Interventional radiologist starting injections

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bronchospasm

Interventional Pain Physician
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So today, I get a call from one of the referring physicians that the Interventional radiologists are trying to solicit buisness for Pain injections. Apparently, they have been doing this for the past year and are set to go live January 1st.

This is after I met with them a few months ago and they were like you are our highest referrals for MRI’s. Thank you for ordering over 450 MRI’s... blah blah blah

I am pissed that they would do this so I called the head of the radiology group and let them know that I would not be sending them any more MRI’s in a very non threatening manner.

Maybe there is a push from the hospital. They are obviously unhappy that all procedures are being done in the office.

One advice that I got from my chairman was that never to trust hospitals, they will screw you in a heartbeat. Turns out this is true.
 
They have become quite predatory, reading a MRI or x-ray ordered by a PCP or orthopedist, then calling the referring doctor recommending an injection/kyphoplasty/RF. Sometimes they don't even consult the referring physician, and do the injection anyway. This practice is effectively self referral, and hopefully the feds will eventually penalize them for this type of health care fraud.
 
I have always thought IR might be a better career path than Anesthesiology or PMR for spine injections. What is worrisome for radiologists - lots of boarded docs in low cost areas in places like India where they are happy to review MRI's and anything else that can be digitized. Someday the tech disruptors are going to go after medicine and when they do USA radiologists will be first to get badly hurt. My two cents.
 
you have to have a state medical license for the state the films are originating from. Foreign radiologists typically are not eligible or they wouldn’t be in India anymore
 
They have become quite predatory, reading a MRI or x-ray ordered by a PCP or orthopedist, then calling the referring doctor recommending an injection/kyphoplasty/RF. Sometimes they don't even consult the referring physician, and do the injection anyway. This practice is effectively self referral, and hopefully the feds will eventually penalize them for this type of health care fraud.

All this without even seeing a patient.
 
I have always thought IR might be a better career path than Anesthesiology or PMR for spine injections. What is worrisome for radiologists - lots of boarded docs in low cost areas in places like India where they are happy to review MRI's and anything else that can be digitized. Someday the tech disruptors are going to go after medicine and when they do USA radiologists will be first to get badly hurt. My two cents.

Night owl started by hiring US trained and boarded radiologists to read images by setting up offices in India and Australia. But all radiologists have to be boarded and have a license in the US.
 
All this without even seeing a patient.
Quote from "House of God" by Sam Shem. 24 - The house of God
//
The Fat Man listed these six on the blackboard and told us he would list, with our suggestions, the advantages and disadvantages of each. "Game theory," he called it. This chart would "optimize" our specialty choice.

"First," said Fats, "is Rays. Advantages of Radiology?"

"Money," said Chuck. "Big money."

"Exactly," said Fats, "a veritable fortoona. Other advantages?"

Aside from the assumed "No Patient Care," no, no one could think of any other advantages, and Fats asked for disadvantages.

"Gomers," I said. "You do bowel runs on gomers.

"Narcolepsy," said Hooper, "you're always in the dark."

"Gonads," said the Runt. "X rays can fry your sperm. Your first kid comes out with one eye, two teeth, and eight fingers to a hand.

"Terrific!" said Fats, writing them down. "Men, we're on our way!"

We proceeded to construct a table of the NPC Specialties:

SPECIALTY ADVANTAGES DISADVANTAGES

RAYS Money (100K/annum) Gomers.

Dark offices, narcolepsy.

Damaged gonads; 8?fingered progeny.

Barium enemas and bowel runs.//
 
My brother in law is a radiologist. Neuro primarily. He works a lot. Lots of partial weekends some nights. He also gets 40 days of vacation/year. He still bitches. I took 10 days off this year two of which was because of a 5mm kidney stone. I bitch. Everyone bitches.
 
our rads guys do occasional CT guided LESIs (won't touch cervical) and other joints and what not when ordered by the surgeons. they actually started hiring PAs and were teaching them to do the epidurals until we put an end to it.
 
My brother in law is a radiologist. Neuro primarily. He works a lot. Lots of partial weekends some nights. He also gets 40 days of vacation/year. He still bitches. I took 10 days off this year two of which was because of a 5mm kidney stone. I bitch. Everyone bitches.

how much does he make?

best guess or ballpark numbers acceptable?
 
this was 1978, but still. for all of our b@tching, we must be doing something right if rads is making 5x that amount right now....
That's good but how much more does a house cost now compared to 1978. I'm sure it's more than 5x
 
One of the local radiologists here puts his recs in the final report. Of course without ever seeing the patient. Usually goes... "patient with large disc extrusion at l5/S1, likely would benefit from epidural arranged through this office". I have an easy solution..... When I get a referral from the pcp after this guy does the esi (which probably isn't even appropriate as he didn't exam the patient) I specifically decline the referral and send it back with the line... "to ensure continuity of care I decline the referral and recommend the radiologist manage all aspects of the patients pain management". We will see if it makes a difference.
 
One of the local radiologists here puts his recs in the final report. Of course without ever seeing the patient. Usually goes... "patient with large disc extrusion at l5/S1, likely would benefit from epidural arranged through this office". I have an easy solution..... When I get a referral from the pcp after this guy does the esi (which probably isn't even appropriate as he didn't exam the patient) I specifically decline the referral and send it back with the line... "to ensure continuity of care I decline the referral and recommend the radiologist manage all aspects of the patients pain management". We will see if it makes a difference.
Nice thought but don’t think it will work. That because the rad is acting just like any needle jockey and not as a pain doctor. The PCP may feel you two are just alike, only caring about the wRVU for the shot alone.

Better yet would be to teach the PCP that you as a pain doctor do more than a radiologist and more than stick needles without the proper training.

Remind them that the radiologist could soon start casting their minor Injury patients instead of sending them to ortho, or prescribe Abx (they are doctors after all) to those ppl they send for CXR, or even start chemo....

Finally, let rad chief know that you won’t be sending MRIs to that location. That would be most effective.

Addendum According to this site AMGA: Median radiologist salary nears $500K , MGMA 50% for radiology in 2016 was $490,000
 
Nice thought but don’t think it will work. That because the rad is acting just like any needle jockey and not as a pain doctor. The PCP may feel you two are just alike, only caring about the wRVU for the shot alone.

Better yet would be to teach the PCP that you as a pain doctor do more than a radiologist and more than stick needles without the proper training.

Remind them that the radiologist could soon start casting their minor Injury patients instead of sending them to ortho, or prescribe Abx (they are doctors after all) to those ppl they send for CXR, or even start chemo....

