Increasing the Pain Specialist Pipeline

[Blitz2006]

What other metric?

There is a simple fix to all this. Reimburse much higher for medication management visits, and force physicians to spend more time (minimum 30 minutes?) with patients. Make the billing codes like Psychiatry, where you are reimbursed more with more time spent. This is why cash only psychiatrists all spend 45 minutes with their patient for therapy, 30 minutes for medication management. That is standard of care.

So why not do the same in pain? But of course, the problem in pain is, overhead costs are 50%, versus psych which is like 20%. So if you stop doing procedures and only do medication management, you will be out of business pretty soon I imagine.

And this has nothing to do with "socialized" healthcare. Canada is socialized, but it is also fee for service. Pain Doctors are easily among the highest paid in Canada (even higher than Ortho). Pain doctors in Canada can easily hit 700-800k. But again, its because of fee for service model, where procedures are reimbursed the best. So Canada has same problems that U.S does, specifically with pain management/opioid crisis.

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[Billy Jack]

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.

This. Socialism steals from the productive to give to the unproductive. All those employed MD's making 50% of IPM salaries should be grateful to their more productive PP counterparts who are driving up the productivity number.

 

[101N]

First doctorcommonsense - Russo - and now lax has found the forum

 

[drusso]

First doctorcommonsense - Russo - and now lax has found the forum

I'm not @DrCommonSense, but I do offer this in the name of balance...

Over 500 Canadian doctors protest raises, say they're being paid too much (yes, too much)

"These increases are all the more shocking because our nurses, clerks and other professionals face very difficult working conditions, while our patients live with the lack of access to required services because of the drastic cuts in recent years and the centralization of power in the Ministry of Health," reads the letter, which was published February 25.

"The only thing that seems to be immune to the cuts is our remuneration," the letter says."

 

[SSdoc33]

I'm not @DrCommonSense, but I do offer this in the name of balance...

Over 500 Canadian doctors protest raises, say they're being paid too much (yes, too much)

"These increases are all the more shocking because our nurses, clerks and other professionals face very difficult working conditions, while our patients live with the lack of access to required services because of the drastic cuts in recent years and the centralization of power in the Ministry of Health," reads the letter, which was published February 25.

"The only thing that seems to be immune to the cuts is our remuneration," the letter says."

canada is a big country. lots of doctors. this "letter" contained only 500 signatures and includes residents...... something tells me most canadian doctors arent crying foul.

sort of like "some" of us support the AMA.....

 

[Blitz2006]

canada is a big country. lots of doctors. this "letter" contained only 500 signatures and includes residents...... something tells me most canadian doctors arent crying foul.

sort of like "some" of us support the AMA.....

Correct.
Canadian physician statistics

There are 83 000 physicians in Canada. 500? just over 0.5% of physicians. This article represents the vast minority.

"the cost of running his family practice, and though he brought in $231,033 ($300,000 Canadian), he was left with $136,906 ($177,876 Canadian) after subtracting his business expenses — but before taxes and employment benefits are taken out."

I will say, PCPs in Canada do earn a lot more than PCPs in USA. I'm not saying they are overpaid, but reimbursement is far better. Because countries like UK, Canada, Australia value primary care/preventative care more than here. So while procedures are still valued more in Canada, the disparity between primary care/non-procedure based care and procedure based care is a narrower gap compared to here.

and remember, med school in Canada is a drop in the bucket compared to here:

"For Canadian citizens or permanent residents, tuition for the first year of medical school ranges from $2567 ($3,334 Canadian) to $20,064 ($26,056 Canadian)"

 

[101N]

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.

This is a long story that started in 2003 with Jane's NEJM article, 2004 with the Hurwitz trial, 2005 with DEA FAQ's fiasco, 2010 when the crew from Seattle published (Dunn et al)
published the first dose/death paper. It was around then PROP self-assembled under Andrew's guidance. What a great, inspiring group of people. There is a long line of inspiring
pain/addiction folks running from Seattle to Stanford. I'm glad I get to hang out with them as they have served as my north star during the epidemic.

