new place (though my hometown) that is a different state than my residency training before I get all gung ho about building an ECT program.

I do think it would be interesting and add some variety to my practice. Otherwise I will be sending folks who need it 2-4 hours away. Seems like a pretty big obstacle when someone is in a treatment resistant depression.
 
90870 reimburses about (medicare) $110 in the facility setting and $180 in the office setting. 99% of these cases should be done in the facility. At $110 doing 4-6 an hour, if you line up cases back to back one day a week, it can be lucrative. As a comparison, a cervical epidural steroid injection (medicare) pays about $90 dollars in a facility and the max per hour is about 4 cases, most often 3.
 
How does the anesthesiologist get paid?

which really goes to the root of the problem to make ECT not even close to cost effective overall....each session in a series of ect requires our billing, their billing, facility fees and other fees....and that's if you can get all those people to play nice with you(which is not a given....relative to other anesthesia requiring procedures it obviously is chump change).....

once you add the total cost up for an ect series, you are talking serious $$
 
So the consensus is that the psych will take home 150 on average per patient for ECT?
 
I asked a very specific question lol what are you unclear about

Hopefully others will respond because I think this remains an important, underutilized modality. My impression is that it doesn't pay much more than a med check which is unfortunate but hopefully someone with first hand experience will chime in.
 
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Hopefully others will respond because I think this remains an important, underutilized modality. My impression is that it doesn't pay much more than a med check which is unfortunate but hopefully someone with first hand experience will chime in.

I agree but the unfortunate reality is if it’s only paying slightly more than a med check it’s simply not financially viable to do
 
So the consensus is that the psych will take home 150 on average per patient for ECT?

Reimbursement varies like everything else. I would need to take a substantial pay cut to do ECT. It is generally done at inpatient hospitals only in my area. Psychiatrists that work the inpatient unit and thus already going to the hospital may find it slightly more lucrative than more inpatients. Essentially current inpatients and those doing it outpatient will start being prepped early like 6am or earlier. By the time psych and anesthesia arrives, you may have 12+ rolling beds lined up. It’s treated like a conveyor belt. As soon as it’s over, rounding begins.
 
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I think ECT has the potential to be extremely lucrative, but the challenge is that it only becomes so with volume. Paying nursing staff, an anesthesiologist, whatever it costs to have the space, the device itself, etc. is going to be expensive and completely non-viable if you're treating only a handful of patients each day. However, if you can get a bustling service going - maybe treating 15-20 patients if not more on each treatment day - I imagine that this can be fairly viable, even with all of the overhead. The challenge is actually surviving the costs of developing the volume to make it viable. Telling a patient that you won't be able to start treatments for 2-3 months because you need to have a certain number of patients just isn't going to work, thus you will be losing money until you have the volume to pay those costs.

Based strictly on wRVUs, treating one patient is roughly equivalent to a level 4 new patient assessment ("typical" time of 45 minutes, per CMS) or a level 5 established patient visit ("typical" time of 40 minutes, per CMS). If you have staff that know what they're doing, you're efficient, patients show up on time, and you're only running one treatment room, I think it's possible to treat anywhere from 3-5 patients per hour. If you really get things running and can run two rooms at once (i.e., treating one patient in one room while waiting for the patient you just treated to be cleared to move to recovery), you could double that, but that would be an extremely busy day and arguably unsafe. Obviously you are going to have to pay for all of the above, so your actual take home is going to be less, but you could safely (from a patient care perspective) potentially gross anywhere from 7.5-12.5 wRVUs per hour if you have the volume. At one point, our ECT service was treating 20-30 patients per day before we scaled back. This would typically involve doing treatments from 8am to 3-4pm. However, we also have a PA as well as UR RNs that work solely with our service and allows the physicians to focus on treatment rather than talking with insurance companies, fielding patient calls, etc. etc. Without that support, the time involved would be substantially more.

I say this as someone who does "interventional psychiatry" - primarily ECT - full-time. However, I'm at an academic center so I'm insulated from many of the pressures that would be present if you were trying to do things on your own. From the perspective of the medical center, these treatments are by far the most financially lucrative that we offer, thus there is no doubt that there is money available in interventional psychiatry. The challenge is surviving the growing pains to make such a practice financially lucrative.
 
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Keep following my 'Practice in Progress' thread.