Finally, let rad chief know that you won’t be sending MRIs to that location. That would be most effective.

Addendum According to this site AMGA: Median radiologist salary nears $500K , MGMA 50% for radiology in 2016 was $490,000

I agree... I don't send any imaging requests to this guy at all. Never have and never will. My thought is will be that the pcp will realize that when the random esi doesn't work for the patient they will have less options of where to send the patient. Some of the pcps were sending patients to another rads group closer to town. Told them my rules of not seeing the patient in the future if they go to rads for a procedure and that changed quickly. We will see what happens I guess over time.
 
I agree... I don't send any imaging requests to this guy at all. Never have and never will. My thought is will be that the pcp will realize that when the random esi doesn't work for the patient they will have less options of where to send the patient. Some of the pcps were sending patients to another rads group closer to town. Told them my rules of not seeing the patient in the future if they go to rads for a procedure and that changed quickly. We will see what happens I guess over time.
I can't speak for everyone, but as a PCP if you told me (in a nice way, of course) that you couldn't take over patients after the IR injections didn't fix the problem I would stop sending to them pretty darn fast. Otherwise, exactly as you say, then I'm stuck with managing their pain on my own going forward.
 
Someday the tech disruptors are going to go after medicine and when they do USA radiologists will be first to get badly hurt. My two cents.

Thats already happening. My friends national group is contracted with IBM and they are training Watson to read films. They know it will kill the field in the long run, but they figured it is going to happen anyway.
 
I can't speak for everyone, but as a PCP if you told me (in a nice way, of course) that you couldn't take over patients after the IR injections didn't fix the problem I would stop sending to them pretty darn fast. Otherwise, exactly as you say, then I'm stuck with managing their pain on my own going forward.

Truthfully, I am ok with that. I realize that is a risk I am taking. If they call me, say "hey I got this guy/girl had an ESI that didn't help...would you take a look at them and see if there is anything else to offer" that is one thing. That's not what happens most of the time though. It's...ESI didn't work, kick to "pain management". I don't take over 99% of opioids from PCP's as it is. I am fortunate and I know it. I have built in referral base with the multi-specialty clinic I am in but I feel that I work patients up appropriately and give procedures (and withhold them) when appropriate. Also, I still do anesthesia part of the week. We do complex cases. If I need to go back to doing straight anesthesia as opposed to pain then so be it. I declined two today. One was from an OSH PCP where the patient had a crapload of ESI's through the radiology department. WC said they wanted me to see the pt for an eval. regarding a SCS (even though they specifically state they won't approve them for any WC procedure). Basically buried in his notes was "feels appropriate that medication managed by pain specialist". Nope, not going to do it.
 
Truthfully, I am ok with that. I realize that is a risk I am taking. If they call me, say "hey I got this guy/girl had an ESI that didn't help...would you take a look at them and see if there is anything else to offer" that is one thing. That's not what happens most of the time though. It's...ESI didn't work, kick to "pain management". I don't take over 99% of opioids from PCP's as it is. I am fortunate and I know it. I have built in referral base with the multi-specialty clinic I am in but I feel that I work patients up appropriately and give procedures (and withhold them) when appropriate. Also, I still do anesthesia part of the week. We do complex cases. If I need to go back to doing straight anesthesia as opposed to pain then so be it. I declined two today. One was from an OSH PCP where the patient had a crapload of ESI's through the radiology department. WC said they wanted me to see the pt for an eval. regarding a SCS (even though they specifically state they won't approve them for any WC procedure). Basically buried in his notes was "feels appropriate that medication managed by pain specialist". Nope, not going to do it.
I think I must have not been clear - I would stop using the radiologist, not stop sending to you.

I'd rather piss off IR than lose an actual pain practice.
 
I think I must have not been clear - I would stop using the radiologist, not stop sending to you.

I'd rather piss off IR than lose an actual pain practice.

No, you were clear. I just read it wrong. I agree with you 100%. Sorry for the confusion.
 
here in my area, the orthopods are the ones sending injections to IR. That is, if they are not doing the injections themselves in their own ASC.
 
here in my area, the orthopods are the ones sending injections to IR. That is, if they are not doing the injections themselves in their own ASC.
asshats.... hopefully their profession becomes a dinosaur with the continuing development of injectable stem cells and biologics
 
Update:

Got a call from one of the radiologists today that we need to go get a beer and that all this misunderstanding because he was on vacation. They are going to roll back plans to do any Pain injections and would rather read MRI’s.

I called my spine surgeons who were pissed as well and assured me that they were not going to be a part of this and that they would boycott the hospital radiologist group as well.

So guys stand up for what you think is right.
 
Oh my goodness.... so much to respond to I don't know where to start... I don't want you to think I'm being defensive about my field... I'm not. Also, it's a stupid political move as a radiologist to start an interventional spine service if you know many of your referrals are coming from pain docs. The least the rad could do is talk with you and offer you injection slots for patient's you find difficult (super obese, or need for CT guided (pudendal) injections or just a PITA) or those who may need to get in sooner but can't fit in the schedule.

So being a radiologist and a pain doc, I can tell you that I can derive the patient's primary pain generator on a spine MRI (if it's present on the scan) and that correlates better than the clinical exam. I always practiced "treat the patient and not the image." After doing that enough, I figured out it's not always true and, in fact, is probably wrong most of the time. It doesn't stop me from doing a comprehensive exam, though. I also wonder if some forget that once you send the patient to get an MRI... it's not JUST sending the patient to get an MRI... you are asking for a consultation from a radiologist on diagnostics and management. Now some feel it's only for diagnostics, but I can tell you, that's not how the field works. "Clinical correlation advised" I know is a cop out... but most radiologists are fairly good clinicians and understand patient management. I had 8 months of IR plus primary care sports medicine continuity clinic throughout radiology residency. The rads who make injection recommendations are not doing it without some background.

Also, there are very subtle things I've learned to look for that are not taught during radiology residency or neuroradiology fellowship or in pain fellowship (subtle edema on MRI in various locations, subtle cystic changes, findings I was always taught were "in everybody", so let's not get all high and mighty about how the radiologist didn't "see or examine the patient" when in reality, he/she literally saw INSIDE your/their patient and if he/she did due diligence, there was a detailed pain history intake form prior to MRI. I think we all know what an acutely herniated disc looks like in a hot radic. If I could inject those patients in the MRI scanner I would because they are so easy to treat. So, if that's seen on MRI, you can sure as heck bet that I'll be putting in an injection recommendation "without seeing the patient". Same goes for a hot facet (edematous, enhancement). Those aren't clinical decisions, as much as they are easy, quick, pattern based, reflexive decisions that tend to have good outcomes the earlier they are treated. They don't need a full H and P with separate billing codes (driving up healthcare costs) and delayed time to treat in order to fit into the office procedure or ASC schedule. With that said, I wouldn't do it on a chronic spinal stenosis MRI with chronic facet and disc... that's a clinical decision between patient and doc with lots of diagnostic injections, possible RFA and stim.

