Financial Benefit of Running Inpatient Pain Service?

[DrMDAware]

Most pain docs are outpatient, I get that.

An opportunity was presented to run a couple of hospitals' inpatient pain services.

Obviously can't be in two places at once and majority of time will be in clinic doing outpatient stuff.

I assume the outpatient provides a higher ROI for the time spent.

1. How does running an inpatient pain service in addition to a clinic-based pain set-up financially make sense? Does one just focus on referrals that lead to larger procedures (stims, pumps, kyphos) and peel those off to your own ASC?

2. Can one make it work financially by pure volume by billing for new patient and follow up visits?

3. Do people get big stipends from the hospital and make money that way?

All thoughts appreciated.

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[RoloTomassi]

Financially it can make sense if it is in addition to your clinic, not in place of. So see consults before/after clinic, lunch, downtime. Or have mid-level do it and you round after they do the legwork.

Not worth it in imo from quality of life standpoint. Most consults are going to be PITA. Pre/post-op pain control on hard to manage patients due to illicit drug use or heavy chronic opioids, discitis in IV drug users, lot of PCA pump management, then they have to DC on PO, which means follow up with you in clinic.

Whether you get anything good like kypho out of it depends on hospital. Maybe they all go to IR or NSG. Maybe you can negotiate first dibs for your pain and suffering. They might want you to do it in house though.

It can be a way of networking with docs in the hospital, building your reputation and clinic referrals.

 

[afob100]

Agree with the above. I "run" our hospital's inpatient service in addition to my full time outpatient clinic. In reality, I have an NP do everything inpatient by herself. She can call me if there is a difficult consult for advice but I don't sign her notes/ take liability (hopefully not).

I don't have time or energy to go see those patients... especially if I'm at a satellite office that day.

My understanding is the an inpatient pain service can usually cover the cost of a mid level but not doc.

 

[afob100]

Also, when the service first started, I gave talks to all the hospital departments to advertise the service.. that got my name out there for outpatient referrals as well.

 

[willabeast]

The worst problem with an inpatient pain service is you become the substitute covering doctor when the surgeon goes out of town for the weekend. To put it another way, at least 50% of my inpatient (impatient?) consults would be initiated on a Friday. This is how i greatly reduced my inpatient consults (BTW am retired now). Worked at Kaiser so they would give me overtime (once) for the consult. I simply doubled the time charged. In a matter of months the inpatient consults dried up. Like magic 😎

 

[Doctodd]

lunch at dr's lounge....my hospital delegated/hired NP's to do it cuz none of us dr's were interested

 

[Orin]

A good APP can handle inpatient with oversight. You likely won't enjoy your quality of life if you staff it personally.

If you're already in their hospital affiliated clinic, I would take their bait or they'll find someone who will. You can offer a poor service as above or try to just add value when possible to at least avoid them pushing you out with a young doc dumb enough to take the gig.

If you're not in their system and it's a fresh negotiation, then angle for them to cover the boots on the ground at those locations or access to their referral volume for things that would make you enough money to make it worthwhile or both. The psychosocial issues that confound the inpatient cases are not something you can handle while doing another job, but hospital systems want access to your outpatient clinic to get patients discharged with followup and access to your inpatient services to help their quality metrics/retention of other staff that hate these patients.

 

[painfree23]

Be prepared to be the day of discharge triplicate pad. They do all the management until it’s time to go home…then consult pain for the script for the oxycodone 10mg q4h. Oh yea and the surgeon said “not to use the one with Tylenol Bc it’s bad for my liver”…so don’t try changing anything.

 

[kstarm]

I run an inpatient pain service. It is hard for me to think financially you will come out ahead inpatient vs outpatient. One of the biggest issues is volume control. You won't have say on how many inpatient consults you get. In clinic, if you want to see more people you can schedule more. I am not sure what the referral set up is like in your system but there is likely already IR or some other group handling inpatient procedures that you would consider doing. Also you lose efficiency with transition time to the different locations. If you were to get a stipend to run the service that may offset some of the potential losses, I get one and it helps but I also then am expected to be involved in all the quality improvement and hospital leadership stuff related to pain, which takes more time away from clinic. You do get to know many of the docs and admin, and those relationships have led to referrals and other opportunities within the hospital. It is likely I could transition at some point to a physician admin/leadership position in the future based on this if I wanted to. That's not for everyone though.

 

[DrMDAware]

Thanks. All great points.

"Impatient"...ha ha! I like that.

