How to improve procedure volume

[drrosenrosen]

I'm in my third year at this practice. 2022, my first full year (started in August) I had 3813 pt encounter, 731 new pts, 1067 procedures. Last year I had 4944 pt encounters, with 746 new and 1426 procedures. So volume is going up, but % procedures is remaining steady at about 30% of all encounters. In the first third of this year, I'm on track for about a 5% increase in overall volume, but the % procedures is holding steady. I'm wanting to increase my procedural volume, but not sure how best to attack that. Should I be marketing more aggressively to get more new consults? Reconsidering where my consults are coming from? Any good strategies to make sure pts aren't being lost to followup at a greater than usual rate? I'd appreciate any ideas the braintrust has to offer.

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[SSdoc33]

if you do a crappy job, there are always more injections to be done.

just kidding. sort of.

focus on repeat RFs. may be a good idea to keep track of these and give a call out 1 year after the RFs to see how they are doing. or schedule a f/u 1 year from RFs.

referrals from surgeons more often lead to injections than those from PCPs.

move away from prescribing medication. thats a dead end

 

[Ducttape]

let me get this right... you are seeing slightly more people, but the percent of people getting injections is unchanged.


it sounds like you are maintaining your own standards of who "qualifies" for an injection. not everyone needs an injection.


if you want that percent number to change, then change your standards and instead of thinking about what would help the patient, focus on the $$$ and order more injections to improve the financial standing of the clinic. Be the needle jockey. own it.




after all, everyone deserves at least a trigger point, if not a stim.

 

[SpineandWine]

PRN lot of the patients who got relief, will clear up some slots
Then they can call when they want injection- just tell them it can be repeated after 3 months if pain comes back

More procedures.


Or find a surgical referral base where they want diagnostic injections

 

[BobBarker]

I like the way you are analyzing this. I agree on focusing on repeat RF’s. That is the easiest way to do this. Knee visco under fluoro series of 3. You can make money on the j code if you buy a large amount of the product.

 

[po_boy]

I like the way you are analyzing this. I agree on focusing on repeat RF’s. That is the easiest way to do this. Knee visco under fluoro series of 3. You can make money on the j code if you buy a large amount of the product.

Can you elaborate on how to optimize visco? Which product are you using and why? Thanks

 

[BobBarker]

I use TriVisc. But I bought 250 units over a year ago and just now I am on my last box. Just use it for Medicare only basically. Durolane might pencil out better at the moment last time I checked prices.


You used to be able to make major money with visco but those days are over.

Medicare reimbursement is calculated off average sales price so you have to buy enough volume to get on the very low end of that curve.

 

[drrosenrosen]

I like the way you are analyzing this. I agree on focusing on repeat RF’s. That is the easiest way to do this. Knee visco under fluoro series of 3. You can make money on the j code if you buy a large amount of the product.

We do Hyalgan for medicare buy & bill, series of 3, about 50/50 fluoro vs ultrasound. I like the idea of maybe scheduling followup for RF to stay on top of them. Might do a 6 month followup on successful RFAs in the future

 

[drrosenrosen]

if you do a crappy job, there are always more injections to be done.

just kidding. sort of.

focus on repeat RFs. may be a good idea to keep track of these and give a call out 1 year after the RFs to see how they are doing. or schedule a f/u 1 year from RFs.

referrals from surgeons more often lead to injections than those from PCPs.

move away from prescribing medication. thats a dead end

I've been trying to slowly curtail my med prescribing. It's a little hard because the referral base is very used to pain docs prescribing in this market, but straight med refills I try to decline the referrals. Also being stricter on criteria to continue therapy (ie, "are you really getting pain relief from that Norco?")

 

[RoloTomassi]

Keep track of patients you order MRIs on and make sure they follow through. Then make sure they come back for MRI f/u. Make sure procedure patients always have f/u for next step of plan. Track no shows (office and procedure) and make sure they reschedule. These are all points of potential loss.

How full/booked out are your procedure blocks?

 

[Agast]

How do you structure your post procedure follow up visit? Are you doing counseling and education plus a debriefing on what the patient had done, so they understand when to return to clinic

 

[stsa84]

let me get this right... you are seeing slightly more people, but the percent of people getting injections is unchanged.


it sounds like you are maintaining your own standards of who "qualifies" for an injection. not everyone needs an injection.


if you want that percent number to change, then change your standards and instead of thinking about what would help the patient, focus on the $$$ and order more injections to improve the financial standing of the clinic. Be the needle jockey. own it.




after all, everyone deserves at least a trigger point, if not a stim.

