Increasing the Pain Specialist Pipeline

[drusso]

Coping with the Physician Specialist Shortage

These findings are corroborated by the Association of American Medical Colleges' study issued March 2017 that finds the physician deficit by 2030 could be 40,800 to 104,900 — with 61,800 specialists among that higher count.

"Because physician training can take up to a decade, a physician shortage in 2030 is a problem that needs to be addressed now," says AAMC. The organization's solutions include "a moderate increase in the use of advanced practice nurses (APRNs) and physician assistants (PAs), greater use of alternate settings such as retail clinics, delayed physician retirement and rapid changes in payment and delivery (e.g., accountable care organizations, or ACOs)."

Every indicator points to a mammoth shortage of pain specialists well into the next decade in the midst of a massive opioid crisis and chronic pain epidemic. How should the specialty respond to this need?

• More fellowship training spots?
• Increased implementation of "team models of care" using physician extenders?
• "Mini-fellowships" for physicians from non-anesthesia/PM&R/Neuro training backgrounds?
• Increased incorporation of DC's, ND's, PhD's, etc into pain clinic operations?

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[SSdoc33]

Coping with the Physician Specialist Shortage

These findings are corroborated by the Association of American Medical Colleges' study issued March 2017 that finds the physician deficit by 2030 could be 40,800 to 104,900 — with 61,800 specialists among that higher count.

"Because physician training can take up to a decade, a physician shortage in 2030 is a problem that needs to be addressed now," says AAMC. The organization's solutions include "a moderate increase in the use of advanced practice nurses (APRNs) and physician assistants (PAs), greater use of alternate settings such as retail clinics, delayed physician retirement and rapid changes in payment and delivery (e.g., accountable care organizations, or ACOs)."

Every indicator points to a mammoth shortage of pain specialists well into the next decade in the midst of a massive opioid crisis and chronic pain epidemic. How should the specialty respond to this need?

• More fellowship training spots?
• Increased implementation of "team models of care" using physician extenders?
• "Mini-fellowships" for physicians from non-anesthesia/PM&R/Neuro training backgrounds?
• Increased incorporation of DC's, ND's, PhD's, etc into pain clinic operations?

"delayed physician retirement"

WTF? and who decides that?

 

[lobelsteve]

Be as stupid as anesthesia and give it all away to less trained, less skilled noctors. Not a good idea.

Specialists need to be doctors. Use of extenders by specialists is disrespectful. And speaking out on it can get you fired.

 

[deleted185747]

Increase payment for what you want to accomplish and talent will gravitate there

 

[Disciple]

Since that’s not going to happen, what’s the next best option?

 

[emd123]

"delayed physician retirement"

Not it!

 

[clubdeac]

They need to start reimbursing services they believe are beneficial, or at least for pain modalities that have the "most" evidence i.e. interventional procedures, mental health and physical therapy. They then need to increase the number of pain fellowship slots and require ACGME fellowship training in order to practice pain management.

 

[lobelsteve]

Not it!

You never touched the side of your nose. You are it.

 

[SeniorWrangler]

This may be a little controversial, but I don't think increasing pain fellowship spots is going to do much for the combined public health crisis of pain and opioid misuse. Even on this forum, not too many of us are interested in chronic pain patients who have complex, messy clinical pictures with comorbidities that don't lend themselves to procedures.

Conversely, most of our cool pain procedures only work well in patients who have fairly simple conditions and no significant psych comorbidity. That's a small fraction of the total pain epidemic and not the most difficult part anyway.

Those patients will continue to be the responsibility of primary care docs, even if we somehow doubled the number of pain specialists in this country. It would only result in even more procedures for patients with shaky indications who are then sent back to the primary care providers.

What really needs to happen in my opinion is for pain specialists to be able to make a sustainable living co-managing pain patients together with their primary care docs; that doesn't exist now.

 

[101N]

I make 50th % MGMA IPM managing chronic pain patients who have complex, messy clinical pictures with comorbidities that don't lend themselves to procedures.
It much, much harder and stressful than doing procedures. My bosses are providing a HUGE community service.

 

[Disciple]

This may be a little controversial, but I don't think increasing pain fellowship spots is going to do much for the combined public health crisis of pain and opioid misuse. Even on this forum, not too many of us are interested in chronic pain patients who have complex, messy clinical pictures with comorbidities that don't lend themselves to procedures.

Conversely, most of our cool pain procedures only work well in patients who have fairly simple conditions and no significant psych comorbidity. That's a small fraction of the total pain epidemic and not the most difficult part anyway.

Those patients will continue to be the responsibility of primary care docs, even if we somehow doubled the number of pain specialists in this country. It would only result in even more procedures for patients with shaky indications who are then sent back to the primary care providers.

What really needs to happen in my opinion is for pain specialists to be able to make a sustainable living co-managing pain patients together with their primary care docs; that doesn't exist now.

Addiction "Medicine" just recently was approved as an ABMS specialty, despite having been practiced by many physicians for quite some time. You can be grandfathered in from any specialty for the next 5 years.

I'd wager the opioid epidemic had a little bit to do with the recent approval.

 

[drusso]

What really needs to happen in my opinion is for pain specialists to be able to make a sustainable living co-managing pain patients together with their primary care docs; that doesn't exist now.

The health system based Opioid Refill Clinic model is predicated upon revenue arbitrage from site of service differentials and ancillary revenue streams. The hospital admins/bosses reap substantial revenue from billing clinic visits as HOPD site of service and hospital-based tox fees (which get reimbursed off a different schedule than physician-owned tox services). Even under capitated models, there is often extra "juice" for the hospital admins in terms of "wrap fees," "community benefit," etc.

In order for that work to be broadly appealing, it has to be resourced and rewarded.

 

[Disciple]

I make 50th % MGMA IPM managing chronic pain patients who have complex, messy clinical pictures with comorbidities that don't lend themselves to procedures.
It much, much harder and stressful than doing procedures. My bosses are providing a HUGE community service.

101,

One recurring point of contention in these threads is whether private practicioners should be heavily involved in this type of work.