Your words confirm my suspicion.

1) I honestly don't see how writing opioids for patients so surgeons can dump these patients can be financially rewarding for me.

2) Agreed about an APP.

3) Would it be possible to have the non-opioid seeking/IV drug abusers follow up in clinic while the other ones can go elsewhere?

4) In my ideal world the referring physicians would see my name over and over and then give me some nice referrals down the line. I'm afraid there is no way to guarantee this, though. Like you said, get in front of them and get my name out there.

5) I'd be upset if I'm managing PCAs and ordering tylenol while IR gets the kyphos. Again, the hospital gets all the value and I get..... what exactly?

 

[kstarm]

Thanks. All great points.

"Impatient"...ha ha! I like that.

Your words confirm my suspicion.

1) I honestly don't see how writing opioids for patients so surgeons can dump these patients can be financially rewarding for me.

2) Agreed about an APP.

3) Would it be possible to have the non-opioid seeking/IV drug abusers follow up in clinic while the other ones can go elsewhere?

4) In my ideal world the referring physicians would see my name over and over and then give me some nice referrals down the line. I'm afraid there is no way to guarantee this, though. Like you said, get in front of them and get my name out there.

5) I'd be upset if I'm managing PCAs and ordering tylenol while IR gets the kyphos. Again, the hospital gets all the value and I get..... what exactly?

Many of these things are boundaries of practice that you should decide on beforehand. Often when people post about inpatient experiences on this forum there is a lot of doomsdaying. My experience has been so different. I can count on one hand the number of times I have written discharge opioid scripts. All the surgical services know that isn't our role. I do not see anyone for outpatient opioid management after discharge unless already my established clinic patient. We just write recommendations, we aren't being called after hours for ongoing pain issues, PCA issues etc. No call, no weekends or holidays. Addiction service handles most of the addiction stuff. We co-treat a lot with them. They are crazy busy and so we will occasionally pick up consults if they need help and we are slow. It takes a bit of a different skill set to do inpatient pain management and you need to know what you feel comfortable with (are you going to refill pumps in the hospital, are you going to start suboxone to help with opioid withdrawal, etc) Most systems are willing to make it what you want as there is a lot of quality metrics, joint commission pressure, and dearth of knowledge on how to manage complex pain situations. If you are interested I would think hard about how you would like the service to be ran, what your expectations are and present it to the hospital leadership and see what they say. Many times you have more bargaining power then other situations.

 

[drusso]

Just hire an NP and 1099 her to do all the hospital/inpatient stuff. You won't regret it.

 

[DrMDAware]

Just hire an NP and 1099 her to do all the hospital/inpatient stuff. You won't regret it.

Will that be financially rewarding?

Many of these things are boundaries of practice that you should decide on beforehand. Often when people post about inpatient experiences on this forum there is a lot of doomsdaying. My experience has been so different. I can count on one hand the number of times I have written discharge opioid scripts. All the surgical services know that isn't our role. I do not see anyone for outpatient opioid management after discharge unless already my established clinic patient. We just write recommendations, we aren't being called after hours for ongoing pain issues, PCA issues etc. No call, no weekends or holidays. Addiction service handles most of the addiction stuff. We co-treat a lot with them. They are crazy busy and so we will occasionally pick up consults if they need help and we are slow. It takes a bit of a different skill set to do inpatient pain management and you need to know what you feel comfortable with (are you going to refill pumps in the hospital, are you going to start suboxone to help with opioid withdrawal, etc) Most systems are willing to make it what you want as there is a lot of quality metrics, joint commission pressure, and dearth of knowledge on how to manage complex pain situations. If you are interested I would think hard about how you would like the service to be ran, what your expectations are and present it to the hospital leadership and see what they say. Many times you have more bargaining power then other situations.

Point well taken. One hospital system has hospitalists who are not comfortable ordering anything stronger than oxy 5mg. The nurses feel that if a patient needs a PCA then they need to be in the ICU. The floor nurses do not know how to connect the epidural tubing and the pharmacy routinely takes 4-5 hours to deliver the meds. And, alas, addiction services do not really exist.

Like you said this situation is vastly different than the other hospital system with which I'm familiar.

No, I would not feel professionally fulfilled refilling pumps at the expense of seeing patients in clinic and in the fluoro suite. In the hospital I've been bumped enough times or had 6pm start times to challenge the work-life balance.

I'm open to hearing more however I feel that the juice aint worth the squeeze (unless there is an NP running things and boundaries are very clear).

