Hospital Employed Position

[Shirin12]

Hi Everyone,
I have a few questions specific to hospital-employed positions. My understanding is that most of these jobs offer a base guaranteed salary with then the incentive of giving a certain dollar amount per wRVU generated. My first question is this: what is a reasonable wRVU?
Most of the threads here I think discuss negotiations for pure private practice positions (i.e trying to get a part of the facility fee, tox screen, other ancillary income, etc). My understanding is that these avenues are not on the table for negotiation for "hospital-employed with incentive" positions. What aspects of the contract can/should one try to negotiate when applying for these jobs?

Thank you.

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[neutro]

negotiate a higher salary, median is around 7000 first year, but if its a new practice, unlikely that you will be able to cross it.

you will never know the true numbers and the revenue you generate...the hospitals tend to lack transparency in this regard, thats why negotiate a higher base and atleast know what you will make guaranteed.

 

[Shirin12]

Neutro what is a reasonable base in your opinion? Is median MGMA or whatever other database they use a reasonable base?

 

[neutro]

mgma is total compensation which includes the benefits they pay you plus marpractice they pay for you and sometimes vacation pay and their share of medicare taxes for you - so for instance MGMA of 420 k may really mean salary of 350K + CME ..malpractice cost, vacation pay are considered benefits so that total package is 420-440K

i see 420-440k being thrown out as MGMA median, but to be honest with you, I have not seen that number besides rural/ undesirable areas. 350K base with benefits seems average for a new grad. 300K in big cities with rvu based...

more important than compensation is case mix, facilities, support staff and administration...there is not a big difference between 350k and 380k...youll pay half that money in taxes anyway...so take the job where youll be happier, thats if you must take a job...best is to be solo/independent IMO, but may not be feasible when youre just starting out...

 

[Ducttape]

1. there are many different permutations.

high base salary, high wRVU (7000-8000) before bonus.
low base salary, low wRVU
low base salary, high $/wRVU.
etc. get what you feel comfortable. I chose relative high base with low $/wRVU and low limit to hit the bonus. its worked out fine for me.


if you are starting a new clinic, go in knowing that it is unlikely that you will exceed 6000 wRVU the first year out.

2. from the start, be aggressive in requesting about the numbers and reimbursement. ive seen others post that "they wont ever tell you anything", "they will lie to you", "they are going to cheat you out of everything you have", etc.
I for one have never had an issue on any aspect. part is because of the administrator that I first met, and part is because I insisted on the numbers so that I could improve the clinic financials.

let them know as you are negotiating your contract that you want to be given this information.

FWIW, I know the professional and facility charges for each procedure from each of the major insurances I see, I know how many wRVUs I generated each year, the cost of the facility (up until last year - had been renting), even staff salaries. at one point, I was given a spreadsheet of office equipment supply costs...

 

[IN2B8R]

Ductape: would you please PM me the office equipment supply costs, perishables & non-perishables? Thanks in advance.


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[gdub25]

I just graduated and feel like I have a pretty good understanding of this whole process. I looked at a couple hospitals in Texas as well as Oklahoma in the base salary that I was offered was 417,000 with $64 per RVU for everything over 6400. The hospital system in Texas that I looked at at seven other pain doctors and their outlying hospitals and they averaged about 10,000 RVU Per year. The last new doctor they had joined was two years ago and in his first year he did 7000 his first year. This was a hospital system that very much understood how to run a pain clinic and gave them great support and help them run efficiently and that's how they were able to generate such high volume so quickly. This was a hospital system in the Austin area so it was definitely not a terrible place to live. The hospitals in Oklahoma were similar to this offering so I assume this is probably the standard for this area of the country.

 

[Got Em]

Are there a lot of employed hospital positions available? All I see on gaswork and indeed are private practice positions.

I'd like to be hospital employed in the future, so I can get on quality/safety committees and eventually do hospital admin. Just wondering if these job aspects are limited except for bigger systems like Kaiser.

 

[paindoc007]

Something you learn painfully early, is staffing is everything. 25 patients a day can feel like cake or miserable depending on how much staff you have and what they do for you.

 

[drusso]

Are there a lot of employed hospital positions available? All I see on gaswork and indeed are private practice positions.

I'd like to be hospital employed in the future, so I can get on quality/safety committees and eventually do hospital admin. Just wondering if these job aspects are limited except for bigger systems like Kaiser.