For a private practicioner, primarily doing this type of work would likely result in <5th % IPM MGMA, and rapid physician burnout.

I had previously stated my opinion that these models of care are best instituted through large health systems, FQHCs or universities.

Were you a solo practicioner, or in a small 2 physician group, would you do the work that you do, without the administrative support/controls that you have, and for FP or Peds income?

drusso has the closest thing to a private practice version of this service that I've seen described on this forum, and the sentiment on some of these threads seems to be that because he doesn't take all comers, he is still not doing enough.

For full disclosure, I will be helping to design this type of system for a defined territory of a local hospital system, but, as an affiliate, not an employee. Given that dynamic, I have no idea how it will turn out.

 

[drusso]

drusso has the closest thing to a private practice version of this service that I've seen described on this forum, and the sentiment on some of these threads seems to be that because he doesn't take all comers, he is still not doing enough.

Clarification: I'm not doing enough because I'm not resourced enough to do it. Every single one of these "high needs, medically complex pain patients" is a medico-legal tar-baby and a negative financial event. You can be busy all day and go broke seeing these people. Pay what work is worth, and set aside the hocus-pocus health system accounting (SOS, wrap fees, differential reimbursement schedules, etc), and I believe that work would get done and get done well.

 

[Timeoutofmind]

I make 50th % MGMA IPM managing chronic pain patients who have complex, messy clinical pictures with comorbidities that don't lend themselves to procedures.
It much, much harder and stressful than doing procedures. My bosses are providing a HUGE community service.

Can I ask:

How many patients you see a day?
(By yourself or with midlevel)?
Does your employer push you to see more patients each day than you currently are/expand your clinic/add other providers/etc?
Are you production based or straight salary?
How did you go about getting this job? Just approached a hospital system and said "I will manage all your narcs trying to reign into CDC guidlines as best as possible for 50% MGMA"??

Thanks in advance!

 

[101N]

101,

One recurring point of contention in these threads is whether private practicioners should be heavily involved in this type of work.

For a private practicioner, primarily doing this type of work would likely result in <5th % IPM MGMA, and rapid physician burnout.

I had previously stated my opinion that these models of care are best instituted through large health systems, FQHCs or universities.

Were you a solo practicioner, or in a small 2 physician group, would you do the work that you do, without the administrative support/controls that you have, and for FP or Peds income?

drusso has the closest thing to a private practice version of this service that I've seen described on this forum, and the sentiment on some of these threads seems to be that because he doesn't take all comers, he is still not doing enough.

For full disclosure, I will be helping to design this type of system for a defined territory of a local hospital system, but, as an affiliate, not an employee. Given that dynamic, I have no idea how it will turn out.

No, this can't be done in PP the incentives are wrong.

 

[drusso]

No, this can't be done in PP the incentives are wrong.

Beth Darnall's study was done in a private practice in Colorado.

Opioid Tapering in Community Outpatients With Chronic Pain

"Currently Dr. Stieg sees patients in a private practice in Frisco, Colorado 2 days per week and until 2014 served as Medical Director of the Centennial Rehabilitation Associates, a private institution in Aurora that offered several outpatient programs for patients with traumatic brain injuries, chronic pain and concurrent psychiatric disorders, including addiction to prescription and illicit drugs."

Curriculum Vitae

 

[Disciple]

Clarification: I'm not doing enough because I'm not resourced enough to do it. Every single one of these "high needs, medically complex pain patients" is a medico-legal tar-baby and a negative financial event. You can be busy all day and go broke seeing these people. Pay what work is worth, and set aside the hocus-pocus health system accounting (SOS, wrap fees, differential reimbursement schedules, etc), and I believe that work would get done and get done well.

There you go.

My point in all this-Let's not look down on colleagues because they don't want to work for peanuts.

 

[101N]

Can I ask:

How many patients you see a day? 15-20
(By yourself or with midlevel)? I recruited a friend - ANP - who works with our clinic 2d/wk.We have an excellent PharmD who
is seeing FMS patients on schedule 3-4 1/2d per week in a 'collaborative practice agreement' and another pain/PMR doc for .12FTE.
Does your employer push you to see more patients each day than you currently are/expand your clinic/add other providers/etc?
My employer is very supportive as is the community and the state. I tend toward the work-a-holic personality so I push myself.
Are you production based or straight salary? Right now straight salary.
How did you go about getting this job? Just approached a hospital system and said "I will manage all your narcs trying to reign into CDC guidlines as best as possible for 50% MGMA"?? Long story, but my bosses used to house a traditional pain clinic and it was lucrative.
But the community - to their credit - realized that pills and procedures weren't in the best interests of patients. The medical board
pointed them toward me and I pitched them.

Thanks in advance!

BTW: Duct & 61 are both very interested in this model. It will get more refined as more smart young folks get involved.

 

[Ducttape]

I would be fearful that the impression would develop that IPM to make oodles of money and contribute to the opioid crisis (I am not saying that anyone on this board is guilty of this, to be clear), but it is not okay for them to put in their piece to help fix what they wrought?

if that were the case, then IPM is no better - no worse - than interventional orthopedics or fusion focused spine surgeons.

I have been party to this already, 8 years ago, where one of the community private pain doctors elected to only do procedures and sent patients to the University pain clinic with the express purpose of prescribing the opioids.

 

[LoveMyBuckeye]

This:

BTW: Duct & 61 are both very interested in this model. It will get more refined as more smart young folks get involved.

I am about to start fellowship in July, and while I certainly desire to be a skilled proceduralist (including SCS) and know that with my training program I will be - I am motivated by being a good doc who serves the needs of my community first and foremost. I see the only place to really do this well as being academics, which is fine because I like doing research as well. Do y’all agree that academics is the best place to practice an appropriate balance of medical management and IPM? I hear about guys a year ahead of me eager to do injections for a chiro group in Tahoe making close to $700K... and it makes me have no hope for being a good pain doc in PP. is there truly appetite for better models out there?