I get what you're saying, though there are other ways to improve procedure % besides doing unnecessary procedures. #1 would be encouraging referrals from sources which will likely have pathology amenable to procedural options, such as surgeons. My procedure % from PCP's range from as low as 5-10% for some who send crappy referrals, to maybe 40-50% for some others. For surgeons, it ranges from 20% from some (one sends me all his post-crani headache patients 🙄) and up to 80-90% from a few.

Maybe work on encouraging some pathways from surgeons. Meet them, give them your cell, let them know you can get people in within a week or two, or same day if there's urgency. I've had some success breaking surgeons out of their established referral routes just by being the easiest to get patients in to. They tested things out for a few weeks, then started sending me everybody.

 

[SpineandWine]

If you want to go this route
- Can you do two diagnostic SSN prior to ablation, two genics prior to ablation, etc.
- do diagnostic SI joints to ensure pathology prior to therapeutic SI joint with steroid
- sympathetic blocks q1 weekx3 prior to assessment
- unilateral RFAs followed 2 weeks with other side

 

[cowboydoc]

I get what you're saying, though there are other ways to improve procedure % besides doing unnecessary procedures. #1 would be encouraging referrals from sources which will likely have pathology amenable to procedural options, such as surgeons. My procedure % from PCP's range from as low as 5-10% for some who send crappy referrals, to maybe 40-50% for some others. For surgeons, it ranges from 20% from some (one sends me all his post-crani headache patients 🙄) and up to 80-90% from a few.

Maybe work on encouraging some pathways from surgeons. Meet them, give them your cell, let them know you can get people in within a week or two, or same day if there's urgency. I've had some success breaking surgeons out of their established referral routes just by being the easiest to get patients in to. They tested things out for a few weeks, then started sending me everybody.

Agree with this! This doesn't have to be about lowering standards to get more revenue.

Educating referral sources on what you can and want to do can be worth it's weight in gold. It's probably hard to get face time with most of them, but if you can give an elevator speech about who is a good patient referral. The PCPs I've run into and explained the basics of radic and facet pain, getting them to PT, not sending to surgeon first, etc. send me far more potential procedures and not fibro/opioid patients now. Half my referrals are from surgeons, who are much more likely to be appropriate for a procedure.

You can do the right thing for the right patient at the right time. It can be much easier if others are appropriately screening patients before they get to you.

Based on OP description, I'd strongly prefer to put effort into getting better referrals than more referrals.

 

[drrosenrosen]

How do you structure your post procedure follow up visit? Are you doing counseling and education plus a debriefing on what the patient had done, so they understand when to return to clinic

Yes I always 1) assess how the injection went, 2) if good, check if there's anything else we need to work on/other areas of pain, 3)if good and nothing else, make sure they know when they can repeat and to call for another shot, 4)if bad, look for other injections to do as appropriate. Also, if they're doing say 75% better and haven't had PT recently I'll send them back to PT and follow up in 2 months.

 

[drrosenrosen]

Keep track of patients you order MRIs on and make sure they follow through. Then make sure they come back for MRI f/u. Make sure procedure patients always have f/u for next step of plan. Track no shows (office and procedure) and make sure they reschedule. These are all points of potential loss.

How full/booked out are your procedure blocks?

Those are good tips. I've been paying closer attention to MRI followups lately and making sure we're not losing folks who just "never heard from the imaging center". Need to do a better job of tracking no shows and making sure we're recapturing them.

I have an open schedule - that is, no procedure blocks. It's all in office, so I book procedures and np/fu all mixed together. I tend to be full for the current week and next week, then have openings, although I try to overbook procedures as there are inevitably no shows and reschedules.

 

[geauxg8rs]

Yes I always 1) assess how the injection went, 2) if good, check if there's anything else we need to work on/other areas of pain, 3)if good and nothing else, make sure they know when they can repeat and to call for another shot, 4)if bad, look for other injections to do as appropriate. Also, if they're doing say 75% better and haven't had PT recently I'll send them back to PT and follow up in 2 months.

