hospital privileges

[promethius]

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As pertains specifically to physicians who have an outpatient pain management practice, what are the pros and cons of getting hospital privileges? I know they are not necessary, but are they helpful? Are there any reasons not to get privileged at a local hospital? Appreciate any responses.

 

[Taus]

Getting on commercial insurance panels.

 

[promethius]

I have gotten on all the major commercial insurance panels without hospital privileges and have been practicing independently for a few years now. I have a primary care physician who will admit for me if needed on credentialing applications, but have never had to use it. Just wondering if there is any reason I should sign up for hospital privileges at this point in time.

 

[bedrock]

I have gotten on all the major commercial insurance panels without hospital privileges and have been practicing independently for a few years now. I have a primary care physician who will admit for me if needed on credentialing applications, but have never had to use it. Just wondering if there is any reason I should sign up for hospital privileges at this point in time.

How did you do that? I’ve never found it possible to get credentialed with insurance without having at least one local hospital privilege.

 

[RoloTomassi]

Should not be any cons other than maybe a PITA process

 

[thecentral09]

access to the PACS if u send a lot of MRIs to that hospital. Pts carding mri on discs are a PITA

 

[Sig123]

Free food.

 

[PinchandBurn]

I have gotten on all the major commercial insurance panels without hospital privileges and have been practicing independently for a few years now. I have a primary care physician who will admit for me if needed on credentialing applications, but have never had to use it. Just wondering if there is any reason I should sign up for hospital privileges at this point in time.

Not sure what magic you did.

I thought commercial plans require it. Good for you though.

I don't even have epic access. It's a pain. But I still pay dues.

 

[BobBarker]

It is so slow to log in to the epic portals for the big hospitals. It sounds better to have access to it than it really is.

 

[geauxg8rs]

access to the PACS if u send a lot of MRIs to that hospital. Pts carding mri on discs are a PITA

I have access to local hospital epic system even though no privileges

 

[thecentral09]

Thats nice of them. I left the hospital, and now they are weaponizing access to the PACS as a mechanism to make my process more inefficient in an attempt to remain vindicative. They are also considering not re-credentialing me as they "have enough pain providers". Therefore, sometimes access to the PACS is a tricky thing in certain political circumstances.

 

[Taus]

Having access their to pacs is helpful, gets images and reports from both hospital based and their community-affiliated sites…. But logging in takes too long and I like to have the images quickly accessible when needed later. All patients are still asked to get their images on CD (also written via template on mri rx) so I always have them quickly when needed without pita logins. They get uploaded and saved in my pacs system.

 

[callmeanesthesia]

Possibly specialty-dependent. I, anesthesia primary specialty, am required by our private insurers to maintain hospital privileges. My partner, PM&R, is not.

 

[PinchandBurn]

Thats nice of them. I left the hospital, and now they are weaponizing access to the PACS as a mechanism to make my process more inefficient in an attempt to remain vindicative. They are also considering not re-credentialing me as they "have enough pain providers". Therefore, sometimes access to the PACS is a tricky thing in certain political circumstances.

This has happened to me too.

Patients followed me. I now direct stuff to a private facility where I have access to their PACS and the radiology report.

Problem is patients can bring their CDs. Thye are a pain to open. Also I always like to scan the official report into my emr for future reference. Most hospital rads do not have the official report from rads in the CD. So then it takes time to request faxes etc to get it

 

[thecentral09]

Having access their to pacs is helpful, gets images and reports from both hospital based and their community-affiliated sites…. But logging in takes too long and I like to have the images quickly accessible when needed later. All patients are still asked to get their images on CD (also written via template on mri rx) so I always have them quickly when needed without pita logins. They get uploaded and saved in my pacs system.

So u have purchased your own PACS? What do u pay a month to keep outstanding MRIs on your PACS? The last I looked into it cost was exorbitant.

 

[PinchandBurn]

So u have purchased your own PACS? What do u pay a month to keep outstanding MRIs on your PACS? The last I looked into it cost was exorbitant.

Are you guys looking at MRIs before every minor esi or mbb?

I look at all the images. But months or years later I will look at the reports. That's what they r for. Also I have done legal work for malpractice. You can look at mri all day long it's good to do. But none of us are board certified radiologists. Ultimately you will get grilled on the stand if you have a huge difference in opinion from what a radiologist says. On the flip side. I have seen cases where there was a bad outcome due to severe stenosis. However radiologist said no severe stenosis. The doctor was let off the lawsuit because he was going of what the 'expert" BC radiologist had dictated...