What's your level of comfort regarding autonomy versus being told what to do?

 

[BobBarker]

What's your level of comfort regarding autonomy versus being told what to do?

Nobody tells me what to do! I think that is the same for most of us who do not work for the VA or Kaiser.

 

[SSdoc33]

Are there a lot of employed hospital positions available? All I see on gaswork and indeed are private practice positions.

I'd like to be hospital employed in the future, so I can get on quality/safety committees and eventually do hospital admin. Just wondering if these job aspects are limited except for bigger systems like Kaiser.

or maybe this:



or this



or this

Sad Jim Carrey GIF - Find & Share on GIPHY

 

[Ducttape]

IF you want to get in to hospital admin, do you have an MBA or MPA? to go into admin, I think you really need that extra degree.

there is also this train of thought - at least on this board - that there are hospital based employees that have to bring in coffee to their administrators, blithely follow orders without hesitation, etc.

obviously I don't agree with oh wait master is calling I gotta go hope its just a coffee run...

 

[drusso]

IF you want to get in to hospital admin, do you have an MBA or MPA? to go into admin, I think you really need that extra degree.

there is also this train of thought - at least on this board - that there are hospital based employees that have to bring in coffee to their administrators, blithely follow orders without hesitation, etc.

obviously I don't agree with oh wait master is calling I gotta go hope its just a coffee run...

Medical Practice Owner or Hospital-Employed Physician? | Physicians Practice

In my experience, being employed by a large hospital includes several negative aspects.

1: You are no longer in charge of your own practice. This can include hiring and firing decisions, schedules, supplies, and even medical practice protocols. There certainly can be headaches with having to deal with these issues but I must say that being in control is much easier than being told what to do and how to do it.

2: You are now just a cog in the wheel. You may be required to refer to other physicians within your system (even if you think another specialist is better for the patient). You might be expected to see many more patients in a workday than might make you comfortable.

3: The ability to branch out into new medical interests may be difficult due to the need to stay profitable for the hospital.

What is good about being a hospital-based physician? There are positives.

1: You will not need to take out large loans to cover practice expenses until you become profitable. And you will likely have a very good benefit package due to the large number of employees in a hospital setting.

2: Management will be provided and you can concentrate on your patients rather than the daily details of managing personnel.

3: Your salary will be paid. As an owner, everyone else gets paid before you do, especially if your practice experiences lean times.

Make sure you know the positives and negatives associated with being independent or part of a large organizations. And remember, you can always change how you practice medicine.

 

[Got Em]

IF you want to get in to hospital admin, do you have an MBA or MPA? to go into admin, I think you really need that extra degree.

there is also this train of thought - at least on this board - that there are hospital based employees that have to bring in coffee to their administrators, blithely follow orders without hesitation, etc.

Yes, I already have an MBA. The goal is to become the administrator, so I guess others can bring me coffee instead. I'm really not worried about being a hospital employee. Just trying to see if these options are easy to find.

 

[Got Em]

Medical Practice Owner or Hospital-Employed Physician? | Physicians Practice

In my experience, being employed by a large hospital includes several negative aspects.

1: You are no longer in charge of your own practice. This can include hiring and firing decisions, schedules, supplies, and even medical practice protocols. There certainly can be headaches with having to deal with these issues but I must say that being in control is much easier than being told what to do and how to do it.

2: You are now just a cog in the wheel. You may be required to refer to other physicians within your system (even if you think another specialist is better for the patient). You might be expected to see many more patients in a workday than might make you comfortable.

3: The ability to branch out into new medical interests may be difficult due to the need to stay profitable for the hospital.

What is good about being a hospital-based physician? There are positives.

1: You will not need to take out large loans to cover practice expenses until you become profitable. And you will likely have a very good benefit package due to the large number of employees in a hospital setting.

2: Management will be provided and you can concentrate on your patients rather than the daily details of managing personnel.

3: Your salary will be paid. As an owner, everyone else gets paid before you do, especially if your practice experiences lean times.

Make sure you know the positives and negatives associated with being independent or part of a large organizations. And remember, you can always change how you practice medicine.