 

[Doctodd]

the best thing about inpatient is you can feed the office...but you have to take the good with the bad and set the boundaries(if you are able). The hospitalists usually write all discharge meds for 5 days and they must see you for anything longer. Outpatient postsurgical pain is easy.

 

[DrMDAware]

I'm wondering now if it would be easier to target select people within the hospital and nurture those relationships to get 'quality' consults to take as outpatients instead of a blanket referral system that could be abused by some.

 

[painfree23]

I'm wondering now if it would be easier to target select people within the hospital and nurture those relationships to get 'quality' consults to take as outpatients instead of a blanket referral system that could be abused by some.

Wats an example of a “quality “ in patient consult?

 

[deleted131481]

I did plenty of inpatient consults in fellowship and cover 2-3 days a month at an academic center.

I don't know how many you need to be profitable, but these are quick visits and I'll see about 4 patients/hour including note. 98% is just medication management. You've got your adjuncts + opioid du jour - plan is basically set based on chart review before I walk in. PRN stronger opioid BIDPRN so no one gets called middle of the night. We usually just put recs although some services ask for orders which is fine. Never get off hour calls. If I don't want to come that weekend day I'll give phone recs and see them next day. We see occasional IT pump refugees which can be annoying.

I do find it quite boring however.

 

[DrMDAware]

I did plenty of inpatient consults in fellowship and cover 2-3 days a month at an academic center.

I don't know how many you need to be profitable, but these are quick visits and I'll see about 4 patients/hour including note. 98% is just medication management. You've got your adjuncts + opioid du jour - plan is basically set based on chart review before I walk in. PRN stronger opioid BIDPRN so no one gets called middle of the night. We usually just put recs although some services ask for orders which is fine. Never get off hour calls. If I don't want to come that weekend day I'll give phone recs and see them next day. We see occasional IT pump refugees which can be annoying.

I do find it quite boring however.

Well said.

Do you bill follow up visits each time you see a patient after the initial consult?

Do you have to physically examen them in order to bill?

What about weaning the patients from IV to POs and the discharge recommendation requests?

Wats an example of a “quality “ in patient consult?

one that would lead to an interventional procedure done at our ASC (stim, kypho, vertiflex, rfa)

 

[Agast]

Inpatient consults are the worst. Patient has severe abdominal pain and constipation, you get consulted because they want dilaudid for their pain from constipation.

When I was a fellow, on weekends I used to arrive at the hospital at 6am to start seeing follow ups and consults. Usually about 30 patients. Done and out the door by noon. Everyone else started rounds after 8am. At 12:30 pm the services would start paging for new consults and you’d never leave after that if they caught you. And the midlevels were always shocked I wasn’t going to drive back to the hospital to see their “urgent” pain consults. Some of them were script consults for discharge, and they tried to convince me the patient wouldn’t be able to go home if I didn’t see them. Some even claimed their attending didn’t own a triplicate pad! And yet they always managed to work it out after I said No. I think 80% of our consults were so the primary team wouldn’t get paged in the middle of the night. I even had nurses page me in the middle of the night asking orders on patients we never saw, and playing dumb when I called them out on it. A verbal order showed up in inbox to sign on a patient we never saw and I never heard about it so I refused to sign it. Some admin tried to threaten me and I wrote a stern email about fraud and patient endangerment from poor nursing, so they dropped it. I’m still fuming about that one.

TL;DR I hate inpatient consults

 

[oreosandsake]

inpatient pain consults or kidney stone... ?

damn


how many mm stone we talking?

 

[painfree23]

Inpatient consults are the worst. Patient has severe abdominal pain and constipation, you get consulted because they want dilaudid for their pain from constipation.

When I was a fellow, on weekends I used to arrive at the hospital at 6am to start seeing follow ups and consults. Usually about 30 patients. Done and out the door by noon. Everyone else started rounds after 8am. At 12:30 pm the services would start paging for new consults and you’d never leave after that if they caught you. And the midlevels were always shocked I wasn’t going to drive back to the hospital to see their “urgent” pain consults. Some of them were script consults for discharge, and they tried to convince me the patient wouldn’t be able to go home if I didn’t see them. Some even claimed their attending didn’t own a triplicate pad! And yet they always managed to work it out after I said No. I think 80% of our consults were so the primary team wouldn’t get paged in the middle of the night. I even had nurses page me in the middle of the night asking orders on patients we never saw, and playing dumb when I called them out on it. A verbal order showed up in inbox to sign on a patient we never saw and I never heard about it so I refused to sign it. Some admin tried to threaten me and I wrote a stern email about fraud and patient endangerment from poor nursing, so they dropped it. I’m still fuming about that one.