 

[hyperalgesia]

This:



I am about to start fellowship in July, and while I certainly desire to be a skilled proceduralist (including SCS) and know that with my training program I will be - I am motivated by being a good doc who serves the needs of my community first and foremost. I see the only place to really do this well as being academics, which is fine because I like doing research as well. Do y’all agree that academics is the best place to practice an appropriate balance of medical management and IPM? I hear about guys a year ahead of me eager to do injections for a chiro group in Tahoe making close to $700K... and it makes me have no hope for being a good pain doc in PP. is there truly appetite for better models out there?

You can have an ethically sound and rewarding pp still. You're not gonna make 700k in Tahoe but you can still do well.

Some helpful ingredients are:
-Willingness to handle socially challenging pts who pay nothing. You don't have to give them what they want but making an effort to assist the Pcp with managing these types of pts will make you popular with referring docs.

-Flexibility in where you practice. Go to an area that is underserved. Making money ethically is not about you.

-Learn to love marketing yourself. If you don't make a constant effort, either through advertising or personal diplomacy, your competitors will.

- Learn the business side of things.

 

[244913]

This:



I am about to start fellowship in July, and while I certainly desire to be a skilled proceduralist (including SCS) and know that with my training program I will be - I am motivated by being a good doc who serves the needs of my community first and foremost. I see the only place to really do this well as being academics, which is fine because I like doing research as well. Do y’all agree that academics is the best place to practice an appropriate balance of medical management and IPM? I hear about guys a year ahead of me eager to do injections for a chiro group in Tahoe making close to $700K... and it makes me have no hope for being a good pain doc in PP. is there truly appetite for better models out there?

Ethical pain medicine is a moveable feast

Academics, and hospital employee jobs give you the chance to work within a health system and opioid free clinics are fairly common, esp. at the universities and in the VA system

Depending on the market saturation of your chosen location, you may have some very lean years if you don't prescribe opioids, b/c your competitors have midlevels who will.

The typical PP model- not necessarily reflective of how posters on this board practice- is a proceduralist seeing new patients and injecting them (often on the same day) and a midlevel in the bowels of the office keeping everyone on opioids.

As procedural reimbursement falls, these models try to make up the $$ shortfall by increasing procedure volume. Opioids grease the procedural skids, so to speak

So if opioids aren't your thang, do some very careful research on the places you want to work.

Etherbunny and Hoya11 both took well paying PP pain jobs, Ether from an academic job and Hoya out of fellowship and their experiences might be instructive for you.

- ex 61N

 

[emd123]

This:



I am about to start fellowship in July, and while I certainly desire to be a skilled proceduralist (including SCS) and know that with my training program I will be - I am motivated by being a good doc who serves the needs of my community first and foremost. I see the only place to really do this well as being academics, which is fine because I like doing research as well. Do y’all agree that academics is the best place to practice an appropriate balance of medical management and IPM? I hear about guys a year ahead of me eager to do injections for a chiro group in Tahoe making close to $700K... and it makes me have no hope for being a good pain doc in PP. is there truly appetite for better models out there?

You absolutely can have hope of being a good, ethical pain doc in PP. Do the right thing. And just as important, is to match your lifestyle to your income, don't try to match your income to your lifestyle. Live on 90% of your income and you'll always feel rich, no matter how much your income is. Live on 110% of your income and you'll always feel poor, no matter how much you earn. And that way there's no temptation to do the unethical, out of desperation or greed.

 

[emd123]

Let's not be deceived by those who are naive or willfully blind, and want to think and preach that academic practices and employed jobs are shelters from ethical temptations or lapses. Hospitals often exert their own pressure for their MDs to order expensive tests within the hospital system, and provide unnecessary, costly care to maximize profits. The RVU system often used in hospital-employed settings provides the same exact motivations for physicians to perform procedures and surgeries for the profit motive. Academics often push people to do research to survive. This has at times led to shady or outright falsified, dishonest research. Don't forget that many of of the Founding Fathers of the American opiate overdose epidemic were not only in organized medicine and academics, but at the highest levels. So if anyone thinks being in an employed or academic environment shields them from ethical temptations, they're kidding themselves. Where there are humans, there will be some percentage of them doing the wrong thing. One has to have his own conscious, and be his own guide.

 

[drusso]

Let's not be deceived by those who are naive or willfully blind, and want to think and preach that academic practices and employed jobs are shelters from ethical temptations or lapses. Hospitals often exert their own pressure for their MDs to order expensive tests within the hospital system, and provide unnecessary, costly care to maximize profits. The RVU system often used in hospital-employed settings provides the same exact motivations for physicians to perform procedures and surgeries for the profit motive. Academics often push people to do research to survive. This has at times led to shady or outright falsified, dishonest research. Don't forget that many of of the Founding Fathers of the American opiate overdose epidemic were not only in organized medicine and academics, but at the highest levels. So if anyone thinks being in an employed or academic environment shields them from ethical temptations, they're kidding themselves. Where there are humans, there will be some percentage of them doing the wrong thing. One has to have his own conscious, and be his own guide.

Employed vs. Independent: Doctors Speak Out | Physicians Practice

"Hospitals wants to have high throughput and high quotas. That’s how they get paid. As a hospitalist, I had 15-20 patients on my roster per day, including a few discharges and admissions per day. You got paid for doing more; the quality was secondary. You get paid by CPTs codes, so if you can rack up more CPT codes that means more [relative value units], which means more compensation. That's the bottom line," Roussel says. "That's frustrating because RVUs don't translate to better patient [care]."

Being independent gives him peace of mind and the ability to create his own schedule, rather than chasing a carrot on a stick on a treadmill. In turn, he can provide better care to his patients, rather than seeing them as a means to fill a quota. Thus far, his DPC practice is half full and thanks to an aggressive marketing plan, he expects it to be completely booked within the next year."