Drusso, thank you for the response. I understand the concern for being a hospital based employee. However, my main goal is to get into hospital administration from the hospital based position. I understand I'll be giving up a lot of autonomy during this process, but after a some years of clinical practice I'll only work a few shifts a month while being a hospital executive full time (chief of quality/safety, CEO, CMO, etc).

My reason of bumping this thread was to see if there are many of these hospital based positions available. I actually haven't seen any in Texas. Was just wondering what my options are in the future. Thanks!

 

[Ferrismonk]

Medical Practice Owner or Hospital-Employed Physician? | Physicians Practice

In my experience, being employed by a large hospital includes several negative aspects.

1: You are no longer in charge of your own practice. This can include hiring and firing decisions, schedules, supplies, and even medical practice protocols. There certainly can be headaches with having to deal with these issues but I must say that being in control is much easier than being told what to do and how to do it.

2: You are now just a cog in the wheel. You may be required to refer to other physicians within your system (even if you think another specialist is better for the patient). You might be expected to see many more patients in a workday than might make you comfortable.

3: The ability to branch out into new medical interests may be difficult due to the need to stay profitable for the hospital.

What is good about being a hospital-based physician? There are positives.

1: You will not need to take out large loans to cover practice expenses until you become profitable. And you will likely have a very good benefit package due to the large number of employees in a hospital setting.

2: Management will be provided and you can concentrate on your patients rather than the daily details of managing personnel.

3: Your salary will be paid. As an owner, everyone else gets paid before you do, especially if your practice experiences lean times.

Make sure you know the positives and negatives associated with being independent or part of a large organizations. And remember, you can always change how you practice medicine.

One more negative, in the hospital setting, THEY decide how much "medical management" you must handle. I know of a hospital system where the pain clinic was 100% interventional, then the hospital admins decided it would be profitable and in the hospital's interest for the pain clinic to handle meds as well. The docs were not pleased. True, the hospital cannot force you write any prescription, but they can make your life hell if you don't play nice with them.

 

[Ducttape]

at a hospital based clinic, you can always leave (be fired or quit voluntarily) and go on to better pastures without having to sacrifice all the hard non-clinical work that you put in towards developing your clinic.

in addition, the bottom dollar/bottom line does not have to be the majority focus of medical care. you can, for example, see primarily Medicaid patients with the hope that you can change the high rates of opioid use and even change a system's culture regarding these pain medications...

 

[101N]

in addition, the bottom dollar/bottom line does not have to be the majority focus of medical care. you can, for example, see primarily Medicaid patients with the hope that you can change the high rates of opioid use and even change a system's culture regarding these pain medications...[/QUOTE]

This specialty doesn't attract those kinds of people.

 

[BobBarker]

The hospital does not want a major opioid prescribing doctor as an employee. They do want someone willing to write medications when it is appropriate to do so and someone to wear the black hat when it is not.

 

[Ducttape]

This specialty doesn't attract those kinds of people.

It did... once...

 

[nvrsumr]

I don’t think there ever was a halcyon period of ethical pain management. It might have been easier to lie to oneself about prescribing massive opioid doses but I suspect it was like smoking 70 years ago. Everyone knew it was bad news. Didn’t need a surgeon general warning or a 90med limit for that matter

 

[NeuroGuyIP]

I am working for a hospital and do all of my procedures at one of their surgical centers. I am curious if someone could provide the range of the facility fees? I realize this varies based on insurance, but I am curious of what the average facility fee is especially given that the hospital owns the surgery center so much of what they collect is profit. Sure there is overhead, such as nurse salaries and equipment, but they must be making a killing on faculty fees alone.


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[101N]

It did... once...

 

[cowboydoc]

I am working for a hospital and do all of my procedures at one of their surgical centers. I am curious if someone could provide the range of the facility fees? I realize this varies based on insurance, but I am curious of what the average facility fee is especially given that the hospital owns the surgery center so much of what they collect is profit. Sure there is overhead, such as nurse salaries and equipment, but they must be making a killing on faculty fees alone.


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Some pts. Have told me their bill for RFA was about 3k. RVUs for procedure about 1/10 that. Those OR nurses sure must be expensive. I had RF at neighboring ASC and facility fee was about $800.

 

[BobBarker]

The Medicare fee schedule is on ASIPPs website.

 

[drusso]

View attachment 227548

Was it a hospital-based/OR fellowship with site of service differentials?

