I really HOPE you’re analysis of the future of office practice is incorrect. An association/employment with a hospital system is quite nauseating
I really HOPE you’re analysis of the future of office practice is incorrect. An association/employment with a hospital system is quite nauseating
Well........................... I hope so as well, but I don't think so. I've been at it for 27 years and see that model as being in its final stages.
Over the last 25 years, office practices flourished, as they allowed one to be much more efficient. Hospital and surgery centers are notoriously inefficient (and costly) for pain management.
The world has changed. Now we have a situation in which quality contracts are dominating reimbursement strategies for health systems and large groups. Pain clinics are sites in which patients enter (and rarely leave) and suddenly their cost of healthcare expenditures rises dramatically, driven by the cost of meds, imaging, and countless and repeated procedures.
These high costs are targeted by those who control the ACO contracts, seeking more evidence based (and lower cost) treatments. This emphasis is on reducing the procedure mills and putting patients through cheaper, more evidence based treatments. A few rounds of PT and some tramadol or NSAIDs is much cheaper than someone getting rfs a couple times of year, coupled with multiple office visits, tons of imaging, and a slew of UDS studies. For example, I saw a guy back after seeing him two months ago. He had undergone over $250K of procedures at another clinic in the previous year. I sent him for core exercises with two sessions of PT and four tramadol per day. He is a lot better now, but had not improved one bit after a stim implant, removal of stim implant, hospitalization for infected stim with time in the unit, and two failed lumbar rfs. Big brother is watching these events.
The competing issues are :
1. cheap, evidence based, effective treatments that contribute to larger profits for an ACO and a practice style that limits and rationally orders imaging. The era of "everybody gets an MRI" is long gone. However, may pain clinic require imaging before they see patients (even those who have only axial pain and no "red flags"). This, of course, is not only bad practice, but very costly.
2. pain practices attempting to maximize profits (which translates into as many procedures as possible). Pain clinics make money on procedures, not ordering PT, arranging pool therapy, and instructing patients on lifting mechanics and strategies to increase activity- no bucks there. However, procedure oriented clinics requires a lot of staff as well as equipment- gotta feed the bulldog.
An office based, procedure oriented practice does nothing financially for anyone, except the pain doc. A hospital based system is able to generate sometimes 7X the revenue for a procedure, if done in the hospital system. The hospital systems and healthcare systems (as we have seen) have stronger lobbies and have been able to maintain reimbursement in those systems, as we have seen with pain reimbursement as opposed to office based practices. The hospital is able to "employ" physicians at rates they are somewhat accustomed to, while allowing them to "whack" the costly component of pain (imaging and meds), allowing them to prosper not only from procedures, but reduced cost through less imaging and meds.
Due to tax considerations of being non-profits, the health and hospital systems are better able to endure overhead as well as recruit new physicians, while private clinics do not have these advantages. The office based doc has nothing to offer in terms of profitability for the hospitals or the aco (or risk contracts). Thus they have no "friends" in these giant financial octopi which view them simply as a cost center that offers little advantage to them.
There are a couple of sucker new grads who have my old practice (from 1.5 years ago which I am glad to be out of) that are facing these cruel realities, coupled with an inability to crank out 30 procedures per doc per day, a lack of experience in stratifying payers, lack of experience using NPs, and a combined overhead of $1.6 million. Most new grads do not have the ability to compete effectively in the office based system, as they are not fast enough and do not have the business training to minimize overhead expenses and remain efficient.
I'm glad I'm in my last five years of practice, rather than the first five, as I would find it very difficult to navigate this environment, despite having been very adept in the era of the office based practice.