I realize that you all really, really want those hot radics... but sometimes, earlier is just better for the patient. There's enough to go around and it is about patient care and not always about the wallet. The truth is that most radiology practices actually lose money on doing spinal injections. It's literally chump change compared to other procedures and it's offered to increase referrals to the practice and demonstrate genuine interest in patient management and treatment. Many of those injections are not even reimbursed... think all of those medicaid patients who "aren't eligible" for injections... guess what, a lot of them are done for charity in radiology practices... how you say? Because the fluoro techs are already there, you have a motivated doc who really enjoys the procedure, and the patient is already familiar with the site... the few hundred bucks from the injection is a drop in the bucket compared to a repeat customer who will need follow up MRI and other imaging needs. I can guarantee you that if you told the radiology practice that if they had a hot radic on the table and you could guarantee their patient an injection later that day, they would JUMP at the chance to send the patient to you. But instead of cultivating the referral relationships with your friendly neighborhood radiologists, pain docs tend to focus on the PCPs or neurosurgeons or orthos.

Now, where you SHOULD be worried is when a rad becomes buddy buddy with a neurosurgeon who implants SCS and then passes off chronic pain management to his employed NP or PA. Those are the people trying to take your business. Not the simple epidurals.

Now, as far as the profession itself goes... radiologists take care of their own MUCH better than pain docs do. Competition is intense among pain docs (even competition that is bread WITHIN a single practice). In the area I practiced pain there were docs flat out lying about their credentials in order to get business. Buy ins for partnership are insane... vacation is non-existent and quite frankly those in the field who are most financially successful are outright criminals. I went from two weeks vacation to 7 months vacation (I work nights) and INCREASED my salary by moving from pain back to rads. I don't worry about drug addicts busting through my secretaries threatening to shoot me and I don't have extreme production pressures to the point where I'm entering false codes for procedures *cough* epidurograms *cough* or unnecessary procedures/medications *cough* sedation *cough*. I'm still shocked when I talk to friends of mine in the field about how they were pressured by their "senior" partners to do 3 of every type of injection on every patient or that every patient needs sedation at the ASC owned by the boss. I've never once come across that kind of crap in radiology but yet admin at my pain job was telling me how I wasn't coding "well enough" for my procedures and not using sedation so I was going to get paid less... uh huh and the urine tox schemes and the excessive opioids because "return customers are good business." None of that kind of stress in radiology. There are different types of stressors but not nearly as bad as I experienced in pain.

For the IBM Watson topic above... artificial intelligence is being trained to interpret imaging data. However, it's far from taking over the field. There will always be a need for a physician to interpret the cluster of findings. And as of now, there isn't enough "big data" to train an AI to learn all the diagnoses (especially the zebras) and be reliable. There are interesting discoveries, however, coming from machine learning. For example, there are algorithms now that can predict a genotype for specific brain tumors based on imaging... without any discernable imaging characteristic... no one knows how it's doing it but it ends up correct well over 90% of the time. The best I can hope for is that AI will be able to pick up and describe some of the incidental CYA findings I'm always having to dictate rather than focusing on the major clinical problem for the patient.

TL;DR
Radiologists are mostly cool. Talk to them. They also enjoy treating patients.
Radiologists treat radiologists better than pain docs treat pain docs.
AI is not taking over for radiology; the tech isn't there yet and won't be for a looooooong time.
 
The facts:
1. Nearly 100% of the time radiologists reading MRIs (if they are even in the same state) do this without a clinical exam of the patient. They are at the mercy of whatever information is given to them, and if the request for a MRI with a vague "low back pain" indication, their recommendations may be overtly wrong after reading the MRI or may fall for red herrings that have nothing to do with the pathology.
2. Radiologists that want to read MRIs/CTs then cajole the referring physician to let them do injections are not taking care of patients. They are mindless block jocks, no better than the block shops that do 50 injections a day. Fortunately insurance carriers are putting a stop to this shameless effectively self-referral to do a block earlier. Most insurance carries will no longer approve same day diagnostic evaluation and spinal injections, so the pollyannish hyperpragmatic suggestion of an immediate block becomes a source of immense patient anger once they get stuck with the astronomically high bill from the hospital when radiologists want to do these injections in the hospital or even in an freestanding imaging center immediately after imaging. The intraneural damage from a disc herniation occurs inside of 6 hours so it is unlikely the timing ultimately will make any difference in the block, especially given that disc resolution occurs spontaneously via metalloproteinases in most patients.
 
Oh my goodness.... so much to respond to I don't know where to start... I don't want you to think I'm being defensive about my field... I'm not. Also, it's a stupid political move as a radiologist to start an interventional spine service if you know many of your referrals are coming from pain docs. The least the rad could do is talk with you and offer you injection slots for patient's you find difficult (super obese, or need for CT guided (pudendal) injections or just a PITA) or those who may need to get in sooner but can't fit in the schedule.

So being a radiologist and a pain doc, I can tell you that I can derive the patient's primary pain generator on a spine MRI (if it's present on the scan) and that correlates better than the clinical exam.
.

Great post.
You have the unique skill of being well trained in radiology and Pain are able to clinically correlate and look at the bigger picture. Not sure if that is the case with just radiologists.

Maybe there should be a greater emphasis on radiology during Pain fellowships if the images are providing more information than the clinical exam.
 
Oh my goodness.... so much to respond to I don't know where to start... I don't want you to think I'm being defensive about my field... I'm not. Also, it's a stupid political move as a radiologist to start an interventional spine service if you know many of your referrals are coming from pain docs. The least the rad could do is talk with you and offer you injection slots for patient's you find difficult (super obese, or need for CT guided (pudendal) injections or just a PITA) or those who may need to get in sooner but can't fit in the schedule.