 

[Disciple]

View attachment 227548

101N,

Is there a citation for that excerpt?

 

[101N]

Dream Land, pg 310.

 

[nvrsumr]

View attachment 227548

Wanting to get paid is not unethical. Pretty easy in the 90s and aughts in interventional PM. I don’t have any envy of the plastic and derms who worked their a**es off for what they have.

Being a feral physiatrist prescribing high dose narcs for decades with a sprinkling of poorly performed injections learned at weekend courses then switching gears to holier than than suboxone “addictionologist” (again a weekend x waiver course) is the definition of unethical

 

[drusso]

Wanting to get paid is not unethical. Pretty easy in the 90s and aughts in interventional PM. I don’t have any envy of the plastic and derms who worked their a**es off for what they have.

Being a feral physiatrist prescribing high dose narcs for decades with a sprinkling of poorly performed injections learned at weekend courses then switching gears to holier than than suboxone “addictionologist” (again a weekend x waiver course) is the definition of unethical

Properly trained--ACGME accredited fellowship--pain specialists never bought into the high dose opioid clap-trap.

 

[onewithpain]

mgma is total compensation which includes the benefits they pay you plus marpractice they pay for you and sometimes vacation pay and their share of medicare taxes for you - so for instance MGMA of 420 k may really mean salary of 350K + CME ..malpractice cost, vacation pay are considered benefits so that total package is 420-440K

i see 420-440k being thrown out as MGMA median, but to be honest with you, I have not seen that number besides rural/ undesirable areas. 350K base with benefits seems average for a new grad. 300K in big cities with rvu based...

more important than compensation is case mix, facilities, support staff and administration...there is not a big difference between 350k and 380k...youll pay half that money in taxes anyway...so take the job where youll be happier, thats if you must take a job...best is to be solo/independent IMO, but may not be feasible when youre just starting out...

Sorry to redirect this conversation but I have seen this in other threads and so I asked the HR manager from my group about it. From what he forwarded to me from MGMA it sounds like people are getting the MGMA #s plus bennies ;


Here is MGMA’s description of Total Compensation; no mention of CME, so probably not included:

State the dollar amount reported as direct compensation on the following forms: W2, 1099, or K1. If using a W2, report Box 5. If using a K1, report the sum of boxes 1 and 4, minus deductions. Contact MGMA with questions. Include:

1. Provider wages (including contracted wages, on-call compensation coming from the reporting practice, and all other salary included in Box 5)
2. Bonus and/or incentive payments
3. Research stipends
4. Honoraria
5. Distribution of profits

Do not include:

1. The dollar value of expense reimbursements;
2. Fringe benefits paid by the medical practice (such as retirement plan contributions, life and health insurance, automobile allowances); and/or
3. Any employer contributions to a 401(k), 403(b), or Keogh Plan

*Groups fully or partially acquired by a third party: Do not include stock or equity related compensation. This should be included in "Additional Compensation".

 

[onewithpain]

The spaces that just have an asterisk are figures that MGMA did not get enough responses for from their survey to provide accurate data. My HR manager said that the data for the western region is inaccurate because of low #s of survey responses so he doesn't use those #s, even though we are on the west coast. Notice the low # of wRVUs being generated.

 

[DrCommonSense]

Sorry to redirect this conversation but I have seen this in other threads and so I asked the HR manager from my group about it. From what he forwarded to me from MGMA it sounds like people are getting the MGMA #s plus bennies ;


Here is MGMA’s description of Total Compensation; no mention of CME, so probably not included:

State the dollar amount reported as direct compensation on the following forms: W2, 1099, or K1. If using a W2, report Box 5. If using a K1, report the sum of boxes 1 and 4, minus deductions. Contact MGMA with questions. Include:

1. Provider wages (including contracted wages, on-call compensation coming from the reporting practice, and all other salary included in Box 5)
2. Bonus and/or incentive payments
3. Research stipends
4. Honoraria
5. Distribution of profits

Do not include:

1. The dollar value of expense reimbursements;
2. Fringe benefits paid by the medical practice (such as retirement plan contributions, life and health insurance, automobile allowances); and/or
3. Any employer contributions to a 401(k), 403(b), or Keogh Plan

*Groups fully or partially acquired by a third party: Do not include stock or equity related compensation. This should be included in "Additional Compensation".

