Here we go again . . . which job opportunity looks most intriguing?

[Medman2737]

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Greetings and salutations pain doc brethren,

I am again in a position where I must look for a new opportunity. My current role, a small neurosurgical office where the surgeon also does all his own pain procedures, but insists on charging me 25% of the overhead with no opportunity for true partnership, is becoming non-sustainable as he fronted my first six months of salary and is now demanding it back by only paying me $1000/week. I cannot stay in this situation that does not look like it will improve any time soon.

Thus, I have been presented with three VERY different offers, each with their own pro's and con's. Help me see which is best for long-term success:

Option 1: Auto accident/PI clinic owned by a chiropractic group with PE backing. PLEASE KEEP READING!! They have 13 different clinics and I would only be involved in the procedures, no sleazy lawyers!! Come in, do the list of procedures, go home, get paid $3K per day as a 1099. Straight up needle jockey, but minimal high-end procedures (BVNA, SI fusion, SCS, etc.) I must admit, the opportunity to just come in and drop needles sounds nice.

Option 2: Large Orthopedic Group with PE backing. Multiple office sites, already employ 8 pain specialists. Will likely be responsible for entire range of procedures including peripheral blocks/RFA (if CMS allows), stim, kypho, everything (including med management, but minimal). Compensation is productivity based 60/40% up to 1 million in collections then flips to 40/60%. This practice is much closer to my residence, and it seems that every doc has at least 1 mid-level for follow-up's. Opportunity for partnership buy-in after 3 years.

Option 3: Large private neurosurgery group. Well-established group (>20 years) that has never had an in-house pain management doctor. The new ("younger") medical director understands the potential of keeping pain management in-house. Referrals would be abundant, mid-level support is abundant, but office is 75-90 minutes away from my home. Compensation is also productivity based, but it seems the potential for hitting bonus at 800K seems pretty easy. Opportunity for partnership buy-in after 2 years.

What does everyone think?

Provide some feedback if you feel one job is clearly superior to another. Thanks folks!!

 

[drusso]

Greetings and salutations pain doc brethren,

I am again in a position where I must look for a new opportunity. My current role, a small neurosurgical office where the surgeon also does all his own pain procedures, but insists on charging me 25% of the overhead with no opportunity for true partnership, is becoming non-sustainable as he fronted my first six months of salary and is now demanding it back by only paying me $1000/week. I cannot stay in this situation that does not look like it will improve any time soon.

Thus, I have been presented with three VERY different offers, each with their own pro's and con's. Help me see which is best for long-term success:

Option 1: Auto accident/PI clinic owned by a chiropractic group with PE backing. PLEASE KEEP READING!! They have 13 different clinics and I would only be involved in the procedures, no sleazy lawyers!! Come in, do the list of procedures, go home, get paid $3K per day as a 1099. Straight up needle jockey, but minimal high-end procedures (BVNA, SI fusion, SCS, etc.) I must admit, the opportunity to just come in and drop needles sounds nice.

Option 2: Large Orthopedic Group with PE backing. Multiple office sites, already employ 8 pain specialists. Will likely be responsible for entire range of procedures including peripheral blocks/RFA (if CMS allows), stim, kypho, everything (including med management, but minimal). Compensation is productivity based 60/40% up to 1 million in collections then flips to 40/60%. This practice is much closer to my residence, and it seems that every doc has at least 1 mid-level for follow-up's. Opportunity for partnership buy-in after 3 years.

Option 3: Large private neurosurgery group. Well-established group (>20 years) that has never had an in-house pain management doctor. The new ("younger") medical director understands the potential of keeping pain management in-house. Referrals would be abundant, mid-level support is abundant, but office is 75-90 minutes away from my home. Compensation is also productivity based, but it seems the potential for hitting bonus at 800K seems pretty easy. Opportunity for partnership buy-in after 2 years.

What does everyone think?

Provide some feedback if you feel one job is clearly superior to another. Thanks folks!!

Option 4: Open your own shop. It's literally never been easier with AI. Get a consultant to line up your credentialing, payer contracts, policies & procedures manual, a cloud-based subscription EHR/PM, and an SBA-backed line of credit, and you're off to the races!