So being a radiologist and a pain doc, I can tell you that I can derive the patient's primary pain generator on a spine MRI (if it's present on the scan) and that correlates better than the clinical exam. I always practiced "treat the patient and not the image." After doing that enough, I figured out it's not always true and, in fact, is probably wrong most of the time. It doesn't stop me from doing a comprehensive exam, though. I also wonder if some forget that once you send the patient to get an MRI... it's not JUST sending the patient to get an MRI... you are asking for a consultation from a radiologist on diagnostics and management. Now some feel it's only for diagnostics, but I can tell you, that's not how the field works. "Clinical correlation advised" I know is a cop out... but most radiologists are fairly good clinicians and understand patient management. I had 8 months of IR plus primary care sports medicine continuity clinic throughout radiology residency. The rads who make injection recommendations are not doing it without some background.

Also, there are very subtle things I've learned to look for that are not taught during radiology residency or neuroradiology fellowship or in pain fellowship (subtle edema on MRI in various locations, subtle cystic changes, findings I was always taught were "in everybody", so let's not get all high and mighty about how the radiologist didn't "see or examine the patient" when in reality, he/she literally saw INSIDE your/their patient and if he/she did due diligence, there was a detailed pain history intake form prior to MRI. I think we all know what an acutely herniated disc looks like in a hot radic. If I could inject those patients in the MRI scanner I would because they are so easy to treat. So, if that's seen on MRI, you can sure as heck bet that I'll be putting in an injection recommendation "without seeing the patient". Same goes for a hot facet (edematous, enhancement). Those aren't clinical decisions, as much as they are easy, quick, pattern based, reflexive decisions that tend to have good outcomes the earlier they are treated. They don't need a full H and P with separate billing codes (driving up healthcare costs) and delayed time to treat in order to fit into the office procedure or ASC schedule. With that said, I wouldn't do it on a chronic spinal stenosis MRI with chronic facet and disc... that's a clinical decision between patient and doc with lots of diagnostic injections, possible RFA and stim.

I realize that you all really, really want those hot radics... but sometimes, earlier is just better for the patient. There's enough to go around and it is about patient care and not always about the wallet. The truth is that most radiology practices actually lose money on doing spinal injections. It's literally chump change compared to other procedures and it's offered to increase referrals to the practice and demonstrate genuine interest in patient management and treatment. Many of those injections are not even reimbursed... think all of those medicaid patients who "aren't eligible" for injections... guess what, a lot of them are done for charity in radiology practices... how you say? Because the fluoro techs are already there, you have a motivated doc who really enjoys the procedure, and the patient is already familiar with the site... the few hundred bucks from the injection is a drop in the bucket compared to a repeat customer who will need follow up MRI and other imaging needs. I can guarantee you that if you told the radiology practice that if they had a hot radic on the table and you could guarantee their patient an injection later that day, they would JUMP at the chance to send the patient to you. But instead of cultivating the referral relationships with your friendly neighborhood radiologists, pain docs tend to focus on the PCPs or neurosurgeons or orthos.

Now, where you SHOULD be worried is when a rad becomes buddy buddy with a neurosurgeon who implants SCS and then passes off chronic pain management to his employed NP or PA. Those are the people trying to take your business. Not the simple epidurals.

Now, as far as the profession itself goes... radiologists take care of their own MUCH better than pain docs do. Competition is intense among pain docs (even competition that is bread WITHIN a single practice). In the area I practiced pain there were docs flat out lying about their credentials in order to get business. Buy ins for partnership are insane... vacation is non-existent and quite frankly those in the field who are most financially successful are outright criminals. I went from two weeks vacation to 7 months vacation (I work nights) and INCREASED my salary by moving from pain back to rads. I don't worry about drug addicts busting through my secretaries threatening to shoot me and I don't have extreme production pressures to the point where I'm entering false codes for procedures *cough* epidurograms *cough* or unnecessary procedures/medications *cough* sedation *cough*. I'm still shocked when I talk to friends of mine in the field about how they were pressured by their "senior" partners to do 3 of every type of injection on every patient or that every patient needs sedation at the ASC owned by the boss. I've never once come across that kind of crap in radiology but yet admin at my pain job was telling me how I wasn't coding "well enough" for my procedures and not using sedation so I was going to get paid less... uh huh and the urine tox schemes and the excessive opioids because "return customers are good business." None of that kind of stress in radiology. There are different types of stressors but not nearly as bad as I experienced in pain.

For the IBM Watson topic above... artificial intelligence is being trained to interpret imaging data. However, it's far from taking over the field. There will always be a need for a physician to interpret the cluster of findings. And as of now, there isn't enough "big data" to train an AI to learn all the diagnoses (especially the zebras) and be reliable. There are interesting discoveries, however, coming from machine learning. For example, there are algorithms now that can predict a genotype for specific brain tumors based on imaging... without any discernable imaging characteristic... no one knows how it's doing it but it ends up correct well over 90% of the time. The best I can hope for is that AI will be able to pick up and describe some of the incidental CYA findings I'm always having to dictate rather than focusing on the major clinical problem for the patient.

TL;DR
Radiologists are mostly cool. Talk to them. They also enjoy treating patients.
Radiologists treat radiologists better than pain docs treat pain docs.
AI is not taking over for radiology; the tech isn't there yet and won't be for a looooooong time.


AI won't take over the field immediately but it will allow 1 radiologist to do the work of 10 in the near future. So the supply of radiologist services will outweight the demand very rapidly in the near future.

I think that is the concern he is speaking about. AI won't take over totally for another 20 years but it will dramatically increase the supply year over year.
 
Oh my goodness.... so much to respond to I don't know where to start... I don't want you to think I'm being defensive about my field... I'm not. Also, it's a stupid political move as a radiologist to start an interventional spine service if you know many of your referrals are coming from pain docs. The least the rad could do is talk with you and offer you injection slots for patient's you find difficult (super obese, or need for CT guided (pudendal) injections or just a PITA) or those who may need to get in sooner but can't fit in the schedule.

So being a radiologist and a pain doc, I can tell you that I can derive the patient's primary pain generator on a spine MRI (if it's present on the scan) and that correlates better than the clinical exam. I always practiced "treat the patient and not the image." After doing that enough, I figured out it's not always true and, in fact, is probably wrong most of the time. It doesn't stop me from doing a comprehensive exam, though. I also wonder if some forget that once you send the patient to get an MRI... it's not JUST sending the patient to get an MRI... you are asking for a consultation from a radiologist on diagnostics and management. Now some feel it's only for diagnostics, but I can tell you, that's not how the field works. "Clinical correlation advised" I know is a cop out... but most radiologists are fairly good clinicians and understand patient management. I had 8 months of IR plus primary care sports medicine continuity clinic throughout radiology residency. The rads who make injection recommendations are not doing it without some background.