401K match and benefits are not included in Total Compensation? Total Comp is basically just straight salary?

Seems pretty high when not counting those additional aspects.

 

[DrCommonSense]

Wanting to get paid is not unethical. Pretty easy in the 90s and aughts in interventional PM. I don’t have any envy of the plastic and derms who worked their a**es off for what they have.

Being a feral physiatrist prescribing high dose narcs for decades with a sprinkling of poorly performed injections learned at weekend courses then switching gears to holier than than suboxone “addictionologist” (again a weekend x waiver course) is the definition of unethical

Thats the norm for the Suboxone pimp crew.

The ones who for decades prescribed ridiculous dosages of narcotic medications for zero reasons have become the "holier than thou" crew once the Suboxone train hit.

Now they pretend there is an "opioid epidemic" that was totally created by doctors and ANY level of narcotic medications inappropriate. Interestingly, these are the SAME doctors who were the most GUILTY of inappropriate prescribing in the past.

Dont know if its a guilty conscience thing about their horrible prescribing practices in the past whereby they assuage themselves by blaming everyone else for this problem equally. They are also jealous of legit pain docs who made a good living without being ridiculous opioid prescribers in the past.

They have found the cash for Suboxone racket far more profitable than their former high dosage of narcotic racket as they were very poor physicians in the past and will likely do better financially to make that shift.

 

[Ducttape]

I thought this thread was about hospital employment, not imagined practice patterns.

Nvm. Look who posted....

 

[244913]

Thats the norm for the Suboxone pimp crew.

The ones who for decades prescribed ridiculous dosages of narcotic medications for zero reasons have become the "holier than thou" crew once the Suboxone train hit.

Now they pretend there is an "opioid epidemic" that was totally created by doctors and ANY level of narcotic medications inappropriate. Interestingly, these are the SAME doctors who were the most GUILTY of inappropriate prescribing in the past.

Dont know if its a guilty conscience thing about their horrible prescribing practices in the past whereby they assuage themselves by blaming everyone else for this problem equally. They are also jealous of legit pain docs who made a good living without being ridiculous opioid prescribers in the past.

They have found the cash for Suboxone racket far more profitable than their former high dosage of narcotic racket as they were very poor physicians in the past and will likely do better financially to make that shift.

Interventional pain created a lot of iatrogenic addicts in the 90's and 00's. Some IPM docs (and/or their midlevels) are still very free with the prescription pad as long as the billable interventions keep rolling in.

That was the business model- rx opioids, so you can keep needling these patients. Or worse, refuse to prescribe opioids responsibly (wean) but still needle the high dose opioid patients referred to you by PCP's and surgeons.

For all of us doing interventional pain medicine, I challenge you to try this experiment in your clinics: for your new patients, take opioids off the table. Offer multimodal therapy- including injections- but be explicit to new patients that they will not receive opioids from you and you would not recommend their PCP or surgeon give them opioids either.

For your legacy patients being managed by the midlevel whom you inject q 3 months- and who aren't functional- tell them you are going to wean off or not prescribe opioids anymore.

See what happens to your procedure volume.

Might be a wake up call for those of us who place so much stock in a 22 g needle and a squirt of steroid

- ex 61N

 

[101N]

Interventional pain created a lot of iatrogenic addicts in the 90's and 00's. Some IPM docs (and/or their midlevels) are still very free with the prescription pad as long as the billable interventions keep rolling in.

That was the business model- rx opioids, so you can keep needling these patients. Or worse, refuse to prescribe opioids responsibly (wean) but still needle the high dose opioid patients referred to you by PCP's and surgeons.

For all of us doing interventional pain medicine, I challenge you to try this experiment in your clinics: for your new patients, take opioids off the table. Offer multimodal therapy- including injections- but be explicit to new patients that they will not receive opioids from you and you would not recommend their PCP or surgeon give them opioids either.

For your legacy patients being managed by the midlevel whom you inject q 3 months- and who aren't functional- tell them you are going to wean off or not prescribe opioids anymore.

See what happens to your procedure volume.