 

[244913]

Let's not be deceived by those who are naive or willfully blind, and want to think and preach that academic practices and employed jobs are shelters from ethical temptations or lapses. Hospitals often exert their own pressure for their MDs to order expensive tests within the hospital system, and provide unnecessary, costly care to maximize profits. The RVU system often used in hospital-employed settings provides the same exact motivations for physicians to perform procedures and surgeries for the profit motive. Academics often push people to do research to survive. This has at times led to shady or outright falsified, dishonest research. Don't forget that many of of the Founding Fathers of the American opiate overdose epidemic were not only in organized medicine and academics, but at the highest levels. So if anyone thinks being in an employed or academic environment shields them from ethical temptations, they're kidding themselves. Where there are humans, there will be some percentage of them doing the wrong thing. One has to have his own conscious, and be his own guide.

Do you think that the fee for service model encourages practitioners to perform highly (relatively) reimbursed procedures and surgeries? Of course it does. Academics and hospital employed positions are not immune I suppose, but if you are being paid a salary - which in some cases is not RVU based- then it stands to reason that your decision to perform a particular procedure or surgery is necessarily less dependent on the financial considerations.

I think it would be an interesting, albeit impossible, experiment to take the most procedure heavy specialties (Ortho, Ophtho, Pain) and just pay them straight up MGMA 50% salary that is not dependent at all on procedural revenue. Maybe give them more compensated vacation or something. I wonder what would happen to procedure volumes, number of surgeries in that setting?

Why do my group's neurosurgeons- who are salaried- frequently decline to operate, and in fact say they never would have operated in the first place- on some of the fusion revisions that come through our doors from the community? You know the type- 45 yo smoker on disability with mild facet changes on MRI...

I do agree with you that ethical pain medicine is a moveable feast. But let's not kid ourselves about where most of the pills-shots-UDS abuses occur.

- ex 61N

 

[101N]

The same can be said for Kaiser's Ortho, Ophtho, and pain specialists.

 

[Disciple]

I think it would be an interesting, albeit impossible, experiment to take the most procedure heavy specialties (Ortho, Ophtho, Pain) and just pay them straight up MGMA 50% salary that is not dependent at all on procedural revenue. Maybe give them more compensated vacation or something. I wonder what would happen to procedure volumes, number of surgeries in that setting?

Why would that be impossible? That's Kaiser in a nutshell.

 

[Disciple]

Can I ask:

How many patients you see a day? 15-20
(By yourself or with midlevel)? I recruited a friend - ANP - who works with our clinic 2d/wk.We have an excellent PharmD who
is seeing FMS patients on schedule 3-4 1/2d per week in a 'collaborative practice agreement' and another pain/PMR doc for .12FTE.
Does your employer push you to see more patients each day than you currently are/expand your clinic/add other providers/etc?
My employer is very supportive as is the community and the state. I tend toward the work-a-holic personality so I push myself.
Are you production based or straight salary? Right now straight salary.
How did you go about getting this job? Just approached a hospital system and said "I will manage all your narcs trying to reign into CDC guidlines as best as possible for 50% MGMA"?? Long story, but my bosses used to house a traditional pain clinic and it was lucrative.
But the community - to their credit - realized that pills and procedures weren't in the best interests of patients. The medical board
pointed them toward me and I pitched them.

Thanks in advance!
Click to expand...

BTW: Duct & 61 are both very interested in this model. It will get more refined as more smart young folks get involved.

101,

If you are willing, and can distill it into a post, please take us on your journey from run-of-the-mill IPM/Interventional Spine doctor, to Deprescribing Renaissance Man.

 

[emd123]

I think it would be an interesting, albeit impossible, experiment to take the most procedure heavy specialties (Ortho, Ophtho, Pain) and just pay them straight up MGMA 50% salary that is not dependent at all on procedural revenue. Maybe give them more compensated vacation or something. I wonder what would happen to procedure volumes, number of surgeries in that setting?

The utopian concept of paying doctors (or anyone else, for that matter) to do as little as possible, or even to do just somewhat less, isn't real. It's literally, not a thing. We are, and always will be, paid to do what we do, and no reasonable employer is going to pay us, or anyone else more, the less we do.

You can wax philosophical all you want about 'eliminating' the profit motive, but when you take it to it's logical conclusion, it's pure fantasy. It would be very easy to set up, in theory only. At the beginning of the year give everyone a contract that guarantees them MGMA average. And you attach to it an RVU system, but an inverse RVU system. All RVU generating office visits, procedures, surgeries or tests ordered are deducted from your guaranteed yearly salary. instead of getting paid more, the more you work and the more bills you run up, it's the opposite. The more you do, the more patients an internist sees, the more surgeries a surgeon does, the more procedures you and I do, the less we make.

See! Easy! Problem fixed!

With that system, nobody would order any tests, do any procedures, see any patients or do any surgeries. And your profit motivated, cost inflating problem is gone. AND......Also.....you're patient's get no care, your hospitals go out of business and the insurance companies all go bankrupt become no one needs them. For example, if you had a system where the doctor is given a flat salary and can see anywhere from 0 to 10,000 patients a year, and still make his salary with no penalty and no financial incentive to see more, no doctor in his right mind, would assume the liability of seeing a single patient. Even if you created a floor or minimum patients (which is itself creating a financial motivation to see more patients), still there's no incentive to take on the liability of going over the limit, even by one patient.

In reality, the more productive you are the more you get paid. Period. The less productive you are, the less you get paid. This is how it is in every line of work, every industry and always will be. It's no different for doctors and never will be.

There has to be some financial incentive for people to work, be productive and do their job, otherwise if you pay them more the less they do, they'll do nothing. In whatever payment model you describe, even in an academic or employed position, there's always, ALWAYS, some motivator to spur the doctor to do his job, even if it's simply termination, if his productivity falls below a certain level. And if a physician's duty is to operate, do procedures, or see patients, then that's what they'll do. Employers are going to pay us to work. They're not going to pay us not to work. Anything to the contrary is just focus-group, fantasy-land talk, coming out of some committee of people who have no real clue how the real world works.

The utopian concept of paying doctors (or anyone else, for that matter) to do as little as possible, or even to do just somewhat less, isn't real. It's literally, not a thing. We are, and always will be, paid to do what we do, and no reasonable employer is going to pay us, or anyone else more, the less we do.