AMA Independent Practice Accelerator Workshop

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[Medman2737]

That sounds fun, but I am in the process of burning out a 20 mile non-compete and will add another 25 mile non-compete to my area once I leave my current position. Plus, contracts here where I live top out at 72% of Medicare.

 

[Medman2737]

Actually, option 4 is to pull my kids out of the only school they've ever known, sell my home (just finished a $150K patio renovation), and move clear across the state to an area where my buddy is simply destroying it. He has built up his practice to three offices, and is now drowning, and needs help.

My wife will always support the decision though my kids are getting to an age where resentment might linger in their hearts and minds.

 

[SSdoc33]

Greetings and salutations pain doc brethren,

I am again in a position where I must look for a new opportunity. My current role, a small neurosurgical office where the surgeon also does all his own pain procedures, but insists on charging me 25% of the overhead with no opportunity for true partnership, is becoming non-sustainable as he fronted my first six months of salary and is now demanding it back by only paying me $1000/week. I cannot stay in this situation that does not look like it will improve any time soon.

Thus, I have been presented with three VERY different offers, each with their own pro's and con's. Help me see which is best for long-term success:

Option 1: Auto accident/PI clinic owned by a chiropractic group with PE backing. PLEASE KEEP READING!! They have 13 different clinics and I would only be involved in the procedures, no sleazy lawyers!! Come in, do the list of procedures, go home, get paid $3K per day as a 1099. Straight up needle jockey, but minimal high-end procedures (BVNA, SI fusion, SCS, etc.) I must admit, the opportunity to just come in and drop needles sounds nice.

Option 2: Large Orthopedic Group with PE backing. Multiple office sites, already employ 8 pain specialists. Will likely be responsible for entire range of procedures including peripheral blocks/RFA (if CMS allows), stim, kypho, everything (including med management, but minimal). Compensation is productivity based 60/40% up to 1 million in collections then flips to 40/60%. This practice is much closer to my residence, and it seems that every doc has at least 1 mid-level for follow-up's. Opportunity for partnership buy-in after 3 years.

Option 3: Large private neurosurgery group. Well-established group (>20 years) that has never had an in-house pain management doctor. The new ("younger") medical director understands the potential of keeping pain management in-house. Referrals would be abundant, mid-level support is abundant, but office is 75-90 minutes away from my home. Compensation is also productivity based, but it seems the potential for hitting bonus at 800K seems pretty easy. Opportunity for partnership buy-in after 2 years.

What does everyone think?

Provide some feedback if you feel one job is clearly superior to another. Thanks folks!!

option 2

option 3 only if you are willing to move your family

 

[SSdoc33]

Actually, option 4 is to pull my kids out of the only school they've ever known, sell my home (just finished a $150K patio renovation), and move clear across the state to an area where my buddy is simply destroying it. He has built up his practice to three offices, and is now drowning, and needs help.

My wife will always support the decision though my kids are getting to an age where resentment might linger in their hearts and minds.

need a picture of this patio to make an informed recommendation

 

[DOctorJay]

option 3 and move closer
option 2 - how much can you really buy into as a partner if it's PE backed?

 

[BobBarker]

3 is the best job, but 2 is fine also.
They aren’t paying enough at 1. I get MVA patients from a consortium and they pay for my services off of an agreed fee schedule to me directly and keep the extra once the case pays off. If I saw 3 of their patients a day I would make more than you are getting per day at 1. They should pay you $10,000 a day if the full day is all MVA procedures.

 

[BobBarker]

Can’t just go join the big hospital as an employee? Even the university here pays well.

 

[Medman2737]

I asked to join the hospital and got turned down since I am not ACGME boarded. I said, true, but I was trained by Dr. Steve Lobel in Canton, Georgia !!!
That somehow made it worse, and the nice men with the tasers escorted me from the premises.

 

[Agast]

Actually, option 4 is to pull my kids out of the only school they've ever known, sell my home (just finished a $150K patio renovation), and move clear across the state to an area where my buddy is simply destroying it. He has built up his practice to three offices, and is now drowning, and needs help.

My wife will always support the decision though my kids are getting to an age where resentment might linger in their hearts and minds.

We moved for my dad’s job when I was a high school freshman. I cried every night for a few months. I don’t resent him. It would have been ridiculous for us to stay when his career had so much potential.