Might be a wake up call for those of us who place so much stock in a 22 g needle and a squirt of steroid

- ex 61N

Still, Becker, who researches pain management at Yale, does not believe more pain specialists will solve the problem. “Yes, there are not nearly enough ‘pain specialists,'” he said. “But really pain specialists are not suited to managing chronic pain. Historically, they have been more interested in highly reimbursed procedures that aren’t really what improve outcomes in patients with chronic pains.” He pointed to epidural steroid injections for the back, which, he said, have not been demonstrated as effective for long-term relief. “We need more generalists who are fluent in the treatment of chronic pain,” he said.

 

[nvrsumr]

I have had a zero narcs practice for... ever. Usuallly too busy to even take a bathroom break. Have an executive bathroom so only 6 feet from my desk.

I have to admit I don’t really focus on chronic pain patients but more subacute pain and “sports” med. My stimulator numbers are a joke.

That being said I do have a subgroup of caid patients that I treat with multiple pain generators and overlying psych/social issues. Have many “successes” but the bar is set low. When caid patients take 5 bus connections over two hours from the halfway house to my office to make their yearly lumbar rf hard not to believe something is working despite the gigo metas. It is my pleasure to be their doc.

No narcs was a difficult lift at first and you take a huge pay hit. Not the easy road but more rewarding to be an ethical doc who puts patients over the easy profits of narcotic prescription/Utox/bup

 

[101N]

It would be interesting to see a comparison of SIS/ASSIP membership juxtaposed against CMS opioid prescribing. It's coming.

 

[244913]

I have had a zero narcs practice for... ever. Usuallly too busy to even take a bathroom break. Have an executive bathroom so only 6 feet from my desk.

I have to admit I don’t really focus on chronic pain patients but more subacute pain and “sports” med. My stimulator numbers are a joke.

That being said I do have a subgroup of caid patients that I treat with multiple pain generators and overlying psych/social issues. Have many “successes” but the bar is set low. When caid patients take 5 bus connections over two hours from the halfway house to my office to make their yearly lumbar rf hard not to believe something is working despite the gigo metas. It is my pleasure to be their doc.

No narcs was a difficult lift at first and you take a huge pay hit. Not the easy road but more rewarding to be an ethical doc who puts patients over the easy profits of narcotic prescription/Utox/bup

How do you build a practice like that- subacute/sports focused? I agree that would be realistic with a no narcs philosophy.

Do you establish a reputation over time with Orthopods and PCP's? Are you employed by an Orthopedics/Sports med group?

What sort of interventions do you do for these folks. Sounds like a nice setup.

- ex 61N

 

[drusso]

Interventional pain created a lot of iatrogenic addicts in the 90's and 00's. Some IPM docs (and/or their midlevels) are still very free with the prescription pad as long as the billable interventions keep rolling in.

That was the business model- rx opioids, so you can keep needling these patients. Or worse, refuse to prescribe opioids responsibly (wean) but still needle the high dose opioid patients referred to you by PCP's and surgeons.

For all of us doing interventional pain medicine, I challenge you to try this experiment in your clinics: for your new patients, take opioids off the table. Offer multimodal therapy- including injections- but be explicit to new patients that they will not receive opioids from you and you would not recommend their PCP or surgeon give them opioids either.

For your legacy patients being managed by the midlevel whom you inject q 3 months- and who aren't functional- tell them you are going to wean off or not prescribe opioids anymore.

See what happens to your procedure volume.

Might be a wake up call for those of us who place so much stock in a 22 g needle and a squirt of steroid

- ex 61N

The corticosteroid era is over. It is dawn of the biologics era.

 

[hyperalgesia]

The corticosteroid era is over. It is dawn of the biologics era.

I still haven't seen anything that persuasive to indicate there is a new era approaching.

 

[drusso]

I still haven't seen anything that persuasive to indicate there is a new era approaching.

The wave has crested...kenalog is yesterday's news.

Reversal of Growth of Utilization of Interventional Techniques in Managing Chronic Pain in Medicare Population Post Affordable Care Act. - PubMed - NCBI


Reversal of Growth of Utilization of Interventional Techniques in Managing Chronic Pain in Medicare Population Post Affordable Care Act.
Manchikanti L, et al. Pain Physician. 2017.
Show full citation
Abstract
BACKGROUND: Over the past 2 decades, the increase in the utilization of interventional techniques has been a cause for concern. Despite multiple regulations to reduce utilization of interventional techniques, growth patterns continued through 2009. A declining trend was observed in a previous evaluation; however, a comparative analysis of utilization patterns of interventional techniques has not been performed showing utilization before and after the enactment of the Affordable Care Act (ACA).