I have started an ECT service in the past, as a health system employee, under a wRVU model.

I am likely going to be starting one again as private practice, doing own billing model.

It can take a year to simply open an ECT service. And another year at minimum to get referral patterns to change be aware of the service and get to a steady volume.

Things have changed with CMS, anesthesiology, and other components, that the real world rate is q30 minutes, or 2 procedures an hour. I trained at a place that did 6-7/hr, but those days are gone.
 
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Hi there,
I'm a science editor at the New York Times. I'm working on a story about ECT, and would love to talk to any doctors who have set up an ECT service in the past ~5 years. I'm interested in the general trend of ECT use going down over the past few decades, and whether/how managed care and reimbursement issues have contributed to that. If you're interested in talking with me about your clinical experience, please feel free to write me an email: [email protected]. Thanks!
 
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The ideal setup I've seen is ECT treatment area adjacent to the inpatient psychiatry unit. The psychiatrist rounds on inpatients all day and as ECT patients are ready they call him over to the ECT suite, he pauses with whatever patient he is with and gets to the ECT suite in about 1 minute to briefly check with the patient, CRNA sedates them, and they get treated. After seizure stops psychiatrist returns to rounding on unit and CRNA recovers patient and they basically have a mini PACU right there as well.

If psychiatry has to walk to another wing or another floor to do ECT in a PACU setting it's completely inefficient.
 
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You may get more bites by reaching out to ISEN :: International Society for ECT and Neurostimulation which is the main society in US and probably internationally. There is an email list serve that one of the admin type folks might be able to forward your request into.

The Journal of ECT The Journal of ECT will often have publications sort of documenting trends within in countries around the world. You could possibly look to find some of these for the US to answer your question of trend. Which I believe is diminishing in numbers of treating Psychiatrists and in procedures performed nationally.

I likely fit your target demographic of who you want to interview, but I wish to maintain the illusion of my anonymity. At best you'll get my response here, which because its the internet, maybe I'm a bot? LOL.

I set up an ECT service (in PACU) just before your preferred 5 years timeline within a large health system. It had some ECT at one distant location else where but the not the site that I was at. These are the quick hurdles I ran into:

1) the hospital med staff didn't have on the privileges sheet a description for ECT. They didn't have to have one, but for bureaucracy purposes they decided they wanted one. So I had to find samples form other hospitals, write up a draft. My medical director got involved and changed the wording poorly, and that took more TIME and this committee to approve took more TIME. Then for me to apply for the privilege took more TIME. (TIME = 1-2 months). Then the hospital chief medical officer(s) wanted an outside reviewer to do a chart review of my first few procedures before fully granting the hospital privilege's to me which took TIME and money to pay that outside reviewer. It also took TIME for the hospital to approve and alot the money in their budgeting for the capital for device acquisition, then its delivery, then the biomed person in hospital to look it over, inventory, and stamp approved on it.

2) hospital had nursing union and this was a position that was half in PACU, half in outpatient for the ECT nurse that I wanted. Possibly the role could have been split with receptionist like staff in outpatient and use existing PACU RN staff. However, this is such a unique treatment and unique roll, that from my experiences in residency, a true ECT RN is invaluable and better than a split staffing model. This took TIME to post this position, fight with the union, and get this person training to function in both areas - but yet the PACU nurses retained that they had to hold the paddles - and not the ECT nurse. Ridiculous.

3) My medical director at start stated would also pick up privilege and be my emergency or holiday backup. This person didn't, said no after I approached once my privilege were formally approved (i.e. I would be the one to supervise and sign off this persons privilege). I ran this service solo. It impacted my personal life. I had a back surgery on like a Thursday/Friday, was back to work on Monday. Made sure no opioid Rx to prevent any risk of cognitive impairment. I could only shut the service down at most a week at time - including for my wedding that was on the other side of the globe. My other Psychiatrist colleagues had no interest in picking up privileges from the start, and maintained that stance.

4) I started the service for clinical patient benefit seeing the positive changes from residency and feeling frustrated of not having this option to offer patients I know who could benefit greatly from this modality. Having the service was such a relief. Yet, potential patients that other colleagues had in the outpatient panel, or even on the inpatient unit were under referred; or not even offered the treatment option. The culture at this location was quite different compared to where I trained and the ECT were more common, and recommended to patients.