An amazing set up with a decent honest partner would be a dream!

 

[drusso]

Actually, option 4 is to pull my kids out of the only school they've ever known, sell my home (just finished a $150K patio renovation), and move clear across the state to an area where my buddy is simply destroying it. He has built up his practice to three offices, and is now drowning, and needs help.

My wife will always support the decision though my kids are getting to an age where resentment might linger in their hearts and minds.

Do it and don't look back. Kids make new friends fast.

 

[Ready_User_1]

Don't go orthopedic, you're going to deal with what you are dealing but in a bigger practice.

Option 4 seems like the clear winner followed by option 3.

 

[PM&ARGHH]

In terms of jobs option 3 and 4 both sound great depending on what you want. Pain only group that is thriving is great, but being the only pain doc at a NSGY group could be cush in different ways, though you are gambling they treat you fair. No one but you and your spouse can answer if moving is worth it. People have worked worse jobs than option 2 to support and not uproot families, but it will likely require some degree of checking out to cope with the BS. Option 1 is fine if you don’t value the price of your own soul or the future of your field, but I mean, YOLO.

 

[callmeanesthesia]

Option 1 sucks financially as well as ethically. 1099 means payroll taxes, health insurance, malpractice, medical licensing all come out of your pocket. So about 7.5% for employer paid payroll taxes, maybe 20-30k for malpractice, 40k or more for family health insurance.

It might be fair at twice that daily rate. How do you feel about showing up to work today doing a bunch of epidurals on perfectly normal spines? And god forbid you get a complication and have to explain to a jury why you did the procedure - “Well, the chiropractor ordered it.”

 

[K-hole]

Option 3 but demand that your last procedure/clinic patient is at 3pm. That way you’re home by 5. You will burn out within a few years with option 3 if you’re getting home to your family everyday at 630, no matter how good the money is. This is what I did for 7+ years but eventually the money wasn’t worth the drive and had to move closer to home.

 

[bedrock]

Option 4. Your kids will survive. They will have a happy, content dad instead of someone burnt out. Yes the kids will initially complain and cry, but they'll get over it. Only do this though if you're so confident in your buddys practice that you know you won't move again before your kids go to college.

 

[SSdoc33]

Option 4. Your kids will survive. They will have a happy, content dad instead of someone burnt out. Yes the kids will initially complain and cry, but they'll get over it. Only do this though if you're so confident in your buddys practice that you know you won't move again before your kids go to college.

??? you have moved 7 times and have no kids

not sure if you are the best source for this advice.

 

[SSdoc33]

if you move to the middle of nowhere, you will probably have a better job, but an unhappy wife and pissed off kids (at least for a while). balancing act. the wife is he biggest concern, as it usually is

 

[bedrock]

??? you have moved 7 times and have no kids

not sure if you are the best source for this advice.

LOL, I haven't moved that many times. I've had 3 jobs, but yes I might be getting a 4th.

Having wife on board is important. If the the area where his buddy is working isn't total sticks, and the wife is on board, then yes the kids have to deal with it. But I wouldn't go against the wife.

 

[Medman2737]

***UPDATE***

So, option #3 is probably looking like the way I am headed as the interview went very well and it seems I will be quite busy with 10 plus neurosurgical providers sending procedures my way.

During the interview, the COO asked what I thought would be a fair compensation formula would look like, and he kind of shook me with that question.

Again, this neurosurgery group has never had a pain doctor, so I told him I would get back to him. This is like when you were given the opportunity to grade yourself in high school. Do I set my base salary high just for a cushy safety net? Do I set my salary lower and start my bonus after collections at like $600K?

Do I do a tiered model? $500K base, 60% after 800K, 70% after 1.2 million, 80% after anything above 1.5 million?

If you all could set your own salary formula, how would you structure it?

Please no BS answers, or at least include honest replies alongside the BS answers!

 

[drusso]

Personal professional fee collections (Hands work/gross collections). Cash in the till.
- Direct costs (med mal, salary, CME, PTO, retirement, health insurance, etc)
- Pro-rata allocation of fixed costs (rent, utilities, IT, purchased business services, debt service, etc)
- Variable allocation of indirect costs based upon % collections. If you bring in 18% of the practice revenue, you pay 18% of the variable costs
--------------------------------------------------
= Net collections

This is the number you're bargaining with. Go back to the COO and say, "After I pay for myself and pay my portion of the operating expenses that allow me to pay myself, how much of what's left over do you think an honest person deserves to keep?"