OBJECTIVES: Our aim is to assess patterns of utilization and variables of interventional techniques in chronic pain management in the fee-for-service (FFS) Medicare population, with a comparative analysis of pre- and post-ACA.

STUDY DESIGN: Utilization patterns and variables of interventional techniques were assessed from 2000 to 2009 and from 2009 to 2016 in the FFS Medicare population of the United States in managing chronic pain.

METHODS: The master data from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2016 was utilized to assess overall utilization and comparative utilization at various time periods.

RESULTS: The analysis of Medicare data from 2000 to 2016 showed an overall decrease in utilization of interventional techniques 0.6% per year from 2009 to 2016, whereas from 2000 to 2009, there was an increase of 11.8% per year per 100,000 individuals of the Medicare population. In addition, the United States experienced an increase of 0.7% per year of population growth, 3.2% of those 65 years or older and a 3% annual increase in Medicare participation from 2009 to 2016. Further analysis also showed a 1.7% annual decrease in the rate of utilization of epidural and adhesiolysis procedures per 100,000 individuals of the Medicare population, with a 2.2% decrease for disc procedures and other types of nerve blocks, whereas there was an increase of 0.8% annually for facet joint interventions and sacroiliac joint blocks from 2009 to 2016. Epidural and adhesiolysis procedures showed an 8.9% annual increase, facet joint interventions and sacroiliac joint blocks showed a 17.6% increase, and disc procedures and other types of nerve blocks showed a 7.2% increase annually per 100,000 individuals of the Medicare population from 2000 to 2009.

LIMITATIONS: The limitations of this assessment include lack of analysis of individual procedures. Additional limitations include lack of inclusion of patients from Medicare Advantage plans and lack of complete and accurate data for statewide utilization.

CONCLUSION: From 2009 to 2016, interventional techniques decreased at an annual rate of 0.6% with an overall decrease of 3.9%, compared to an overall increase of 173.6% from 2000 to 2009 with an annual increase of 11.8%. An additional analysis of data with individual procedures is essential to gain further insights into utilization patterns.

KEY WORDS: Interventional pain management, chronic spinal pain, interventional techniques, epidural injections, adhesiolysis, facet joint interventions, sacroiliac joint injections, disc procedures, other types of nerve blocks.

 

[hyperalgesia]

The wave has crested...kenalog is yesterday's news.

Reversal of Growth of Utilization of Interventional Techniques in Managing Chronic Pain in Medicare Population Post Affordable Care Act. - PubMed - NCBI


Reversal of Growth of Utilization of Interventional Techniques in Managing Chronic Pain in Medicare Population Post Affordable Care Act.
Manchikanti L, et al. Pain Physician. 2017.
Show full citation
Abstract
BACKGROUND: Over the past 2 decades, the increase in the utilization of interventional techniques has been a cause for concern. Despite multiple regulations to reduce utilization of interventional techniques, growth patterns continued through 2009. A declining trend was observed in a previous evaluation; however, a comparative analysis of utilization patterns of interventional techniques has not been performed showing utilization before and after the enactment of the Affordable Care Act (ACA).

OBJECTIVES: Our aim is to assess patterns of utilization and variables of interventional techniques in chronic pain management in the fee-for-service (FFS) Medicare population, with a comparative analysis of pre- and post-ACA.

STUDY DESIGN: Utilization patterns and variables of interventional techniques were assessed from 2000 to 2009 and from 2009 to 2016 in the FFS Medicare population of the United States in managing chronic pain.

METHODS: The master data from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2016 was utilized to assess overall utilization and comparative utilization at various time periods.

RESULTS: The analysis of Medicare data from 2000 to 2016 showed an overall decrease in utilization of interventional techniques 0.6% per year from 2009 to 2016, whereas from 2000 to 2009, there was an increase of 11.8% per year per 100,000 individuals of the Medicare population. In addition, the United States experienced an increase of 0.7% per year of population growth, 3.2% of those 65 years or older and a 3% annual increase in Medicare participation from 2009 to 2016. Further analysis also showed a 1.7% annual decrease in the rate of utilization of epidural and adhesiolysis procedures per 100,000 individuals of the Medicare population, with a 2.2% decrease for disc procedures and other types of nerve blocks, whereas there was an increase of 0.8% annually for facet joint interventions and sacroiliac joint blocks from 2009 to 2016. Epidural and adhesiolysis procedures showed an 8.9% annual increase, facet joint interventions and sacroiliac joint blocks showed a 17.6% increase, and disc procedures and other types of nerve blocks showed a 7.2% increase annually per 100,000 individuals of the Medicare population from 2000 to 2009.