It’s amazing what patients are told vs what they hear. I tell them rf lasts 6-12 months. They hear either permanent or three years. So tell them a date. Hey you had your esi on 5/1, call me if the pain returns. We can repeat the esi on 8/2. But if your pain comes back before then please don’t hesitate to call. I then talk about possible si joint or facet pain might get unmasked. There are different tx for those pain.

 

[Ducttape]

If you want to go this route
- Can you do two diagnostic SSN prior to ablation, two genics prior to ablation, etc.
- do diagnostic SI joints to ensure pathology prior to therapeutic SI joint with steroid
- sympathetic blocks q1 weekx3 prior to assessment
- unilateral RFAs followed 2 weeks with other side

so do unnecessary procedures to prop up your volume?


not the right idea.



one option that you could do, though it sounds like you are doing things the right way, is to have a midlevel see more follow ups and get them off of your schedule and focus entirely on new patients and the injections.

 

[Espn123]

Schedule follow ups on all injections and RF

 

[SpineandWine]

so do unnecessary procedures to prop up your volume?


not the right idea.



one option that you could do, though it sounds like you are doing things the right way, is to have a midlevel see more follow ups and get them off of your schedule and focus entirely on new patients and the injections.

Actually I am not doing this at all.

**I misread your text - I am not doing this in my practice. I mostly just do ESIs and TFESIs

 

[SpineandWine]

Schedule follow ups on all injections and RF

PRN them.
If they want to repeat, theyll call and find you

 

[Espn123]

PRN them.
If they want to repeat, theyll call and find you

And then be unhappy with how long it took them to get in, have an office visit that’s required for authorization, and then their injection

 

[Agast]

I think you need to increase the proportion of patients who come in wanting a procedure from the get go, and those are not coming from your referrals. I’ve noticed a lot of relatively healthy middle aged people do not have a PCP. I would do some branding photos and then run an ad campaign on social media to attract that demographic, with emphasis on non surgical and diagnostic services for aches and pains.

 

[drrosenrosen]

I think you need to increase the proportion of patients who come in wanting a procedure from the get go, and those are not coming from your referrals. I’ve noticed a lot of relatively healthy middle aged people do not have a PCP. I would do some branding photos and then run an ad campaign on social media to attract that demographic, with emphasis on non surgical and diagnostic services for aches and pains.

That's an interesting idea. I've always been shy to do direct to patient marketing as I have feared that would yield more drug seekers. I've been wanting to do some PRP and had been thinking of direct to pt marketing for that. I feel like that hits a similar demographic as you're talking about - younger healthy people who don't necessarily go to a doctor often or even have one.

 

[SSdoc33]

That's an interesting idea. I've always been shy to do direct to patient marketing as I have feared that would yield more drug seekers. I've been wanting to do some PRP and had been thinking of direct to pt marketing for that. I feel like that hits a similar demographic as you're talking about - younger healthy people who don't necessarily go to a doctor often or even have one.

wise move.

 

[SSdoc33]

That's an interesting idea. I've always been shy to do direct to patient marketing as I have feared that would yield more drug seekers. I've been wanting to do some PRP and had been thinking of direct to pt marketing for that. I feel like that hits a similar demographic as you're talking about - younger healthy people who don't necessarily go to a doctor often or even have one.

young healthy people dont need shots.

old, sick one do.

you should be going after the stenosis/facet crowd. thats the gift that keeps on giving

 

[Agast]

That's an interesting idea. I've always been shy to do direct to patient marketing as I have feared that would yield more drug seekers. I've been wanting to do some PRP and had been thinking of direct to pt marketing for that. I feel like that hits a similar demographic as you're talking about - younger healthy people who don't necessarily go to a doctor often or even have one.

In your ad you have to make it clear what you are offering. If it says “Tired of being in pain and taking pain medications?!” You will not get the drug seekers.