Also, there are very subtle things I've learned to look for that are not taught during radiology residency or neuroradiology fellowship or in pain fellowship (subtle edema on MRI in various locations, subtle cystic changes, findings I was always taught were "in everybody", so let's not get all high and mighty about how the radiologist didn't "see or examine the patient" when in reality, he/she literally saw INSIDE your/their patient and if he/she did due diligence, there was a detailed pain history intake form prior to MRI. I think we all know what an acutely herniated disc looks like in a hot radic. If I could inject those patients in the MRI scanner I would because they are so easy to treat. So, if that's seen on MRI, you can sure as heck bet that I'll be putting in an injection recommendation "without seeing the patient". Same goes for a hot facet (edematous, enhancement). Those aren't clinical decisions, as much as they are easy, quick, pattern based, reflexive decisions that tend to have good outcomes the earlier they are treated. They don't need a full H and P with separate billing codes (driving up healthcare costs) and delayed time to treat in order to fit into the office procedure or ASC schedule. With that said, I wouldn't do it on a chronic spinal stenosis MRI with chronic facet and disc... that's a clinical decision between patient and doc with lots of diagnostic injections, possible RFA and stim.

I realize that you all really, really want those hot radics... but sometimes, earlier is just better for the patient. There's enough to go around and it is about patient care and not always about the wallet. The truth is that most radiology practices actually lose money on doing spinal injections. It's literally chump change compared to other procedures and it's offered to increase referrals to the practice and demonstrate genuine interest in patient management and treatment. Many of those injections are not even reimbursed... think all of those medicaid patients who "aren't eligible" for injections... guess what, a lot of them are done for charity in radiology practices... how you say? Because the fluoro techs are already there, you have a motivated doc who really enjoys the procedure, and the patient is already familiar with the site... the few hundred bucks from the injection is a drop in the bucket compared to a repeat customer who will need follow up MRI and other imaging needs. I can guarantee you that if you told the radiology practice that if they had a hot radic on the table and you could guarantee their patient an injection later that day, they would JUMP at the chance to send the patient to you. But instead of cultivating the referral relationships with your friendly neighborhood radiologists, pain docs tend to focus on the PCPs or neurosurgeons or orthos.

Now, where you SHOULD be worried is when a rad becomes buddy buddy with a neurosurgeon who implants SCS and then passes off chronic pain management to his employed NP or PA. Those are the people trying to take your business. Not the simple epidurals.

Now, as far as the profession itself goes... radiologists take care of their own MUCH better than pain docs do. Competition is intense among pain docs (even competition that is bread WITHIN a single practice). In the area I practiced pain there were docs flat out lying about their credentials in order to get business. Buy ins for partnership are insane... vacation is non-existent and quite frankly those in the field who are most financially successful are outright criminals. I went from two weeks vacation to 7 months vacation (I work nights) and INCREASED my salary by moving from pain back to rads. I don't worry about drug addicts busting through my secretaries threatening to shoot me and I don't have extreme production pressures to the point where I'm entering false codes for procedures *cough* epidurograms *cough* or unnecessary procedures/medications *cough* sedation *cough*. I'm still shocked when I talk to friends of mine in the field about how they were pressured by their "senior" partners to do 3 of every type of injection on every patient or that every patient needs sedation at the ASC owned by the boss. I've never once come across that kind of crap in radiology but yet admin at my pain job was telling me how I wasn't coding "well enough" for my procedures and not using sedation so I was going to get paid less... uh huh and the urine tox schemes and the excessive opioids because "return customers are good business." None of that kind of stress in radiology. There are different types of stressors but not nearly as bad as I experienced in pain.

For the IBM Watson topic above... artificial intelligence is being trained to interpret imaging data. However, it's far from taking over the field. There will always be a need for a physician to interpret the cluster of findings. And as of now, there isn't enough "big data" to train an AI to learn all the diagnoses (especially the zebras) and be reliable. There are interesting discoveries, however, coming from machine learning. For example, there are algorithms now that can predict a genotype for specific brain tumors based on imaging... without any discernable imaging characteristic... no one knows how it's doing it but it ends up correct well over 90% of the time. The best I can hope for is that AI will be able to pick up and describe some of the incidental CYA findings I'm always having to dictate rather than focusing on the major clinical problem for the patient.

TL;DR
Radiologists are mostly cool. Talk to them. They also enjoy treating patients.
Radiologists treat radiologists better than pain docs treat pain docs.
AI is not taking over for radiology; the tech isn't there yet and won't be for a looooooong time.

Fred, no personal offense meant here. You sound like a pretty ethical dude.

If Radiologists want to do the injections, then I expect them to manage the patients too. That means they admit in case of complications, answer the late night phone calls when the radic got worse or the injection didn't help.

Most importantly, they manage medications when the series of 3 inevitably only improves the pain "55%" and the patients request their percocet QID to take care of the rest.

I haven't been at this very long, but my experience has been that radiologic findings correlate with clinical exam maybe 50-60% of the time. I've been shocked by the number of patients I see with severe stenosis, edematous facets who have pain down the opposite leg, or no axial pain at all.

IR block jocks who inject and then direct patient follow-up calls to the referring surgeon- who then bounces it to the pain doc- infuriate me. Very slimy stuff.

- ex 61N
 
I have enjoyed this discussion immensly. Let's all give each other a hug.

I do agree though - pain physicians do not treat each other very nicely. I don't understand that. We could all learn from the beer brewing industry. They all share their secrets and help each other out, etc. It seems there is always room for more. Here in San Diego, there are over 100 microbrews.

That is my question - is there really so few pain patients that a physician would be getting mad that radiology carries some of the interventional load?

Here is the bottom line - chronic pain is worsening in this country...injections don't seem to change that trajectory...so there should be plenty of work for all.
 
Oh my goodness.... so much to respond to I don't know where to start... I don't want you to think I'm being defensive about my field... I'm not. Also, it's a stupid political move as a radiologist to start an interventional spine service if you know many of your referrals are coming from pain docs. The least the rad could do is talk with you and offer you injection slots for patient's you find difficult (super obese, or need for CT guided (pudendal) injections or just a PITA) or those who may need to get in sooner but can't fit in the schedule.