After he reattaches his dropped jaw, be prepared to argue tooth and nail over what counts as direct, fixed, and variable costs.

His answer to that single question is all the information you need to know about whether you can do business with this group.

 

[Orin]

Personal professional fee collections (Hands work/gross collections). Cash in the till.
- Direct costs (med mal, salary, CME, PTO, retirement, health insurance, etc)
- Pro-rata allocation of fixed costs (rent, utilities, IT, purchased business services, debt service, etc)
- Variable allocation of indirect costs based upon % collections. If you bring in 18% of the practice revenue, you pay 18% of the variable costs
--------------------------------------------------
= Net collections

This is the number you're bargaining with. Go back to the COO and say, "After I pay for myself and pay my portion of the operating expenses that allow me to pay myself, how much of what's left over do you think an honest person deserves to keep?"

After he reattaches his dropped jaw, be prepared to argue tooth and nail over what counts as direct, fixed, and variable costs.

His answer to that single question is all the information you need to know about whether you can do business with this group.

This is difficult as their model for what support a physician needs and how they generate money is very different between NSGY and pain. Many physicians have very lucrative practices with just clinic visits, but that wouldn't make sense for a NSGY service line.

I don't know about making money, but I would also ask them about the models they use for their other physicians and then adjust from there

I would personally avoid driving that far for a job as 2.5-3 hour daily commute sounds like torture but FSD FTW?

 

[drusso]

This is difficult as their model for what support a physician needs and how they generate money is very different between NSGY and pain. Many physicians have very lucrative practices with just clinic visits, but that wouldn't make sense for a NSGY service line.

I don't know about making money, but I would also ask them about the models they use for their other physicians and then adjust from there

I would personally avoid driving that far for a job as 2.5-3 hour daily commute sounds like torture but FSD FTW?

Can you elaborate?

 

[nvrsumr]

I would go with high base.

This is an established group sending you procedures. Not going to control bringing in more patients to group or have faster turnover in asc.

 

[SSdoc33]

any outcome that doesnt end in opening your own practice or controlling your own destiny is a fail in the eyes of drusso

if you start talking about fixed vs. variable costs they will either laugh at you or very quickly withdraw their offer

 

[DrSpine]

Option 1 is complete trash. 3k a day in PI to do some advanced procedures too? LOL Better pay up for that one! The fact that its PE backed it even better.

To be honest Option 1 and 2 sounds like great options to have you create this post again in a year.

 

[Orin]

Can you elaborate?

In my limited experience with hospital-based/academic systems, departmental support tends to follow the revenue that is visible to the department. Usually that means physician professional fees, while a lot of the physician's actual value may accrue elsewhere in the enterprise through facility revenue, downstream referrals, academic output, etc. That can create some odd incentives.

I think the bigger issue here is that NSGY may not really understand what it takes to support a pain practice.

Their compensation and staffing model is probably built around surgeons whose economics come from operating, call, and surgical throughput rather than primarily E&M. Their APPs/nurses/MAs may consequently be optimized for postop visits, wound checks, imaging review, and paperwork, and not longitudinal management of patients with medication issues, psychosocial complexity, PDMP/UDS monitoring, prior authorizations, device coordination, and all the other friction that comes with pain.

They may also say they want to "keep referrals in-house," but that doesn't necessarily mean they envision a comprehensive interventional pain practice. They may really mean they want someone to medically manage the nonoperative patients and keep them within the system until surgery becomes appropriate. That may not mean someone doing SCS, SI fusion, MILD, pumps, or whatever else falls outside the core requirements of getting patients to fusion.

So now you're asking an organization built around one kind of earner to support a very different workflow. A pain physician may need 3+ support staff per physician to function efficiently. The group may look at that and think, "He isn't operating or taking call, so why does he need that much support?"

Financially, you can still construct a contract that looks perfectly palatable on paper. But if the infrastructure isn't there, there may be no realistic way to generate the revenue contemplated by that contract without simply shifting the missing labor onto the physician and burning him out.