TL;DR I hate inpatient consults

Do u have a copy of that email bc I feel like that would come in super handy

 

[deleted131481]

Well said.

Do you bill follow up visits each time you see a patient after the initial consult?

Do you have to physically examen them in order to bill?

What about weaning the patients from IV to POs and the discharge recommendation requests?


one that would lead to an interventional procedure done at our ASC (stim, kypho, vertiflex, rfa)

So I'm academic and billing-naive so take this with a grain of salt. All follow ups are billed. Inpatient requirements I believe you need to satisfy 3 of 3 out of HPI, PE, and MDM. For non-medicare there are 5 levels of codes. Medicare has 3 levels of codes. Our billers probably pick one of the first two lowest codes so probably doesn't pay much. As you point out physical exam is probably the limiting factor - a few points that are usually just visual or quick strength/palpation.

On my visit if I recommend PCA, often I'll put "recommend switch to oxycodone 5mg q4hprn over next 1-2 days" or something to that effect. I'll also mention 1-7 days of discharge opioids with a specific regimen if warranted. I tell the patient so they know to expect it even if they don't agree. This way the primary/surgery service can get them ready for discharge and can blame pain service if patient does not want to come off their dilaudid pca.

 

[RoloTomassi]

Do you bill follow up visits each time you see a patient after the initial consult?

Do you have to physically examen them in order to bill?

Your initial question was about the financial benefit, so yes, definitely bill. If routine outpatient med mx f/u is a level 4, then an inpatient f/u in which there is higher risk, complexity, comorbidity, IV opioids, discussion with other providers, etc is at least a level 4. Documenting PE can help ensure this, and if you're giving IV opioids you better be documenting vitals, respiratory status, mental status, etc to CYA anyway. Check with billing about possibility of using inpatient consult codes vs inpatient E&M codes.

 

[DrMDAware]

Your initial question was about the financial benefit, so yes, definitely bill. If routine outpatient med mx f/u is a level 4, then an inpatient f/u in which there is higher risk, complexity, comorbidity, IV opioids, discussion with other providers, etc is at least a level 4. Documenting PE can help ensure this, and if you're giving IV opioids you better be documenting vitals, respiratory status, mental status, etc to CYA anyway. Check with billing about possibility of using inpatient consult codes vs inpatient E&M codes.

Good call about CYA.

On my visit if I recommend PCA, often I'll put "recommend switch to oxycodone 5mg q4hprn over next 1-2 days" or something to that effect. I'll also mention 1-7 days of discharge opioids with a specific regimen if warranted. I tell the patient so they know to expect it even if they don't agree. This way the primary/surgery service can get them ready for discharge and can blame pain service if patient does not want to come off their dilaudid pca.

I like anticipating the transition to POs. I feel that this transition is especially tricky at certain places. I like setting the expectation.
____
To all, how do you deal with the 2am page that the 'prn doesn't work' or the 'needs prn med early' pages? Set expectations with the patient? Set expectations that the acute pain team is consult only and works 9-5? Put in an additional 'prn' order?

 

[jsaul]

when i first started , i did inpatient and outpatient by myself. no PAs no partners.
i would round in the hospital from 7am to 820am.
clinic from 830 to 1145.
hospital rounding from 12pm to 115pm
clinic from 130 to 5pm
sometimes hospital from 5pm to 6pm

i would do mainly pca mgt post op pain control, etc. it was mainly easy. i would probably see 5-10 inpatients throughout the day. it was a decent boost to income with no additional overhead but after 3 years of that i was done

 

[painfree23]

when i first started , i did inpatient and outpatient by myself. no PAs no partners.
i would round in the hospital from 7am to 820am.
clinic from 830 to 1145.
hospital rounding from 12pm to 115pm
clinic from 130 to 5pm
sometimes hospital from 5pm to 6pm

i would do mainly pca mgt post op pain control, etc. it was mainly easy. i would probably see 5-10 inpatients throughout the day. it was a decent boost to income with no additional overhead but after 3 years of that i was done

Roughly how much $ extra or RVUs extra was that per year?

 

[jsaul]

Roughly how much $ extra or RVUs extra was that per year?

i deal in cash; i dont know RVU... it was about 150-200k

 

[painfree23]

i deal in cash; i dont know RVU... it was about 150-200k

Damn. That’s not bad. Why’d u give it up?