So being a radiologist and a pain doc, I can tell you that I can derive the patient's primary pain generator on a spine MRI (if it's present on the scan) and that correlates better than the clinical exam. I always practiced "treat the patient and not the image." After doing that enough, I figured out it's not always true and, in fact, is probably wrong most of the time. It doesn't stop me from doing a comprehensive exam, though. I also wonder if some forget that once you send the patient to get an MRI... it's not JUST sending the patient to get an MRI... you are asking for a consultation from a radiologist on diagnostics and management. Now some feel it's only for diagnostics, but I can tell you, that's not how the field works. "Clinical correlation advised" I know is a cop out... but most radiologists are fairly good clinicians and understand patient management. I had 8 months of IR plus primary care sports medicine continuity clinic throughout radiology residency. The rads who make injection recommendations are not doing it without some background.

Also, there are very subtle things I've learned to look for that are not taught during radiology residency or neuroradiology fellowship or in pain fellowship (subtle edema on MRI in various locations, subtle cystic changes, findings I was always taught were "in everybody", so let's not get all high and mighty about how the radiologist didn't "see or examine the patient" when in reality, he/she literally saw INSIDE your/their patient and if he/she did due diligence, there was a detailed pain history intake form prior to MRI. I think we all know what an acutely herniated disc looks like in a hot radic. If I could inject those patients in the MRI scanner I would because they are so easy to treat. So, if that's seen on MRI, you can sure as heck bet that I'll be putting in an injection recommendation "without seeing the patient". Same goes for a hot facet (edematous, enhancement). Those aren't clinical decisions, as much as they are easy, quick, pattern based, reflexive decisions that tend to have good outcomes the earlier they are treated. They don't need a full H and P with separate billing codes (driving up healthcare costs) and delayed time to treat in order to fit into the office procedure or ASC schedule. With that said, I wouldn't do it on a chronic spinal stenosis MRI with chronic facet and disc... that's a clinical decision between patient and doc with lots of diagnostic injections, possible RFA and stim.

I realize that you all really, really want those hot radics... but sometimes, earlier is just better for the patient. There's enough to go around and it is about patient care and not always about the wallet. The truth is that most radiology practices actually lose money on doing spinal injections. It's literally chump change compared to other procedures and it's offered to increase referrals to the practice and demonstrate genuine interest in patient management and treatment. Many of those injections are not even reimbursed... think all of those medicaid patients who "aren't eligible" for injections... guess what, a lot of them are done for charity in radiology practices... how you say? Because the fluoro techs are already there, you have a motivated doc who really enjoys the procedure, and the patient is already familiar with the site... the few hundred bucks from the injection is a drop in the bucket compared to a repeat customer who will need follow up MRI and other imaging needs. I can guarantee you that if you told the radiology practice that if they had a hot radic on the table and you could guarantee their patient an injection later that day, they would JUMP at the chance to send the patient to you. But instead of cultivating the referral relationships with your friendly neighborhood radiologists, pain docs tend to focus on the PCPs or neurosurgeons or orthos.

Now, where you SHOULD be worried is when a rad becomes buddy buddy with a neurosurgeon who implants SCS and then passes off chronic pain management to his employed NP or PA. Those are the people trying to take your business. Not the simple epidurals.

Now, as far as the profession itself goes... radiologists take care of their own MUCH better than pain docs do. Competition is intense among pain docs (even competition that is bread WITHIN a single practice). In the area I practiced pain there were docs flat out lying about their credentials in order to get business. Buy ins for partnership are insane... vacation is non-existent and quite frankly those in the field who are most financially successful are outright criminals. I went from two weeks vacation to 7 months vacation (I work nights) and INCREASED my salary by moving from pain back to rads. I don't worry about drug addicts busting through my secretaries threatening to shoot me and I don't have extreme production pressures to the point where I'm entering false codes for procedures *cough* epidurograms *cough* or unnecessary procedures/medications *cough* sedation *cough*. I'm still shocked when I talk to friends of mine in the field about how they were pressured by their "senior" partners to do 3 of every type of injection on every patient or that every patient needs sedation at the ASC owned by the boss. I've never once come across that kind of crap in radiology but yet admin at my pain job was telling me how I wasn't coding "well enough" for my procedures and not using sedation so I was going to get paid less... uh huh and the urine tox schemes and the excessive opioids because "return customers are good business." None of that kind of stress in radiology. There are different types of stressors but not nearly as bad as I experienced in pain.

For the IBM Watson topic above... artificial intelligence is being trained to interpret imaging data. However, it's far from taking over the field. There will always be a need for a physician to interpret the cluster of findings. And as of now, there isn't enough "big data" to train an AI to learn all the diagnoses (especially the zebras) and be reliable. There are interesting discoveries, however, coming from machine learning. For example, there are algorithms now that can predict a genotype for specific brain tumors based on imaging... without any discernable imaging characteristic... no one knows how it's doing it but it ends up correct well over 90% of the time. The best I can hope for is that AI will be able to pick up and describe some of the incidental CYA findings I'm always having to dictate rather than focusing on the major clinical problem for the patient.

TL;DR
Radiologists are mostly cool. Talk to them. They also enjoy treating patients.
Radiologists treat radiologists better than pain docs treat pain docs.
AI is not taking over for radiology; the tech isn't there yet and won't be for a looooooong time.
Fred you went back to rads?! When did this happen? And what was it that pushed you over the edge. Interested to know... oh and can I get into an interventional rads fellowship. I'm ready to jump ship too
 
True dat>"quite frankly those in the field who are most financially successful are outright criminals"
 
True dat>"quite frankly those in the field who are most financially successful are outright criminals"

Thats true of any field in medicine with biggest frauds in oncology, dermatology, home health care and optho so far:

Palm Beach doctor settles massive Medicare fraud lawsuit

Prosecutors insist eye doctor Salomon Melgen stole $136 million from Medicaid

Texas doctor charged in $375 million Medicare scam

Michigan cancer doctor gets 45 years in prison - CNN



And lets not get started on the Suboxone pimps like the ones who run PROP:

Corrupt providers abuse Suboxone treatment <<< This one resembles PROP's business model.

Medical Board Action Against Telemedicine Buprenorphine Physician

A deeper look inside Suboxone clinics and the double-edged drug

11 Investigates: Cash-only Suboxone clinics


Let's be honest, the whole business model for MAT is mostly about how to get more fees out of the patients. Do you honestly believe there would be this level of enthusiasm for "treatment of addicts" for a 42 dollar Medicaid office fee?

The holier than thou attitude of the suboxone pimps is wearing thin as well.
 