Bottom line: If you pay people to work, they'll work. If you don't, they won't.

 

[drusso]

The utopian concept of paying doctors (or anyone else, for that matter) to do as little as possible, or even to do just somewhat less, isn't real. It's literally, not a thing. We are, and always will be, paid to do what we do, and no reasonable employer is going to pay us, or anyone else more, the less we do.

You can wax philosophical all you want about 'eliminating' the profit motive, but when you take it to it's logical conclusion, it's pure fantasy. It would be very easy to set up, in theory only. At the beginning of the year give everyone a contract that guarantees them MGMA average. And you attach to it an RVU system, but an inverse RVU system. All RVU generating office visits, procedures, surgeries or tests ordered are deducted from your guaranteed yearly salary. instead of getting paid more, the more you work and the more bills you run up, it's the opposite. The more you do, the more patients an internist sees, the more surgeries a surgeon does, the more procedures you and I do, the less we make.

See! Easy! Problem fixed!

With that system, nobody would order any tests, do any procedures, see any patients or do any surgeries. And your profit motivated, cost inflating problem is gone. AND......Also.....you're patient's get no care, your hospitals go out of business and the insurance companies all go bankrupt become no one needs them. For example, if you had a system where the doctor is given a flat salary and can see anywhere from 0 to 10,000 patients a year, and still make his salary with no penalty and no financial incentive to see more, no doctor in his right mind, would assume the liability of seeing a single patient. Even if you created a floor or minimum patients (which is itself creating a financial motivation to see more patients), still there's no incentive to take on the liability of going over the limit, even by one patient.

In reality, the more productive you are the more you get paid. Period. The less productive you are, the less you get paid. This is how it is in every line of work, every industry and always will be. It's no different for doctors and never will be.

There has to be some financial incentive for people to work, be productive and do their job, otherwise if you pay them more the less they do, they'll do nothing. In whatever payment model you describe, even in an academic or employed position, there's always, ALWAYS, some motivator to spur the doctor to do his job, even if it's simply termination, if his productivity falls below a certain level. And if a physician's duty is to operate, do procedures, or see patients, then that's what they'll do. Employers are going to pay us to work. They're not going to pay us not to work. Anything to the contrary is just focus-group, fantasy-land talk, coming out of some committee of people who have no real clue how the real world works.

The utopian concept of paying doctors (or anyone else, for that matter) to do as little as possible, or even to do just somewhat less, isn't real. It's literally, not a thing. We are, and always will be, paid to do what we do, and no reasonable employer is going to pay us, or anyone else more, the less we do.

Bottom line: If you pay people to work, they'll work. If you don't, they won't.

It's time to ban productivity from medicine

It’s time to ban productivity from medicine
ROBERT CENTOR, MD | POLICY | SEPTEMBER 25, 2017

According to Wikipedia, “Productivity describes various measures of the efficiency of production. A productivity measure is expressed as the ratio of output to inputs used in a production process, i.e., output per unit of input. Productivity is a crucial factor in production performance of firms and nations.”

Please tell me how this relates to being a physician or a patient. We do not produce anything. Rather we work with individuals to diagnosis, prevent, treat, and hopefully improve both longevity and quality of life.

Physicians work with individual patients. We should strive to tailor care with our patient.

Productivity implies that we can count patient units. That idea really disrupts the essential “why” question?

If you are unfamiliar with “why,” I highly recommend Simon Sinek’s book Start With Why. Why did we become physicians? I think the answer for most physicians includes helping individual patients. We strive to do our best for each patient.

Where did productivity enter our profession? Most experts believe that Hsaio’s NEJM article, “Estimating Physicians’ Work for a Resource-Based Relative-Value Scale,” led to RVUs (relative value units) which many practice administrators use to measure “productivity.” Hsaio, a noted economist, wrote in the abstract of that article:

We found that physicians can rate the relative amount of work of the services within their specialty directly, taking into account all the dimensions of work. Moreover, these ratings are highly reproducible, consistent, and therefore probably valid.

However, this model has led to gaming the system, and equating RVUs with hard work or productivity. But many physicians believe that the RVU system provides many wrong incentives, the most important being that shortening visit time leads to more patients per day and thus more money.

I wish physicians could just ignore RVUs and spend appropriate time with each patient. When physicians try to do this, practice administrators work to get physicians to see patients faster.

This leads to great stress for many physicians, and often unhappy patients. Many physicians believe that shorter visits (especially with primary care physicians) lead to more testing and consultations.

Productivity implies that seeing more patients each day is a good thing. But likely most patients and physicians will agree that we need to optimize the time with each patient. How many patients can we comfortably see in one day and deliver high-quality care? High-quality care does not refer to performance measures, but rather complex multi-dimensional factors that improve the patient experience. For many patients, talking is both therapeutic and diagnostic. We shorten our conversation time at the risk of diagnostic errors, higher health care costs, and dissatisfied, confused patients.

So please join the movement to ban productivity from medicine. We are not producing anything. We are caring for patients who need our full attention.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

 

[emd123]

It's time to ban productivity from medicine

It’s time to ban productivity from medicine
ROBERT CENTOR, MD | POLICY | SEPTEMBER 25, 2017

According to Wikipedia, “Productivity describes various measures of the efficiency of production. A productivity measure is expressed as the ratio of output to inputs used in a production process, i.e., output per unit of input. Productivity is a crucial factor in production performance of firms and nations.”

Please tell me how this relates to being a physician or a patient. We do not produce anything. Rather we work with individuals to diagnosis, prevent, treat, and hopefully improve both longevity and quality of life.

Physicians work with individual patients. We should strive to tailor care with our patient.

Productivity implies that we can count patient units. That idea really disrupts the essential “why” question?

If you are unfamiliar with “why,” I highly recommend Simon Sinek’s book Start With Why. Why did we become physicians? I think the answer for most physicians includes helping individual patients. We strive to do our best for each patient.