Exceptions are for more invasive procedures, stims, Intracept, kypho etc. I look at those for procedure planning.

 

[Taus]

So u have purchased your own PACS? What do u pay a month to keep outstanding MRIs on your PACS? The last I looked into it cost was exorbitant.

In a large ortho group.

Are you guys looking at MRIs before every minor esi or mbb?

I look at all the images. But months or years later I will look at the reports. That's what they r for. Also I have done legal work for malpractice. You can look at mri all day long it's good to do. But none of us are board certified radiologists. Ultimately you will get grilled on the stand if you have a huge difference in opinion from what a radiologist says. On the flip side. I have seen cases where there was a bad outcome due to severe stenosis. However radiologist said no severe stenosis. The doctor was let off the lawsuit because he was going of what the 'expert" BC radiologist had dictated...

Exceptions are for more invasive procedures, stims, Intracept, kypho etc. I look at those for procedure planning.

I look before all esi from other doctors, where I have not personally seen images in office and more advanced procedure pre-op planning.

 

[RoloTomassi]

Osirix

So u have purchased your own PACS? What do u pay a month to keep outstanding MRIs on your PACS? The last I looked into it cost was exorbitant.

 

[RoloTomassi]

Are you guys looking at MRIs before every minor esi or mbb?

Yes. Even bread and butter, important to see severity of stenosis, location of herniation, numbering when transitional segment present, amount of facet hypertrophy

 

[deleted131481]

I don't look at MRI before mbb and won't order one if I really think it's facets.

For ESI I usually dictate major findings and where I'm going in clinic. I still pull up probably more than half before the procedure. CESI I always review.

 

[PinchandBurn]

I don't look at MRI before mbb and won't order one if I really think it's facets.

For ESI I usually dictate major findings and where I'm going in clinic. I still pull up probably more than half before the procedure. CESI I always review.

Agreed. However I only do CESi at c7/t1 or c6/7....once I have dictated and know tht is clear. I always go there. I dont do CESI above that level. Also I don't "push the meds fast". I let most of it infuse to gravity via an extension tubing. I slowly let it go in. If pts feel pressure or discomfort. I usually stop Injecting into epidural space.

 

[RoloTomassi]

I don't look at MRI before mbb and won't order one if I really think it's facets.

How do you choose levels? I think looking at facet hypertrophy, increased joint T2 signal, marrow changes, and levels of disc degeneration can be helpful, more so than relying only on patient's description of pain distribution

 

[lobelsteve]

Agreed. However I only do CESi at c7/t1 or c6/7....once I have dictated and know tht is clear. I always go there. I dont do CESI above that level. Also I don't "push the meds fast". I let most of it infuse to gravity via an extension tubing. I slowly let it go in. If pts feel pressure or discomfort. I usually stop Injecting into epidural space.

Go on, do tell. Gravity feed epidural.

 

[Ducttape]

How do you choose levels? I think looking at facet hypertrophy, increased joint T2 signal, marrow changes, and levels of disc degeneration can be helpful, more so than relying only on patient's description of pain distribution

i will look at MRI before MBB if there is one, but other times it is based on clinical presentation of where the pain is and the xrays and the expectation that more facet .

i look at all MRIs before i order the initial ESI, but i dont pull up images right before the procedure itself.

for those who are doing 50-80 injections a day, how do you find time to look at the MRI, discuss risks/benefits and consent the patient, position them, prep and do the procedure with at least 2 views with contrast, and then get them off the table and home?

 

[pastafan]

How do you choose levels? I think looking at facet hypertrophy, increased joint T2 signal, marrow changes, and levels of disc degeneration can be helpful, more so than relying only on patient's description of pain distribution

While on procedure table push down on facet joints and see which ones hurt. Do more symptomatic side first and see if 100% pain relieved or if bilateral blocks required. Amazing how often 3 level bilateral blocks are not required...

 

[deleted131481]

How do you choose levels? I think looking at facet hypertrophy, increased joint T2 signal, marrow changes, and levels of disc degeneration can be helpful, more so than relying only on patient's description of pain distribution

As ducttape said I will look at imaging (xrays and MRI if present) in clinic before. I target bottom two facets 90%+ of the time unless there is something on history, physical, imaging to strongly tip me off otherwise. I don't think imaging is a reliable gauge of facet pain but I will if the facets look particularly nasty above L4-L5, old compression fx, maybe bad spondy or scoliosis, etc.

edit: curious how often you are going above L3-L4 based on imaging findings?