5) The local Big U had stopped or closed their service down. I was it from one whole state, and a massive chunk of another state. People were doing 'medical tourism' to come to this hospital and routinely the looked around were like, "Why here?" "because I'm here?" *since I left this Big Box shop, the Big U is up and running again and another hospital has a small geriatric inpatient unit focused ECT service - both of which are practically impossible to get patients into.

6) Each state has different laws for involuntary ECT - my state did - and interacting with the local courts to utilize court ordered ECT was its own process.

7) The hospital PACU nurses were very wary of ECT, and quite suspicious of it and its role. It took TIME to get them to see the positive transformation of patients from depressed or floridly manic/psychotic back to their old selves. It soon became the service they enjoyed working with. But that initial culture block and education, and teaching took time. I got more hand written cards from my ECT patients or ECT patient family members expressing gratitude for life saving treatment than I did with the other services I offered.

8) I was part of a large health system so I wasn't able to see what they bills were for patients or how much the insurance processed but I got generic feedback from the suits that it was positive service line. Yet, it was expanding and I needed to add more treatment days/slots and consult blocks to get people in. My employer didn't want to support and expand this service because they valued me more as an inpatient psychiatrist covering the unit.

9) Insurance companies were a constant barrier for I and my ECT nurse. Only approving say 6 or 8 treatments, then wanting my paperwork to authorize more treatments. Then there was the barrier of insurance authorizations to do a continuation phase of ECT after the acute series. Most opted out of this, but those who were interested only a few got authorized by insurance.
 
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Fast forward in time to your 5 year window. I left that Big Box shop job. Briefly stinted at a for profit free standing psychiatrict hospital. But was cautious to put myself out there as going to start another ECT service. Ultimately, their staffing ratios and culture was not what I would want for my own family if I were to start a service there. Many other reasons not related to ECT I left, and focused on the opening of my own private practice.

I intended to do ECT but with another local Big Box shop Hospital. Barriers:
1) they required to even get hospital privileges I have back up. Call back up. Despite being a call exempt specialty! LOL. So I reached out to colleague friend in the area, who bless this persons heart, was also willing to step up for greater societal good, and got privileges with me to be my back up on paper.

2) This hospital didn't have a privileges card either for Psychiatry. So, had to start that process again, but after 12 months, it never got approved.

3) this hospital had CEO turn over several times, impacting the drive to get it going and get the hospital to buy an ECT machine.

4) This health system was heavily majority their medical group. They had very few physicians who were 'outsiders.' And this difference is an underpinning to dealings with large Big Box shops. Their goals are to gobble up market share and independents don't fit their business paradigm. *see next post below

5) barely had any meetings with anesthesiology or PACU folks to get the logistics of flow determined for the total patient experience. Other than 'yeah were interested'

6) I was enrolled in medicare and medicaid in order better service the full population needs of this in demand area. But with medicaid and medicare come so much more bureaucracy, paperwork, billing headaches, etc. Also in order to have priviliges with Big Box shop hospitals they typically require that you are enrolled with medicare/medicaid. I'm staring down the barrel of needing more staff to process this extra paperwork and getting paid less. But for me this was a passion at the time, a dream.

7) Trying to nudge things along as an outsider, I gave up. Year had passed. I had to pivot and change the direction of my practice in order to survive, I couldn't keep hanging on to the dream of ECT. I formally ended my privilege and killed the project. Month or so later... Covid hits. Good timing I suppose. couldn't image trying to start an ECT service the same time as Covid.
 
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Maybe the ECT dream isn't dead? Perhaps one can do it in the office like they used to decades ago? Push the sedation meds my self or with a nurse? Nah. I'm a psychiatrist, we don't really like needles and such, plus I don't want to have to deal with the post recovery hiccups that might happen. Not the best idea. Perhaps do it in the office but get an anesthesiologist? So hard to find them and find one that would think its worth their time. And now you have to invest in all the drugs, crash cart, and store appropriately per DEA regulations. Nope, not the best idea either and just not worth the headache. Then there is the standard of care, I don't know or think there is any Psychiatrist in the country doing this anymore since maybe the 1970s? So even you do things to the utmost standards and have the most militaristic care and safety protocols, when/if there were ever a bad outcome - the simple reality of being outside the standard of care in office, will be a giant bullseye that people will hone in on.