Where did productivity enter our profession? Most experts believe that Hsaio’s NEJM article, “Estimating Physicians’ Work for a Resource-Based Relative-Value Scale,” led to RVUs (relative value units) which many practice administrators use to measure “productivity.” Hsaio, a noted economist, wrote in the abstract of that article:

We found that physicians can rate the relative amount of work of the services within their specialty directly, taking into account all the dimensions of work. Moreover, these ratings are highly reproducible, consistent, and therefore probably valid.

However, this model has led to gaming the system, and equating RVUs with hard work or productivity. But many physicians believe that the RVU system provides many wrong incentives, the most important being that shortening visit time leads to more patients per day and thus more money.

I wish physicians could just ignore RVUs and spend appropriate time with each patient. When physicians try to do this, practice administrators work to get physicians to see patients faster.

This leads to great stress for many physicians, and often unhappy patients. Many physicians believe that shorter visits (especially with primary care physicians) lead to more testing and consultations.

Productivity implies that seeing more patients each day is a good thing. But likely most patients and physicians will agree that we need to optimize the time with each patient. How many patients can we comfortably see in one day and deliver high-quality care? High-quality care does not refer to performance measures, but rather complex multi-dimensional factors that improve the patient experience. For many patients, talking is both therapeutic and diagnostic. We shorten our conversation time at the risk of diagnostic errors, higher health care costs, and dissatisfied, confused patients.

So please join the movement to ban productivity from medicine. We are not producing anything. We are caring for patients who need our full attention.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

Go ahead. Ban productivity.

"Produce nothing, still get paid."

It's like winning the lottery. No need to work, no need to produce, in fact you're a bad guy if you do work, because you're "generating healthcare costs." You'll be shamed, sneered at, shunned. I'd love to get paid to just sit here, see no patients, and read all the classic books ever written, and get paid for it. Imagine all the money we'll save!

Elect Robert Centor President of AMA. Hell, elect him President of the United States, if he can find a way for me to get paid my salary, without every having to work or be "productive.' But the reality of the matter is, that "banning productivity," banning fee for service or eliminating financial motivations for doctors to do their jobs, will never happen, because it's impossible. It's as much fantasy as leprechauns and unicorns.

Why the hell do all the powers that be keep talking about "banning" productivity, like it's some threat?

If it's such a panacea, just do it. Pay us all a flat salary, whether we see 0 patients or 10,000. Let it be up to the doctor. No incentive to "produce" anything, generate any office visits, patient encounters, RVUs, procedures, surgeries, nothing. What are they waiting for?

I'm calling their bluff, right here and right now. Just do it. Ban it. Ban productivity and financial incentive for physicians 100%, right now.

 

[Ducttape]

The utopian concept of paying doctors (or anyone else, for that matter) to do as little as possible, or even to do just somewhat less, isn't real. It's literally, not a thing. We are, and always will be, paid to do what we do, and no reasonable employer is going to pay us, or anyone else more, the less we do.

You can wax philosophical all you want about 'eliminating' the profit motive, but when you take it to it's logical conclusion, it's pure fantasy. It would be very easy to set up, in theory only. At the beginning of the year give everyone a contract that guarantees them MGMA average. And you attach to it an RVU system, but an inverse RVU system. All RVU generating office visits, procedures, surgeries or tests ordered are deducted from your guaranteed yearly salary. instead of getting paid more, the more you work and the more bills you run up, it's the opposite. The more you do, the more patients an internist sees, the more surgeries a surgeon does, the more procedures you and I do, the less we make.

See! Easy! Problem fixed!

With that system, nobody would order any tests, do any procedures, see any patients or do any surgeries. And your profit motivated, cost inflating problem is gone. AND......Also.....you're patient's get no care, your hospitals go out of business and the insurance companies all go bankrupt become no one needs them. For example, if you had a system where the doctor is given a flat salary and can see anywhere from 0 to 10,000 patients a year, and still make his salary with no penalty and no financial incentive to see more, no doctor in his right mind, would assume the liability of seeing a single patient. Even if you created a floor or minimum patients (which is itself creating a financial motivation to see more patients), still there's no incentive to take on the liability of going over the limit, even by one patient.

In reality, the more productive you are the more you get paid. Period. The less productive you are, the less you get paid. This is how it is in every line of work, every industry and always will be. It's no different for doctors and never will be.

There has to be some financial incentive for people to work, be productive and do their job, otherwise if you pay them more the less they do, they'll do nothing. In whatever payment model you describe, even in an academic or employed position, there's always, ALWAYS, some motivator to spur the doctor to do his job, even if it's simply termination, if his productivity falls below a certain level. And if a physician's duty is to operate, do procedures, or see patients, then that's what they'll do. Employers are going to pay us to work. They're not going to pay us not to work. Anything to the contrary is just focus-group, fantasy-land talk, coming out of some committee of people who have no real clue how the real world works.

The utopian concept of paying doctors (or anyone else, for that matter) to do as little as possible, or even to do just somewhat less, isn't real. It's literally, not a thing. We are, and always will be, paid to do what we do, and no reasonable employer is going to pay us, or anyone else more, the less we do.

Bottom line: If you pay people to work, they'll work. If you don't, they won't.

actually, it is a thing, called capitated medicine. very popular during the 80s, and in one community, actually worked very well...

you are exactly touching on the reason for the problem with healthcare, and with medicine as a whole. it is a fee for service system, and one in which procedural medicine is more highly reimbursed. ironically, while we as doctors are taught to think, we are paid better when we just do. you make a lot more being a technician than a thinker.

 

[emd123]

So what I am driving at is perhaps we need to shift the focus in pain from making a lot of $$$$- by doing a lot of procedures...which require a lot of opioids in exchange- to some other metric.

- ex 61N

What other metric?

 

[244913]

What other metric?

That's for people smarter than me to decide. I know it shouldn't be solely be $$$

What do you suggest?

 

[emd123]

That's for people smarter than me to decide. I know it shouldn't be solely be $$$

What do you suggest?

That's for people smarter than me to decide. I know it shouldn't be solely be $$$

What do you suggest?