 

[RoloTomassi]

As ducttape said I will look at imaging (xrays and MRI if present) in clinic before. I target bottom two facets 90%+ of the time unless there is something on history, physical, imaging to strongly tip me off otherwise. I don't think imaging is a reliable gauge of facet pain but I will if the facets look particularly nasty above L4-L5, old compression fx, maybe bad spondy or scoliosis, etc.

edit: curious how often you are going above L3-L4 based on imaging findings?

I do L4-5 almost 100%. L5-S1 90-95%. L3-4 5-10%. This doesn't include the rare fx, hardware etc.

My original post I was thinking more about cervical, which I am much more variable with.

 

[DOctorJay]

I'll do MBBs with just an xray but I haven't done an ESI without the MRI and I want to see the images myself.

 

[deleted131481]

I do L4-5 almost 100%. L5-S1 90-95%. L3-4 5-10%. This doesn't include the rare fx, hardware etc.

My original post I was thinking more about cervical, which I am much more variable with.

Agree much more variable in cervical. I am usually doing C 345 or 456 depending if I think the pain is higher lower, and TON if headaches. I could probably use imaging here more. Definitely prior surgery or hardware will help guide.

 

[Tboned]

Go on, do tell. Gravity feed epidural.

I want to hear about the gravity feed epidural too! @PinchandBurn

 

[PinchandBurn]

Go on, do tell. Gravity feed epidural.

well not sure what gravity 'feed' is.

however. Here it goes. In fellowship we learned LOR or hanging drop. Then hooked a primed (usually saline) tubing to the hub of the Touhy needle once we got LOR. We raised the tubing and saw the saline go down. If no issue, then contrast injected to document epidural spread. Then the glass syringe (minus the plunger for the LOR) was hooked to the tubing. the injectate put in the glass syringe and as fellows, we literally held it there until the injectate was all in. this was painful as a fellow. This whole process wouldnt work in PP as it would tk forever.

why does cervical spinal cord injury occur? Injection of fluid/air causing a syrinx of the cord.

I do the above mentioned. get the LORTA on contralateral. hook a primed tubing. See if it goes down to gravity (epidural space is negative btw learned this in Anesthesia doing hanging drop). If it does i know I am safe. Slowly inject contrast. Then slowly put the injectate in.
this is a more pragmatic way to do sort of what we did in fellowship but at a more efficient manner.

 

[lobelsteve]

well not sure what gravity 'feed' is.

however. Here it goes. In fellowship we learned LOR or hanging drop. Then hooked a primed (usually saline) tubing to the hub of the Touhy needle once we got LOR. We raised the tubing and saw the saline go down. If no issue, then contrast injected to document epidural spread. Then the glass syringe (minus the plunger for the LOR) was hooked to the tubing. the injectate put in the glass syringe and as fellows, we literally held it there until the injectate was all in. this was painful as a fellow. This whole process wouldnt work in PP as it would tk forever.

why does cervical spinal cord injury occur? Injection of fluid/air causing a syrinx of the cord.

I do the above mentioned. get the LORTA on contralateral. hook a primed tubing. See if it goes down to gravity (epidural space is negative btw learned this in Anesthesia doing hanging drop). If it does i know I am safe. Slowly inject contrast. Then slowly put the injectate in.
this is a more pragmatic way to do sort of what we did in fellowship but at a more efficient manner.

You realize hanging drop is not recommended and is useless right?
Dinosaurs.

 

[Baron S]

Will def echo hanging drop is not the way to go. Studies have shown negative pressure in the epidural space is highly variable especially in a prone position.

 

[PinchandBurn]

You realize hanging drop is not recommended and is useless right?
Dinosaurs.

Yup

That's why if you keep reading...

You will see contrast is used. So is live fluro.

No one including me is using just hanging drop. But my point is once contrast shows ur in the epidural space and if you attach tubing and let the injectable go in slowly then you're confirming again that your not injecting into the cord.

 

[PinchandBurn]

Will def echo hanging drop is not the way to go. Studies have shown negative pressure in the epidural space is highly variable especially in a prone position.

I don't disagree.

 

[nvrsumr]

I used fluid column drop extension tubing technique for CESI as well a long time ago. Was helpful before CLO view was commonly used when taking a lateral in big patients doing a seated technique with fluoro and hard to see needle tip.