LIMITATIONS: The limitations of this assessment include lack of analysis of individual procedures. Additional limitations include lack of inclusion of patients from Medicare Advantage plans and lack of complete and accurate data for statewide utilization.

CONCLUSION: From 2009 to 2016, interventional techniques decreased at an annual rate of 0.6% with an overall decrease of 3.9%, compared to an overall increase of 173.6% from 2000 to 2009 with an annual increase of 11.8%. An additional analysis of data with individual procedures is essential to gain further insights into utilization patterns.

KEY WORDS: Interventional pain management, chronic spinal pain, interventional techniques, epidural injections, adhesiolysis, facet joint interventions, sacroiliac joint injections, disc procedures, other types of nerve blocks.

Just going by the abstract, for better or worse, interventional procedures, including IDET and adhesiolysis had a major boom from 2000-2009 and have subsequently declined. I've always been conservative with interventional treatments and I think there's been a major problem in the past with overuse of procedures. It might just be my area but I feel like I have observed a healthier attitude and caution with procedures over the years.

But what does this have to do with a wave of a new era of biologics? We've been hearing the tsunami siren for the past 10 years and all we've gotten are biased, often chiropractic and PT studies along with a lot of fraud and FDA warnings. I think the biologics wave may be cresting...

 

[Ducttape]

this data shows the trends of decreasing but one cannot draw the conclusion that there is going to be a change to some new intervention such as biologics. they are not necessarily mutually connected. a better assumption should be that greater restrictions has lead to reduced use of interventional procedures, because of ACA.

with this decline, it would be interesting to post the amount of procedures for Medicare patients done with biologics. I typically assume it would be zero, as biologics are, from the best of my knowledge, not covered by medicare...

 

[nvrsumr]

How do you build a practice like that- subacute/sports focused? I agree that would be realistic with a no narcs philosophy.

Do you establish a reputation over time with Orthopods and PCP's? Are you employed by an Orthopedics/Sports med group?

What sort of interventions do you do for these folks. Sounds like a nice setup.

- ex 61N

I am a solo doc so not difficult to limit to subacute pain patients. This would be a much more difficult set up if 5 doc group and all the other pain docs in town are "solving problems' for the pcps by prescribing.

I market directly to patients. Getting more and more difficult to find unaffiliated PCP groups or Spine surgery group without "injectionist" to get referrals. Not certain my business model is sustainable forever.

I also offer regen medicine injections but turn down way more people than I accept for treatment.

 

[drpainfree]

Interventional pain created a lot of iatrogenic addicts in the 90's and 00's. Some IPM docs (and/or their midlevels) are still very free with the prescription pad as long as the billable interventions keep rolling in.

That was the business model- rx opioids, so you can keep needling these patients. Or worse, refuse to prescribe opioids responsibly (wean) but still needle the high dose opioid patients referred to you by PCP's and surgeons.

For all of us doing interventional pain medicine, I challenge you to try this experiment in your clinics: for your new patients, take opioids off the table. Offer multimodal therapy- including injections- but be explicit to new patients that they will not receive opioids from you and you would not recommend their PCP or surgeon give them opioids either.

For your legacy patients being managed by the midlevel whom you inject q 3 months- and who aren't functional- tell them you are going to wean off or not prescribe opioids anymore.

See what happens to your procedure volume.

Might be a wake up call for those of us who place so much stock in a 22 g needle and a squirt of steroid

- ex 61N

Has been my practice model from day 1. And why we need midlevel anyway?

 

[Disciple]

I market directly to patients. Getting more and more difficult to find unaffiliated PCP groups or Spine surgery group without "injectionist" to get referrals.

Care to elaborate? Google Adwords, social media, mailers to homes, radio/TV spots, local magazines?

 

[nvrsumr]

I have done most of the above except tv. Google is most bang for buck. Inflight airline mags seem to have a good hit rate too