Okay, perhaps at an ambulatory surgery center (ASC)?
1) I reached out a few, got email addresses, left messages, heck even walked into one personally to try and talk with docs/admin/owners. At best I might have been told no interest, but I think all just gave me silence.
2) okay, maybe start my own ASC? Well, most states are Certificate of Need, a scat process to gift power to hospitals, so you can't just open an ASC in many states. You have to get this need certificate first and that is filled with money and/or politics...
3) Let's say you surpass the CON issue or fortunate to be in a state where it doesn't exist. ASC are built to the standards of actual surgical suites, not just a PACU, which means more MONEY. Million dollars minimum - pre inflation era to undertake this. And the amount of money you would get as a psychiatrist doing ECT, just wouldn't compute to justify the expense. So, maybe you do build something moderate sized with all the surgery suites, and lease out to aspiring private practice surgeons? Now you aren't really a Psychiatrist but more of a business owner running an ASC, and how do you get the MONEY to open one.
4) The other issue is CMS has a list of the things they pay for in ASC and those they won't. If your CPT code procedure isn't on the magic list Medicare/medicaid won't pay. Some insurances regurgitate what CMS does and they might not pay either... Of those few private insurances that might pay (I found one that confirmed by phone verbally, and another by email), they don't pay the facility fee. Psychiatrist paid for service, yep. Anesthesiologist paid for service, yep. No facility fee? ... so how do you pay for the ASC and your nursing staff? CMS isn't too interested in getting this changed for ECT, despite statistics show its practically one of the safety procedures and really belongs in an ASC.
5) Perhaps cash pay only? Unlikely. Not to say couldn't happen, but doubt the price point of cash only ECT has any future.

So there you are. In order to do ECT, you'll likely need privlieges at a Big Box shop hospital, which are joining left and right to be part of larger health systems (Bigger Boxes), and there is limited room for independent private practice doctors to make it viable. Even within a large health system, if you give it your all you still at the mercy of the suits and even the interdepartmental politics/culture. And of course, the mercy of the insurance companies.
 
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Then another barrier that happened after I last did ECT few years back...

ECT devices predated the formation/creation of the FDA I believe? So the devices were sort of grandfathered in as approved under a certain category/rating. They finally decided to do the review and give a more formalized rating. There are 2 companies in the US that I'm aware of. They would have had to pump thousands if not millions of dollars into research studies for this whole process, which their profit margins are likely so low, especially when I suspect there are less ECT services/providers each year, that they only did so much for this review. Long story short, they opted to just stamp on their machines 'brain injury' or something similar to that. So now, ECT psychiatrists have to have a discussion, of "oh, by the way, this device has this stamp that says http://www.thymatron.com/downloads/System_IV_Instruction_Manual_Rev22.pdf the various things on page 8 & 9

Did we even talk about the group of people called Scientologists who protest outside the APA every year and their campaigns with various entities that post on youtube about Psychiatry as a whole and especially ECT? I wonder if Nina Jankowicz would opine on this...
 
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Then another barrier that happened after I last did ECT few years back...

ECT devices predated the formation/creation of the FDA I believe? So the devices were sort of grandfathered in as approved under a certain category/rating. They finally decided to do the review and give a more formalized rating. There are 2 companies in the US that I'm aware of. They would have had to pump thousands if not millions of dollars into research studies for this whole process, which their profit margins are likely so low, especially when I suspect there are less ECT services/providers each year, that they only did so much for this review. Long story short, they opted to just stamp on their machines 'brain injury' or something similar to that. So now, ECT psychiatrists have to have a discussion, of "oh, by the way, this device has this stamp that says http://www.thymatron.com/downloads/System_IV_Instruction_Manual_Rev22.pdf the various things on page 8 & 9

Did we even talk about the group of people called Scientologists who protest outside the APA every year and their campaigns with various entities that post on youtube about Psychiatry as a whole and especially ECT? I wonder if Nina Jankowicz would opine on this...
Thanks so much for these thoughts! very helpful. I have a couple of follow-up questions... if you feel comfortable, could you email me? [email protected]. Our chat can be off the record if you like. I also understand if you'd rather not. I'll try reaching out to ISEN as you suggest...
 
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