 

[drrosenrosen]

young healthy people dont need shots.

old, sick one do.

you should be going after the stenosis/facet crowd. thats the gift that keeps on giving

I see plenty of young healthy pts with acute radic who benefit greatly from shots. Or for PRP where young pts with mild OA or tennis elbow are a perfect use case

 

[SSdoc33]

I see plenty of young healthy pts with acute radic who benefit greatly from shots. Or for PRP where young pts with mild OA or tennis elbow are a perfect use case

true. but that is a one-and done.

you RF the 65 year old, and then you have 15 more RFs coming up.

same with stenosis

 

[lobelsteve]

"10 Free Roxies with every RF"

 

[Orin]

I'm in my third year at this practice. 2022, my first full year (started in August) I had 3813 pt encounter, 731 new pts, 1067 procedures. Last year I had 4944 pt encounters, with 746 new and 1426 procedures. So volume is going up, but % procedures is remaining steady at about 30% of all encounters. In the first third of this year, I'm on track for about a 5% increase in overall volume, but the % procedures is holding steady. I'm wanting to increase my procedural volume, but not sure how best to attack that. Should I be marketing more aggressively to get more new consults? Reconsidering where my consults are coming from? Any good strategies to make sure pts aren't being lost to followup at a greater than usual rate? I'd appreciate any ideas the braintrust has to offer.

You've increased volume. To increase the share of procedures, it's either do more unindicated procedures, find more indicated procedures, or see less patients that don't get procedures.

I think analyzing your referral patterns to find more patients that you feel meet diagnostic criteria for injection makes sense. MI agree with marketing to physicians over patients, but either needs work and effort to get good yield. You may also think about adding other procedures that could treat patients you historically haven't offered things for, but that gets into that whole unindicated procedure space.

 

[Ferrismonk]

1. What you really need to do is get rid of your med patients. They're a time suck and only translate into intermittent procedures for the visits they take. I would recommend getting an NP/PA to see your med patients and routine follow ups so you can see more new patients and more procedure heavy patients.

2. You can order more than one procedure on an office visit (assuming the insurance allows.). For example, I may schedule a TFESI for radicular pain, then a lower facet injection for axial pain 2 weeks later, then maybe an upper facet or repeat lower facet/SIJ or something. Yes, only if indicated. I always tell them they can cancel their later procedures and schedule an office visit instead if they're feeling better, but this way we can avoid the hassle of bringing them into the office unnecessary and wasting money in between procedures.

3. PCP referrals usually are worth less procedure-wise than surgical referrals, even if you pre-screen them. Schmooze the surgeons in town, spine surgeons in particular, and focus on getting their patients in ASAP. They appreciate quick turnaround and that you don't bounce back the crazy non-surgical ones. See if they're interested in doing SCS implants or if you can grease the wheels for them in other ways. Diagnostic SIJ, etc.

4. I disagree with Ducttape, doing mostly injections doesn't necessarily make you a "needle jockey". You provide a service not everyone can do, it makes sense to maximize your referrals to be for the procedures you can do others can't.

5. I would NOT try to increase revenue with Trigger points, Joints, or other sports injections. They all pay crappy and aren't worth your time (unless you're doing PPP/PRP/etc).

 

[lobelsteve]

1. What you really need to do is get rid of your med patients. They're a time suck and only translate into intermittent procedures for the visits they take. I would recommend getting an NP/PA to see your med patients and routine follow ups so you can see more new patients and more procedure heavy patients.

2. You can order more than one procedure on an office visit (assuming the insurance allows.). For example, I may schedule a TFESI for radicular pain, then a lower facet injection for axial pain 2 weeks later, then maybe an upper facet or repeat lower facet/SIJ or something. Yes, only if indicated. I always tell them they can cancel their later procedures and schedule an office visit instead if they're feeling better, but this way we can avoid the hassle of bringing them into the office unnecessary and wasting money in between procedures.

3. PCP referrals usually are worth less procedure-wise than surgical referrals, even if you pre-screen them. Schmooze the surgeons in town, spine surgeons in particular, and focus on getting their patients in ASAP. They appreciate quick turnaround and that you don't bounce back the crazy non-surgical ones. See if they're interested in doing SCS implants or if you can grease the wheels for them in other ways. Diagnostic SIJ, etc.

4. I disagree with Ducttape, doing mostly injections doesn't necessarily make you a "needle jockey". You provide a service not everyone can do, it makes sense to maximize your referrals to be for the procedures you can do others can't.

5. I would NOT try to increase revenue with Trigger points, Joints, or other sports injections. They all pay crappy and aren't worth your time (unless you're doing PPP/PRP/etc).

I can make more money in seeing opiate follow ups than I can for doing epidurals. System broken.
Fortunately I see the elderly and my practice is facet based.