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i like how you post that there are a lot of frauds in oncology, dermatology and home health care and ophtho.

then you post about "suboxone pimps". the logical conclusion to your argument would be to post articles of actual "suboxone pimps" being arrested. but you didnt....

so go ahead, post the arrest articles on your supposed "suboxone pimps".

fyi your articles are ridiculous. the Medical Board Action was against the TELEMEDICINE to prescribe suboxone by phone without an in person exam. and actually the NC board said he should have seen them more - and ostensibly bill more.

A physician, who lived and practiced in the middle of the state, also prescribed Suboxone via telemedicine for patients in the Western part of the state. The medical board was displeased this physician didn’t examine his patients in this second location in person, prior to initiating the Suboxone. The physician stated he felt buprenorphine could be prescribed safely without an in-person exam, but the board didn’t agree.

The medical board faulted the physician for not giving adequate attention to patients’ use of other drugs, and their mental health history. The board said patients were not examined for track marks or withdrawal signs, and that the physician accelerated their doses too quickly. Patients were seen every four weeks from the start, and the medical board opined that was not frequent enough in early treatment.
in the channel 11 article - over 1/2 the interviewed people said they were doing better on suboxone. there were over 2x more sales of oxycontin alone than suboxone.
your 1st article is also ironic. the billing and charged fees of these so called suboxone clinics is to force them to get counselling. it is not "fake" appointments to write more prescriptions - it is to attend more counselling sessions.

ironically, they charge more than the base fees that Medicare charges.

but then again, so do you for all of your follow ups, injections, procedures.

also, the site that article is from is Recovery org after browsing the site, the only thing i see them recommending long term is the 12 step program, which has shown to be so effective in opioid addiction (/sarcasm off)


addendum: SDN would not let me post the name of the site above - calling it a "sneaky URL"....
 
Pearls upon the swine
 
i like how you post that there are a lot of frauds in oncology, dermatology and home health care and ophtho.

then you post about "suboxone pimps". the logical conclusion to your argument would be to post articles of actual "suboxone pimps" being arrested. but you didnt....

so go ahead, post the arrest articles on your supposed "suboxone pimps".

fyi your articles are ridiculous. the Medical Board Action was against the TELEMEDICINE to prescribe suboxone by phone without an in person exam. and actually the NC board said he should have seen them more - and ostensibly bill more.


in the channel 11 article - over 1/2 the interviewed people said they were doing better on suboxone. there were over 2x more sales of oxycontin alone than suboxone.
your 1st article is also ironic. the billing and charged fees of these so called suboxone clinics is to force them to get counselling. it is not "fake" appointments to write more prescriptions - it is to attend more counselling sessions.

ironically, they charge more than the base fees that Medicare charges.

but then again, so do you for all of your follow ups, injections, procedures.

also, the site that article is from is Recovery org after browsing the site, the only thing i see them recommending long term is the 12 step program, which has shown to be so effective in opioid addiction (/sarcasm off)


addendum: SDN would not let me post the name of the site above - calling it a "sneaky URL"....


I have linked articles of Suboxone pimps trading Sub for sex/cash before and being arrested. You can easily find many articles on the subject using a simple google search.

I promise the leadership of PROP aren't making peanuts and doing it for the "greater good". No money= no interest in addicts.

Stop the BS. the "holier than thou" crowd is more money hungry than anyone.
 
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i like how you post that there are a lot of frauds in oncology, dermatology and home health care and ophtho.

then you post about "suboxone pimps". the logical conclusion to your argument would be to post articles of actual "suboxone pimps" being arrested. but you didnt....

so go ahead, post the arrest articles on your supposed "suboxone pimps".

fyi your articles are ridiculous. the Medical Board Action was against the TELEMEDICINE to prescribe suboxone by phone without an in person exam. and actually the NC board said he should have seen them more - and ostensibly bill more.


in the channel 11 article - over 1/2 the interviewed people said they were doing better on suboxone. there were over 2x more sales of oxycontin alone than suboxone.
your 1st article is also ironic. the billing and charged fees of these so called suboxone clinics is to force them to get counselling. it is not "fake" appointments to write more prescriptions - it is to attend more counselling sessions.

ironically, they charge more than the base fees that Medicare charges.

but then again, so do you for all of your follow ups, injections, procedures.

also, the site that article is from is Recovery org after browsing the site, the only thing i see them recommending long term is the 12 step program, which has shown to be so effective in opioid addiction (/sarcasm off)


addendum: SDN would not let me post the name of the site above - calling it a "sneaky URL"....

Over 1/2 people interviewed would say they are "doing better on Oxycontin" as well and essentially need it for pain. Would you accept that argument for Oxycontin or would you demand more information?

I can never tell how long someone stays on Subxone either until they are "cured". Usually its when the Suboxone pimps realize they have no further insurance/cash to milk from an existing patient and it pays more to induce a new one. The money is usually in the initial induction, so a churn and burn method is usually the most effective under the cash model.

For Medicaid patients in areas like Kentucky that have banned Suboxone for cash practices, the best method is to inflate number of "counseling" sessions at high costs for their "initial treatment" with 1000s of dollars in charges before giving them the stamp of "cured" approval..

Im sure these "cured" patients have very low recidivism rates in the future after they are "cured".

The article is very clear on how they inflate the bills and CHANGE their protocols after Kentucky only allowed a 42 dollar office visit for Suboxone rather than cash.

When they were receiving cash, there was no urgent need for high cost office urine testing/counseling treatments/etc to inflate the bill.

What was the sudden need for change after Kentucky banned allowing cash for Medicaid patients? Sounds like an interesting coincidence huh?
 
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Pearls upon the swine

You're upset that I am exposing the Suboxone racket behind the facade of caring and "morals".

The holier than thou nonsense whereby you try to portray yourself as some saintly figure fighting the "system of money hungry" pain docs is just a front to push the lucrative suboxone pimp game.

Suboxone pimps wouldn't be in the game for a 42 dollar Medicaid OV and would magically lose their "concern" for all these "poor addicts" if that is all they could get out of the game.
 
your articles are pure rubbish. i just wasted 3 minutes of my life watching your channel 11 new article, which cant even identify a single one of these cash only suboxone clinics - the commentator just say "they exist".

the long shot of this piece? ironically, the long shot of this piece is that these clinics should should offer MORE counseling, and have MORE office visits... for counseling. MORE CHARGES, NOT LESS.


fact - people don't get cured from opioid addiction. I know its a shocker, but they will not get cured. they require long term ongoing maintenance.