Even if they treat you exactly like their existing physicians, that may not be what you need to succeed. Their typical APP may only need to handle wound checks and paperwork; yours may need to check PDMPs and UDSs, deal with medication issues, manage authorizations, and think very differently from a structural/surgical APP.

That's why I'd be hesitant to reduce this entirely to collections minus overhead. The math may be fair while the operating model is not. Understanding how they think about physician value and what they believe they are actually hiring you to do is probably critical to designing something that succeeds without creating the same kind of bad feelings and business friction that OP seems to be dealing with now.

 

[drusso]

In my limited experience with hospital-based/academic systems, departmental support tends to follow the revenue that is visible to the department. Usually that means physician professional fees, while a lot of the physician's actual value may accrue elsewhere in the enterprise through facility revenue, downstream referrals, academic output, etc. That can create some odd incentives.

I think the bigger issue here is that NSGY may not really understand what it takes to support a pain practice.

Their compensation and staffing model is probably built around surgeons whose economics come from operating, call, and surgical throughput rather than primarily E&M. Their APPs/nurses/MAs may consequently be optimized for postop visits, wound checks, imaging review, and paperwork, and not longitudinal management of patients with medication issues, psychosocial complexity, PDMP/UDS monitoring, prior authorizations, device coordination, and all the other friction that comes with pain.

They may also say they want to "keep referrals in-house," but that doesn't necessarily mean they envision a comprehensive interventional pain practice. They may really mean they want someone to medically manage the nonoperative patients and keep them within the system until surgery becomes appropriate. That may not mean someone doing SCS, SI fusion, MILD, pumps, or whatever else falls outside the core requirements of getting patients to fusion.

So now you're asking an organization built around one kind of earner to support a very different workflow. A pain physician may need 3+ support staff per physician to function efficiently. The group may look at that and think, "He isn't operating or taking call, so why does he need that much support?"

Financially, you can still construct a contract that looks perfectly palatable on paper. But if the infrastructure isn't there, there may be no realistic way to generate the revenue contemplated by that contract without simply shifting the missing labor onto the physician and burning him out.

Even if they treat you exactly like their existing physicians, that may not be what you need to succeed. Their typical APP may only need to handle wound checks and paperwork; yours may need to check PDMPs and UDSs, deal with medication issues, manage authorizations, and think very differently from a structural/surgical APP.

That's why I'd be hesitant to reduce this entirely to collections minus overhead. The math may be fair while the operating model is not. Understanding how they think about physician value and what they believe they are actually hiring you to do is probably critical to designing something that succeeds without creating the same kind of bad feelings and business friction that OP seems to be dealing with now.

If not from professional fees, where does the money come from to pay the providers?

 

[Ducttape]

do you have a noncompete agreement?


why not just open up your own office in the area you currently work in?

 

[Orin]

If not from professional fees, where does the money come from to pay the providers?

I think we're talking past each other a little. I'm not arguing that the physician's compensation shouldn't ultimately be supported by professional fees. I'm saying the bigger question is whether the organization understands what infrastructure is necessary for that physician to generate those professional fees sustainably.

You can give someone a very fair collections-based formula, but if you give them the wrong staffing model, clinic structure, procedural access, or expectations, the only way they hit the collections everyone modeled is by personally absorbing all of the missing work. On paper the economics look fair; in practice you built a burnout machine.

The enterprise-value point is slightly different. If I generate professional fees but also keep patients in the system, fill an ASC, create imaging/PT/surgical referrals, etc., the organization may rationally spend more on supporting my practice than would be justified by looking at my professional-fee margin in isolation. That doesn't mean those facility fees are literally writing my paycheck.

So I agree that collections minus the costs required to generate them is important. My concern is one step upstream: does a neurosurgery group that has never employed a pain physician actually know what those costs and operational requirements are?

That's why I'd spend at least as much time negotiating what the practice is supposed to look like as I would negotiating the percentage.

 

[Medman2737]

I'm glad you brought up that point Orin. I believe this is the purpose of bringing me on, as opposed to hiring a fresh grad right out of fellowship and pay them half of what I'll be asking.