I'd like to see that network expanded to New York and Virginia

 

[SeniorWrangler]

As a veteran, I'd like to note that most veterans have complaints about the VA medical system but also don't want to see it taken away and replaced with vouchers or an HMO. There's an organization called Concerned Veterans for America which advocates this, but does not represent most vets.

 

[244913]

This is a long story that started in 2003 with Jane's NEJM article, 2004 with the Hurwitz trial, 2005 with DEA FAQ's fiasco, 2010 when the crew from Seattle published (Dunn et al)
published the first dose/death paper. It was around then PROP self-assembled under Andrew's guidance. What a great, inspiring group of people. There is a long line of inspiring
pain/addiction folks running from Seattle to Stanford. I'm glad I get to hang out with them as they have served as my north star during the epidemic.

I'd like to see that network expanded to New York and Virginia

Could you post a link to a common sense taper guide that could be used by PCP's that discusses the actual mechanics of the taper, the scheduling of it, how fast to go, what to wean first etc?

Thanks

 

[cheetamorf]

Pain Doctors are easily among the highest paid in Canada (even higher than Ortho). Pain doctors in Canada can easily hit 700-800k. But again, its because of fee for service model, where procedures are reimbursed the best. So Canada has same problems that U.S does, specifically with pain management/opioid crisis.

Do you have a source for this? ....My dual citizenship all of a sudden seems a lot more valuable...

 

[101N]

Could you post a link to a common sense taper guide that could be used by PCP's that discusses the actual mechanics of the taper, the scheduling of it, how fast to go, what to wean first etc?

Thanks

Here is a start.

 

[Blitz2006]

Do you have a source for this? ....My dual citizenship all of a sudden seems a lot more valuable...

Not for pain docs, I only have anecdotal data.

But here is info on ER docs clearing 500-600k: Fifteen ER doctors made more than $400,000 each in 2016

And Ophtho making over 2 million: Eye doctors dominate list of top billers in Manitoba

So if Ophtho can make 2 million, I'll let you deduce how much pain physicians can earn in Canada.

 

[Ducttape]

that ER article is a little deceiving.

the ER docs get 60% premium above regular pay if they are working nights.

in addition, that article is not comparing ER physicians to other physicians throughout Winnipeg - only in the WRHA system, and if you scroll through the lists of people, there are only a few other physicians on the list - or I assume they are physicians if it says WRHA Medical Staff.

no cardiology, ortho, urology, etc. so who knows if this healthcare system of hospitals primarily employ any of those other physicians and what their average salary are.


In terms of the second article, those poor opthalmologists... trying so hard to justify their billing.
I was almost starting to feel sorry until I read these lines:

"In my case, I work five, sometimes six days a week to cover an area where I’m the only ophthalmologist in... a 180,000 (person) catchment area," he said, adding that he’s on call 11-13 days a month.

Rocha, who grew up in Mexico and was trained at McGill University in Montreal, said he takes only three, maybe four, weeks of vacation a year.

boo hoo hoo.

 

[Disciple]

This is devolving into a pros/cons Canadian medical system thread.

 

[anbuitachi]

Whoa- a lot to digest there. Here is what I am trying to say:

Right now, in our fee for service system, procedures are the most highly reimbursed. This is not necessarily a bad thing. We as pain specialists take more risk doing a CESI than a PCP does in managing a blood pressure medication. But the system is ripe for abuse, depending on what specialty you are talking about.

Orthopedics- community guys doing TKA's on nursing home patients with BMI's of 90
Ortho Spine- fusing smoking disabled working aged people with mild degenerative changes
GI- endoscopy/biopsy fest
Pain- needlerama, series of 3 into the sunset

As I emphasize repeatedly, guys on this board seem to practice ethically and this does not necessarily apply to you. But we all know a lot of community PP models that are solely dedicated towards generating procedural revenue.
If people were just getting injections, then it would not necessarily be so bad. A series of 3 every couple months is a lot less damaging to the person and society as a whole then fusing a young working aged person and disabling them.