You have to pay people for their work. There's no other measure.

 

[101N]

There's hope.

 

[Ducttape]

You have to pay people for their work. There's no other measure.

basing injections on this is the wrong metric to use.

it encourages overuse of procedures and injections. it encourages increasing dollars in to healthcare. it encourages doctors to not think about best patient care and to think about, well, making money. by doing more injections. by doing more MRIs. by doing more lab tests. etc.


patient improvement (not through bogus Press Ganey scores, tho), patient satisfaction and safety, reduced opioid prescribing, maintenance of work status, reduced number of ER visits, those are a few right off the top of my head that are not being utilized but could have a positive impact both on patient health and on the overwhelming amount of money we spend on medical care...

 

[emd123]

Not everyone falls into a VA mentality when their paycheck doesn't depend on "productivity." I think that's a strawman argument. What about internal motivations- doing good for your health system, doing good for your society? Some of us- myself included- are workaholic types and just plain enjoy working for the sake of doing it. I was an Army flight surgeon for 4 years. I spent 19 months in Afghanistan. When I was stateside I saw more patients in my aid station than the next 3 flight surgeons combined. Trust me, I wasn't doing it for the money. That was a truly "socialized" system.



- ex 61N

I respect your opinion. You bring up some very good points. And you're right to mention a "truly socialized system," because that's the only system that eliminates the profit, ie, productivity motivations. If that's what you want, just say it. You want socialism. Fine. There are people that believe in socialism and want it to take over their industry and maybe the whole country. And that's really what this whole push for eliminating fee for service, because outside of socialism, there's no other way to pay people to work, other than to pay them to do their work, a certain amount. I'm happy to brainstorm about it, but as long as we have any element of capitalism or profits occurring in healthcare, and be sure the hospitals and insurance companies absolutely are not about to give that up, no employer in their right mind will pay anyone more, to do less.

Also, I think your comment on the VA is interesting, in that your post advocates for a socialist type system, where we entrust everyone to have a "workaholic" type mentality out of the goodness of their own heart such as yourself. Yet at the same time, you admit perhaps by accident that under this exact system (the VA) where productivity is not the motivator, has fallen into a "VA mentality" (your words, not mine). That implies that without motivating people to be more productive, they (maybe not you, or I, but the majority) fall into a mentality exactly the opposite of the hard-driving, hard working mentality you claim should be the standard. This supports my point, that you need a productivity motive, for people (maybe not you or I, but most) to stay maximally productive. Otherwise, we'd have gone to a VA type system nationally a long time ago, and you and I would be furious, calling our Congressmen weekly, to let us go to the VA to get our care. But in reality, it's the opposite. Vets instead clamour to be allowed to go outside of that system.

So, if you believe in socialism, you've found your other payment system and other motivator, as opposed to productivity. It's to work for the goal of "doing good for your health system, doing good for your society." But if you don't think socialism works, or you don't want to work in a socialists system where the laziest and least productive and least hardworking get paid the same as the most hard working and most productive, then you need to pay the most productive, to be the most productive.

Personally, I make about MGMA for Anesth/IPM. I'd gladly take MGMA average and be released from any productivity requirements, demands or incentives. I'd take that in a nanosecond. But how do you do it? Pass a law require every group and hospital to take only IPM of any productivity based payment? Outlaw the free market? Ban for profit hospitals? Ban for-profit MD groups? Ban for-profit insurance companies?

But as somebody who has a role in running a 40 provider (39 of them, not IPM), 5-office multispecialty group, anytime we've had people off contracts that pay based on productivity, with no productivity incentive or requirements, productivity of those physician employees lags, and the company takes a blood-bath of losses. Of course there are highly motivated exceptions, but more often than not, people end up taking more time off, leave early, block the schedule and eventually don't generate enough collections to support their salary. As a board member of my group, I'd be negligent if I recommended and voted to take all our physician employees off productivity based contracts. And there's no way hospitals are going to pay doctors and not hold them accountable for generating enough revenue to pay their own salaries or justify their practice or department's existence. If this was profitable, trust me, every CEO and hospital board of directors in the country would be doing it. But it's not. It leads to losses, not profits, and no economic system (not even socialism) tolerates losses, for very long.

But that's just my opinion. We don't have to agree. It's okay.

 

[emd123]

There's hope.

There is always hope.

 

[drusso]

I respect your opinion. You bring up some very good points. And you're right to mention a "truly socialized system," because that's the only system that eliminates the profit, ie, productivity motivations. If that's what you want, just say it. You want socialism. Fine. There are people that believe in socialism and want it to take over their industry and maybe the whole country. And that's really what this whole push for eliminating fee for service, because outside of socialism, there's no other way to pay people to work, other than to pay them to do their work, a certain amount.

I find it instructive that the people advocating for socialism & socialized medicine on this forum have never really had skin in the game---taken out a small business loan, struggled to make payroll, pay others for months on end before paying oneself, etc.

 

[SSdoc33]

I respect your opinion. You bring up some very good points. And you're right to mention a "truly socialized system," because that's the only system that eliminates the profit, ie, productivity motivations. If that's what you want, just say it. You want socialism. Fine. There are people that believe in socialism and want it to take over their industry and maybe the whole country. And that's really what this whole push for eliminating fee for service, because outside of socialism, there's no other way to pay people to work, other than to pay them to do their work, a certain amount. I'm happy to brainstorm about it, but as long as we have any element of capitalism or profits occurring in healthcare, and be sure the hospitals and insurance companies absolutely are not about to give that up, no employer in their right mind will pay anyone more, to do less.

Also, I think your comment on the VA is interesting, in that your post advocates for a socialist type system, where we entrust everyone to have a "workaholic" type mentality out of the goodness of their own heart such as yourself. Yet at the same time, you admit perhaps by accident that under this exact system (the VA) where productivity is not the motivator, has fallen into a "VA mentality" (your words, not mine). That implies that without motivating people to be more productive, they (maybe not you, or I, but the majority) fall into a mentality exactly the opposite of the hard-driving, hard working mentality you claim should be the standard. This supports my point, that you need a productivity motive, for people (maybe not you or I, but most) to stay maximally productive. Otherwise, we'd have gone to a VA type system nationally a long time ago, and you and I would be furious, calling our Congressmen weekly, to let us go to the VA to get our care. But in reality, it's the opposite. Vets instead clamour to be allowed to go outside of that system.