Their long-term vision is to establish an interventional spine arm to their already super-well established neurosurgery arm. They currently have 6 locations and are planning to build a seventh which will be their "interventional spine and pain hub", with the other six offices acting like satellite referral offices. Their ultimate plan is to build and attach their own ASC to this 7th location.

Even though he's been there for four years now, the COO's background is pulmonary medicine in the hospital, not pain management, so he doesn't know what the everyday workflow of pain management looks like. Neither does the neurosurgeon who is the medical director, but what he does know is that pain management is very lucrative if structured appropriately.

 

[sloh]

I'm glad you brought up that point Orin. I believe this is the purpose of bringing me on, as opposed to hiring a fresh grad right out of fellowship and pay them half of what I'll be asking.

Their long-term vision is to establish an interventional spine arm to their already super-well established neurosurgery arm. They currently have 6 locations and are planning to build a seventh which will be their "interventional spine and pain hub", with the other six offices acting like satellite referral offices. Their ultimate plan is to build and attach their own ASC to this 7th location.

Even though he's been there for four years now, the COO's background is pulmonary medicine in the hospital, not pain management, so he doesn't know what the everyday workflow of pain management looks like. Neither does the neurosurgeon who is the medical director, but what he does know is that pain management is very lucrative if structured appropriately.

You need to discuss with this group exactly what @Orin talked about in his previous two posts and make sure your visions are aligned and they're aware of their own "blind spots." These "partnerships" between interventional pain docs and ortho/neurosurgery practices rarely work out because of the issues @Orin talked about.

 

[Medman2737]

I will be discussing infrastructure with them. Their overhead is already divided 14 ways amongst the doctors (I will be the 15th and it will not start until I have been there for at least six months). They already have a procedure suite in their main office. They already perform kyphoplasties in the office that they are more than willing to hand off to me. They will be "loaning" me one of their HTE mid-levels to see follow-up visits and they have already stated that medications for procedures is not a model they are interested in cultivating.

What am I missing?

 

[bedrock]

Plenty of ortho/NS + pain partnerships work out. The only time it doesn't work out is if the pain doc wants a comprehensive pain practice instead of an interventional spine practice, because then it creates the staffing issues described above.

The main thing to establish up front is that you won't be a dumping ground to write opioids for all their failed back patients.

Edit- them being willing to hand off kyphoplasties to you to be done in office is fantastic.

 

[bubaghanush]

I will be discussing infrastructure with them. Their overhead is already divided 14 ways amongst the doctors (I will be the 15th and it will not start until I have been there for at least six months). They already have a procedure suite in their main office. They already perform kyphoplasties in the office that they are more than willing to hand off to me. They will be "loaning" me one of their HTE mid-levels to see follow-up visits and they have already stated that medications for procedures is not a model they are interested in cultivating.

What am I missing?

Why would they hand off kyphos?

 

[MitchLevi]

A NS group with ten surgeons and no pain doctor is a gold mine. You have to do zero marketing. You are underwater with volume that will never dry up. Low guaranteed salary and high production collections is what you want. No issues with partnership in this setting.

 

[bedrock]

I will be discussing infrastructure with them. Their overhead is already divided 14 ways amongst the doctors (I will be the 15th and it will not start until I have been there for at least six months). They already have a procedure suite in their main office. They already perform kyphoplasties in the office that they are more than willing to hand off to me. They will be "loaning" me one of their HTE mid-levels to see follow-up visits and they have already stated that medications for procedures is not a model they are interested in cultivating.

What am I missing?

We were typing at the same time. This can totally work out. I have made 7 figures at two different surgical practices in my career.

 

[bedrock]

Why would they hand off kyphoplasty

Because lots of surgeons just want to do real surgery. Also because surgeons almost always do kyphoplasty at an ASC/hospital where they are most comfortable, and so they make very little money from those kyphos.

A NS group with ten surgeons and no pain doctor is a gold mine. You have to do zero marketing. You are underwater with volume that will never dry up. Low guaranteed salary and high production collections is what you want. No issues with partnership in this setting.

Agree with Mitch.

 

[MitchLevi]

We were typing at the same time. This can totally work out. I have made 7 figures at two different surgical practices in my career.