The problem is that pain, and other specialties too I suppose, ensure willing procedural candidates by keeping them on opioids. I can think of 3-4 PP's in my local area alone where this is the norm. And it is the opioids, not the procedures themselves, which are so costly to the patient and society as a whole. Diversion, addiction, car accidents, abuse, inevitable disability.

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

The worst is vascular surgery. Finds demented bedridden patients, do angiogram of 1 leg, then other leg, then chop off 1 toe, then another, then another, then TMA, then BKA, then ABA, and with probably some stenting, and bypass along the way

 

[drusso]

The Burnout Crisis in American Medicine

 

[drusso]

There aren’t enough doctors to go around

"In 1997, the Balanced Budget Act capped federal funding of medical residency programs; in 2016, for example, the government spent about $10 billion, the overwhelming majority of it coming from Medicare. Most experts predicted that the cap would soon be lifted; more than 20 years later, it’s still in place. As a result, what we have now is a classic bottleneck condition: More and more people want to practice medicine while less and less funding is available to help create residency programs that meet the demand."

What do you predict will be the need for IPM over the next 20 years?

 

[willabeast]

There aren’t enough doctors to go around

"In 1997, the Balanced Budget Act capped federal funding of medical residency programs; in 2016, for example, the government spent about $10 billion, the overwhelming majority of it coming from Medicare. Most experts predicted that the cap would soon be lifted; more than 20 years later, it’s still in place. As a result, what we have now is a classic bottleneck condition: More and more people want to practice medicine while less and less funding is available to help create residency programs that meet the demand."

What do you predict will be the need for IPM over the next 20 years?

The primary innovators in the world today use technology to disrupt industries. All medical care is ripe for disruption. The answer to your question is probably in a technology pipeline somewhere, and in the future the USA will need way less doctors than we have today. When this happens many docs will be unemployed, and it won't be pretty. The transition is going to be very rough.

 

[bedrock]

The primary innovators in the world today use technology to disrupt industries. All medical care is ripe for disruption. The answer to your question is probably in a technology pipeline somewhere, and in the future the USA will need way less doctors than we have today. When this happens many docs will be unemployed, and it won't be pretty. The transition is going to be very rough.

We will see. I have many friends in silicon valley since college. They've been predicting this tech thing or this program will disrupt medical care and make doctor unneeded for the past 20 years. None of the "amazing" disruptions really changed anything. Patients will always need a human physician to treat them.

 

[willabeast]

We will see. I have many friends in silicon valley since college. They've been predicting this tech thing or this program will disrupt medical care and make doctor unneeded for the past 20 years. None of the "amazing" disruptions really changed anything. Patients will always need a human physician to treat them.

maybe you are right

 

[hyperalgesia]

The primary innovators in the world today use technology to disrupt industries. All medical care is ripe for disruption. The answer to your question is probably in a technology pipeline somewhere, and in the future the USA will need way less doctors than we have today. When this happens many docs will be unemployed, and it won't be pretty. The transition is going to be very rough.

Maybe for radiology and derm and pathology. Maybe even surgery. Human specialties like ours and psych and family med - I think it will be a long time before we can be replaced. Lay people and politicians think docs are like car mechanics, that we just input data and output a solution. They don't understand that our primary value is in relating to patients and leveling with them and educating them.

 

[jimmy johnson123]

We will see. I have many friends in silicon valley since college. They've been predicting this tech thing or this program will disrupt medical care and make doctor unneeded for the past 20 years. None of the "amazing" disruptions really changed anything. Patients will always need a human physician to treat them.

Even in fields like radiology/pathology that are ripe for silicon valley innovation including AI that can read images/slides just as well as a physician, I haven't seen much progress from silicon valley.

I would only worry about this "innovation" when I see radiologists/pathologists out of a career in mass numbers before worrying about this for any procedural physician or physician that actually sees patients.

 

[cowboydoc]

maybe you are right

You missed the best part!