So, if you believe in socialism, you've found your other payment system and other motivator, as opposed to productivity. It's to work for the goal of "doing good for your health system, doing good for your society." But if you don't think socialism works, or you don't want to work in a socialists system where the laziest and least productive and least hardworking get paid the same as the most hard working and most productive, then you need to pay the most productive, to be the most productive.

Personally, I make about MGMA for Anesth/IPM. I'd gladly take MGMA average and be released from any productivity requirements, demands or incentives. I'd take that in a nanosecond. But how do you do it? Pass a law require every group and hospital to take only IPM of any productivity based payment? Outlaw the free market? Ban for profit hospitals? Ban for-profit MD groups? Ban for-profit insurance companies?

But as somebody who has a role in running a 40 provider (39 of them, not IPM), 5-office multispecialty group, anytime we've had people off contracts that pay based on productivity, with no productivity incentive or requirements, productivity of those physician employees lags, and the company takes a blood-bath of losses. Of course there are highly motivated exceptions, but more often than not, people end up taking more time off, leave early, block the schedule and eventually don't generate enough collections to support their salary. As a board member of my group, I'd be negligent if I recommended and voted to take all our physician employees off productivity based contracts. And there's no way hospitals are going to pay doctors and not hold them accountable for generating enough revenue to pay their own salaries or justify their practice or department's existence. If this was profitable, trust me, every CEO and hospital board of directors in the country would be doing it. But it's not. It leads to losses, not profits, and no economic system (not even socialism) tolerates losses, for very long.

But that's just my opinion. We don't have to agree. It's okay.

E/M remuneration should go up. CPT remuneration should go down. problem solved. that way, harder workers still get rewarded.

But you are right, in today's fee for service model, straight salary doesnt make sense.

 

[emd123]

E/M remuneration should go up. CPT remuneration should go down. problem solved. that way, harder workers still get rewarded.

But you are right, in today's fee for service model, straight salary doesnt make sense.

In 2014, when they took IPM CPT payment way down, they only increased E/M payment up a fraction. The reason is, that the relative fraction of people practicing IPM is so small, compared to primary care, so cutting reimbursement to IPM, didn't free up a meaningful or noticeable amount of money to be spread into E/M codes, which are shared by nearly everyone. And to get CMS to increase E/M payment in a game changing way, will be next to impossible since these are non-specialty specific, and everyone uses the, which amounts to a massive, massive number of physicians. An increase in more than a percent or two in E/M codes is a budget buster for CMS, whereas making big cuts to one small/smallish speciality's CPT codes doesn't save much money at all, comparatively.

 

[SSdoc33]

In 2014, when they took IPM CPT payment way down, they only increased E/M payment up a fraction. The reason is, that the relative fraction of people practicing IPM is so small, compared to primary care, so cutting reimbursement to IPM, didn't free up a meaningful or noticeable amount of money to be spread into E/M codes, which are shared by nearly everyone. And to get CMS to increase E/M payment in a game changing way, will be next to impossible since these are non-specialty specific, and everyone uses the, which amounts to a massive, massive number of physicians. An increase in more than a percent or two in E/M codes is a budget buster for CMS, whereas making big cuts to one small/smallish speciality's CPT codes doesn't save much money at all, comparatively.

hey, i didnt say how it would happen, just that it should. and if you slash cpt codes across the board, it would free up a lot of cash.

im not necessarily advocating for this change, but i do think it would probably improve outcomes

 

[mid|ine]

Does everyone even accept the premise, that there will be a shortage?

Personally, I believe there is a glut of healthcare. This is definitely the case in PM. Doctors need to fill their time. If they don't have great candidates for treatments they have to offer, all to often docs use non-indicated treatments or poor patient selection, resulting in poor responses and outcomes to those treatments.

What we need (though wont get), is a complete change that promotes patient personal responsibility for improving and maintaining their own health, and helps give them the tools to do that, primarily through improving diet and exercise.

 

[Ducttape]

no offense, but I think clinic days are much harder work and much more challenging than injection days.

my injection day is called "my fun day".

and drusso, one may make the inverse argument - should the primary determinant of healthcare policy be based on the opinion of individuals who are uniquely focused on financial reimbursement? do we ask drug dealers if the Feds should enforce drug laws? or the NRA to decide on gun laws oh snap, nm

 

[drusso]

and drusso, one may make the inverse argument - should the primary determinant of healthcare policy be based on the opinion of individuals who are uniquely focused on financial reimbursement? do we ask drug dealers if the Feds should enforce drug laws? or the NRA to decide on gun laws oh snap, nm

I had no slow down this year and we have a waiting list. I think that there is a shortage, but I think that the required skills required to this work are going to change.

 

[emd123]

...But I did spend two tours patching up young kids in medevac helicopters- young, white/black/hispanic, high school education and very often from the wrong side of the tracks...
- ex 61N

This reminds me of my 11 year 'tour' in busy EDs, patching up, sewing up, splinting, coding and resuscitating a similar or possibly even less fortunate demographic. Working all times of day, week and year that no one else wants to, never being able to turn a patient away because of insurance, their problem, my specialty or lack of appointment, seeing all the patients no one else will, some drunk, high, suicidal, homicidal, acute pain, chronic pain, dead, dying, sick, not sick, discharge from their pain doctor, under arrest or not yet under arrest, on top of pushing narcan, intubating and resuscitating patients who OD'd from other peoples' opiates, with no limit on the amount of 'walk ins' one can be expected to see, or on the amount of chaos, drunken societal, dysfunction, death, dying and tragedy that blasts through your double doors.

 

[Ducttape]

okay... was that meant to discredit 61N's post?

well, I spent 16 years in the "same" tour. so there!