 

[Agast]

drosen looks a little like Zachary Quinto, so I vote he leans into that with a facebook instagram campaign. I wonder if tiktok ads are cheaper now that it's about to be banned.

 

[SgtThunderfistMD]

I can make more money in seeing opiate follow ups than I can for doing epidurals. System broken.
Fortunately I see the elderly and my practice is facet based.

wRVU (3x [99214+G2211]) >>> wRVU (62323)

 

[callmeanesthesia]

wRVU (3x [99214+G2211]) >>> wRVU (62323)

Why 3x 99214? I could practically do 2 caudals in the time it takes me to see a follow up.

 

[lobelsteve]

Why 3x 99214? I could practically do 2 caudals in the time it takes me to see a follow up.

Sure, if you place two patients at a time on your table.

 

[SSdoc33]

drosen looks a little like Zachary Quinto, so I vote he leans into that with a facebook instagram campaign. I wonder if tiktok ads are cheaper now that it's about to be banned.

thats Fletch

 

[callmeanesthesia]

Sure, if you place two patients at a time on your table.

Most of my follow ups are patients who haven’t had success with injections or are otherwise complicated. The simple MBB f/u visits go on my mid level’s schedules. A follow up usually takes me a solid 10-15 minutes. A caudal probably takes about 8 minutes including turning over the room.

 

[jsaul]

Dr Rosen Rosen is fletch not Kelvin timeline spock

 

[Agast]

thats Fletch

I mean IRL 😉

 

[Ducttape]

I can make more money in seeing opiate follow ups than I can for doing epidurals. System broken.
Fortunately I see the elderly and my practice is facet based.

the system is broken but i dont think this is the main problem.


didnt someone say something about teaching monkeys how to read an EKGs?

your clinical assessment and monitoring of patients on opioids is much more time consuming, intellectually challenging and nuanced than any SI injection or ESI.

 

[lobelsteve]

the system is broken but i dont think this is the main problem.


didnt someone say something about teaching monkeys how to read an EKGs?

your clinical assessment and monitoring of patients on opioids is much more time consuming, intellectually challenging and nuanced than any SI injection or ESI.

Mine sure is, but learned after reviewing over a million pages of review for folks doing it illegally or poorly or both.

 

[drrosenrosen]

1. What you really need to do is get rid of your med patients. They're a time suck and only translate into intermittent procedures for the visits they take. I would recommend getting an NP/PA to see your med patients and routine follow ups so you can see more new patients and more procedure heavy patients.

2. You can order more than one procedure on an office visit (assuming the insurance allows.). For example, I may schedule a TFESI for radicular pain, then a lower facet injection for axial pain 2 weeks later, then maybe an upper facet or repeat lower facet/SIJ or something. Yes, only if indicated. I always tell them they can cancel their later procedures and schedule an office visit instead if they're feeling better, but this way we can avoid the hassle of bringing them into the office unnecessary and wasting money in between procedures.

3. PCP referrals usually are worth less procedure-wise than surgical referrals, even if you pre-screen them. Schmooze the surgeons in town, spine surgeons in particular, and focus on getting their patients in ASAP. They appreciate quick turnaround and that you don't bounce back the crazy non-surgical ones. See if they're interested in doing SCS implants or if you can grease the wheels for them in other ways. Diagnostic SIJ, etc.

4. I disagree with Ducttape, doing mostly injections doesn't necessarily make you a "needle jockey". You provide a service not everyone can do, it makes sense to maximize your referrals to be for the procedures you can do others can't.

5. I would NOT try to increase revenue with Trigger points, Joints, or other sports injections. They all pay crappy and aren't worth your time (unless you're doing PPP/PRP/etc).

I do try to maintain good relationships with surgeons and encourage referrals from them. I'd be interested to hear how you or anyone else deal with referral relationships with surgeons you don't like (professionally)? I have a guy who sends me quite a few pts, but I'm not thrilled to return the favor as I've not seen great results from my pts who have had surgery with him

 

[BobBarker]

You do what you think is best. Single level ACDF is universally their favorite surgery to do and likely the easiest from my understanding. Maybe keep that in mind when deciding who to refer to.

 

[bedrock]

You do what you think is best. Single level ACDF is universally their favorite surgery to do and likely the easiest from my understanding. Maybe keep that in mind when deciding who to refer to.

Close.

Two level ACDF is their favorite surgery.