These groups are not interested in a long term maintenance practice with opiates or anything they’ll have to manage at 3AM when they’re on call, and the OP will most likely NOT take call, so he will be a partner with no call duties most likely. Surgeons hate kyphos bc they’re not worth the hassle and in the ASC they’re not terribly lucrative. HOPD kypho is a financial blood bath and virtually no surgeon will ever participate in a clinic procedural suite. Not to mention the insane amount of oversight with kypho these days. Virtually every one you do will be audited.

 

[BobBarker]

14 neurosurgeons? Do they own a spine hospital with ASC also?

 

[BobBarker]

Yes, with 14 surgeons you will never have time to do anything besides procedures. They will want you to do direct injects. I would meet them halfway and do consult/injections. They will also have to learn how to get auth for 500 plus office procedures a month which will be new for them. Do you really want to do over 500 procedures a month? Some of the surgeons will want you to do things you don’t want to or will never get paid. You can do the things that will never get paid if you want as the good far outweighs the bad. I think you will probably give up resistance and end up doing anesthetic discograms and cervical snrbs to be a team player and you are capable of doing them.

 

[MitchLevi]

you’ll want help within 18 months

 

[Medman2737]

Discograms are rare, even for the old dog NSG'S. I think I've done 4 in the last 5 years.

SCS implantations was another discussion point. Although I do enjoy performing them, they will likely prefer I send my SCS implants to them.

Their biggest concern is that they don't want to completely shut down their referral stream from the other pain practices in the community. They've been referring out pain for nearly 20 years. They do get a fair number of referrals from these sources.

Their beef is that every time they refer a patient out for MBB's/RF, the pain guys hold on the well-insured folks and they eventually return with BVNA's done, their SI joints fused, and an SCS implanted a year later . . . and the patient is no longer agreeable to more surgery.

 

[bedrock]

Discograms are rare, even for the old dog NSG'S. I think I've done 4 in the last 5 years.

SCS implantations was another discussion point. Although I do enjoy performing them, they will likely prefer I send my SCS implants to them.

Their biggest concern is that they don't want to completely shut down their referral stream from the other pain practices in the community. They've been referring out pain for nearly 20 years. They do get a fair number of referrals from these sources.

Their beef is that every time they refer a patient out for MBB's/RF, the pain guys hold on the well-insured folks and they eventually return with BVNA's done, their SI joints fused, and an SCS implanted a year later . . . and the patient is no longer agreeable to more surgery.

Good to hear about discograms. Total reasonable to send them SCS implants. The ASC does much better when surgeons do them vs you.

Totally reasonable for the local pain guys to try BVNA if patient failed RFA.

Not reasonable if they're doing aggressive things like SIJ fusions or SCS for axial only spine pain.

 

[MitchLevi]

That’s stepping on toes man. If a local NS sends me a pt, if I were to trial them I’d do it under the assumption they go back for the perm. I can’t imagine fusing someone’s SIJ and referring them back. Haha.

 

[hyperalgesia]

you’ll want help within 18 months

Within 18 days lol

 

[hyperalgesia]

Discograms are rare, even for the old dog NSG'S. I think I've done 4 in the last 5 years.

SCS implantations was another discussion point. Although I do enjoy performing them, they will likely prefer I send my SCS implants to them.

Their biggest concern is that they don't want to completely shut down their referral stream from the other pain practices in the community. They've been referring out pain for nearly 20 years. They do get a fair number of referrals from these sources.

Their beef is that every time they refer a patient out for MBB's/RF, the pain guys hold on the well-insured folks and they eventually return with BVNA's done, their SI joints fused, and an SCS implanted a year later . . . and the patient is no longer agreeable to more surgery.

It sounds like a great gig to me.

I'm having to increase my commute recently. It's really not bad with podcasts.

 

[DrSpine]

All I know is, no matter what, any group that is PE backed - you'll be writing the same thread in 1-2 years, only faced with a bigger non compete and issue with your kids deeper in school and family entrenched.

 

[bedrock]

All I know is, no matter what, any group that is PE backed - you'll be writing the same thread in 1-2 years, only faced with a bigger non compete and issue with your kids deeper in school and family entrenched.

Agree completely. But that was option 2. He seems to be focusing now on group 3, which is not PE backed.