 

[deleted131481]

Damn. That’s not bad. Why’d u give it up?

Just a guess but with going back and forth, etc that sounds like an extra half day of work on top of clinic. 150-200k for 50% overtime probably sounds great right out of fellowship, but early morning and late evenings even by an hour or two gets old fast.

 

[Laryngospasm]

Maybe do it for a few years to stash some cash.. then tell them double the money or your done. No way you would want to keep up that up forever.

 

[painfree23]

Maybe do it for a few years to stash some cash.. then tell them double the money or your done. No way you would want to keep up that up forever.

Nice.

 

[Laryngospasm]

The voice of fatigue lol

 

[Ferrismonk]

Be prepared to be the day of discharge triplicate pad. They do all the management until it’s time to go home…then consult pain for the script for the oxycodone 10mg q4h. Oh yea and the surgeon said “not to use the one with Tylenol Bc it’s bad for my liver”…so don’t try changing anything.

and don't forget they need the Rx right now even though you are in clinic because the patient "can't be discharged" until you do.

the best thing about inpatient is you can feed the office...but you have to take the good with the bad and set the boundaries(if you are able). The hospitalists usually write all discharge meds for 5 days and they must see you for anything longer. Outpatient postsurgical pain is easy.

Yes, go see the surgeon. You don't want to be covering up something post-op that needs to be evaluated.


Inpatient consults, fine if you are salaried or paid by the hour. Life-stealing if you aren't.

 

[DrMDAware]

when i first started , i did inpatient and outpatient by myself. no PAs no partners.
i would round in the hospital from 7am to 820am.
clinic from 830 to 1145.
hospital rounding from 12pm to 115pm
clinic from 130 to 5pm
sometimes hospital from 5pm to 6pm

i would do mainly pca mgt post op pain control, etc. it was mainly easy. i would probably see 5-10 inpatients throughout the day. it was a decent boost to income with no additional overhead but after 3 years of that i was done

I appreciate you posting the specific time slots you split between clinic and the hospital. Thanks.

Maybe do it for a few years to stash some cash.. then tell them double the money or your done. No way you would want to keep up that up forever.

Not being obtuse or argumentative but whom do you tell to double the money? Aren't you as a physician billing for services yourself? Or are you talking about some sort of stipend?

You don't want to be covering up something post-op that needs to be evaluated.

Yeah that's what I'm worried about - nothing having enough time/energy to do a good job. Both for legal reasons and more importantly quality patient care.

 

[jsaul]

Damn. That’s not bad. Why’d u give it up?

i was rounding before clinic, at lunch time and sometimes after clinic. And on weekends too sometimes. All by myself. And taking call 24/7...
It wore me out after a few years

 

[painfree23]

i was rounding before clinic, at lunch time and sometimes after clinic. And on weekends too sometimes. All by myself. And taking call 24/7...
It wore me out after a few years

Taking call for PCA management? Yes..That sounds bad.

 

[Laryngospasm]

The classic Friday evening consult because the surgeon is going out of town.. or to the lake.. or just doesn’t want to be bothered with a difficult patient. We used to get them every Friday when we covered pain inpatients in residency.

 

[DrMDAware]

Thanks everyone for the replies. Honestly, there’s some good stuff.

Update - there may be an NP to run the service AND the hospital is willing to do no nights, no weekends, consult only style. They would allow me in their hospital system even without me doing the inpatient pain. And, my clinic already has a healthy influx of patients I enjoy seeing and taking care of.

1. Can you bill for a page/call from the nurse?

2. What kind of RVUs are we talking for an inpatient consult and follow up?

3. What are some key metrics that a pain person could help with? I only saw 1-2 key metrics from Medicare in regard to pain.

 

[painfree23]

Thanks everyone for the replies. Honestly, there’s some good stuff.

Update - there may be an NP to run the service AND the hospital is willing to do no nights, no weekends, consult only style. They would allow me in their hospital system even without me doing the inpatient pain. And, my clinic already has a healthy influx of patients I enjoy seeing and taking care of.

1. Can you bill for a page/call from the nurse?

2. What kind of RVUs are we talking for an inpatient consult and follow up?

3. What are some key metrics that a pain person could help with? I only saw 1-2 key metrics from Medicare in regard to pain.

Just make sure it doesn’t turn into a script service. Because essentially ur NP will be just coming to you for the scripts that another doctor recommends you write.