I agree with one point - some people may be using suboxone as a lucrative business in exactly the same way that opioid prescribers in the past have traded injections/office visits/UDS/cash payment for narcotics. yes, some people are using that same model. are they immoral? if you believe that, then you believe that also that someone writing scripts for injections or UDS or cash is also immoral. why? because in these cases, its the same thing.
 
your articles are pure rubbish. i just wasted 3 minutes of my life watching your channel 11 new article, which cant even identify a single one of these cash only suboxone clinics - the commentator just say "they exist".

the long shot of this piece? ironically, the long shot of this piece is that these clinics should should offer MORE counseling, and have MORE office visits... for counseling. MORE CHARGES, NOT LESS.


fact - people don't get cured from opioid addiction. I know its a shocker, but they will not get cured. they require long term ongoing maintenance.


I agree with one point - some people may be using suboxone as a lucrative business in exactly the same way that opioid prescribers in the past have traded injections/office visits/UDS/cash payment for narcotics. yes, some people are using that same model. are they immoral? if you believe that, then you believe that also that someone writing scripts for injections or UDS or cash is also immoral. why? because in these cases, its the same thing.

Are you now arguing cash only Suboxone clinics dont exist and aren't the norm? You can't be serious to even attempt to argue that point.

Critical point: "some people may be using suboxone as a lucrative business in exactly the same way that opioid prescribers in the past have traded injections/office visits/UDS/cash payment for narcotics. yes, some people are using that same model. are they immoral? if you believe that, then you believe that also that someone writing scripts for injections or UDS or cash is also immoral. why? because in these cases, its the same thing.[/QUOTE]"

Correct it is the same thing with the normal Suboxone clinic being run using that business model

Ergo, Suboxone pimps are the last group to be casting stones.

But thanks for acknowledging that OBVIOUS truth.
 
You are making assumptions with no basis. I stated that some clinics might be using the same model as some unscrupulous pain clinics that prescribed narcotics.

YOU made the critical error of assuming that ALL suboxone clinics do that. I have no idea where this lack of critical thinking arises from.
 
I have never argued suboxone clinics that are cash only did not exist. You are arguing - I thought - that they do exist.
Where did this assumption come from?

I will argue that they in no way reflect the majority of suboxone clinics, just as the majority of block shops aren’t narc dealers. And I have yet to see any convincing evidence that they exist to a clinically significant degree.

If they do, then they should incorporate more of what you deem worthless - or counseling.
 
You are making assumptions with no basis. I stated that some clinics might be using the same model as some unscrupulous pain clinics that prescribed narcotics.

YOU made the critical error of assuming that ALL suboxone clinics do that. I have no idea where this lack of critical thinking arises from.

Where did I say all? I said the majority of Suboxone prescribers do it for cash only OR take insurance is a very sparing fashion as mentioned below. PROP has its own scam going on that I showed in other posts.

Cash-only Suboxone clinics fuel fears of new 'pill mills'

This would be the normal suboxone physician billing pattern:

Addiction | Substance Abuse | Opiate Addict Therapy | Suboxone | Heroin Treatment | Detox | Storrs, Connecticut

"
Initial consultation & evaluation, which generally lasts about 60-75 minutes is $250. For medication assisted treated ("MAT") for opioid use disorder a second visit for 'buprenorphine induction' is required, which costs $200. Subsequent visits for medication management and brief counseling, generally lasting 20-30 minutes, are $120 per visit. Discounts are available for full payment at the beginning of each month.

For new buprenorphine (Suboxone/Zubsolv) patients, weekly visits are required until stabilization at no greater than a certain dose of buprenorphine . Therefore, total fees for the first month will be $250 + $200 + $120 + $120 + $120 = $810. For the second month of buprenorphine therapy and thereafter until stabilization at no greater than a certain dose of buprenorphine, weekly visits are required ($120 x 4 totalling approximately $480 per month). After stabilization visits may be decreased to three times per month, and then to every other week (twice a month). Patients must continue visits every other week as long as buprenorphine is prescribed.

For patients not covered by Aetna, Anthem, Cigna, CT Medicaid/Husky, Medicare, or United Healthcare, full payment is required at each visit in the form of cash, credit card, or PayPal. Those non-covered persons may agree to pay at the beginning of each month for the month's services at a discounted fee. If you pay for the first month up front the fee is discounted from $810 to $700. If you pay for subsequent monthly visits at the beginning of each monthly cycle the fee is discounted from $480 to $400."



So just the office visit charges ALONE are 800 for first month and 480/month afterwards then 240/month until they are "cured".

I suspect many are "cured" quite quickly after they can't afford the payments.

Thats not including the UDS benefits that come into play or the percentage from the counseling.

Multiply that by 100 patients (or 275 soon). Not a bad gig for about 20 hours a week of time.
 
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Where did I say all? I said the majority of Suboxone prescribers do it for cash only OR take insurance is a very sparing fashion as mentioned below. PROP has its own scam going on that I showed in other posts.

Cash-only Suboxone clinics fuel fears of new 'pill mills'

This would be the normal suboxone physician billing pattern:

Addiction | Substance Abuse | Opiate Addict Therapy | Suboxone | Heroin Treatment | Detox | Storrs, Connecticut

"
Initial consultation & evaluation, which generally lasts about 60-75 minutes is $250. For medication assisted treated ("MAT") for opioid use disorder a second visit for 'buprenorphine induction' is required, which costs $200. Subsequent visits for medication management and brief counseling, generally lasting 20-30 minutes, are $120 per visit. Discounts are available for full payment at the beginning of each month.

For new buprenorphine (Suboxone/Zubsolv) patients, weekly visits are required until stabilization at no greater than a certain dose of buprenorphine . Therefore, total fees for the first month will be $250 + $200 + $120 + $120 + $120 = $810. For the second month of buprenorphine therapy and thereafter until stabilization at no greater than a certain dose of buprenorphine, weekly visits are required ($120 x 4 totalling approximately $480 per month). After stabilization visits may be decreased to three times per month, and then to every other week (twice a month). Patients must continue visits every other week as long as buprenorphine is prescribed.

For patients not covered by Aetna, Anthem, Cigna, CT Medicaid/Husky, Medicare, or United Healthcare, full payment is required at each visit in the form of cash, credit card, or PayPal. Those non-covered persons may agree to pay at the beginning of each month for the month's services at a discounted fee. If you pay for the first month up front the fee is discounted from $810 to $700. If you pay for subsequent monthly visits at the beginning of each monthly cycle the fee is discounted from $480 to $400."



So just the office visit charges ALONE are 800 for first month and 480/month afterwards then 240/month until they are "cured".

I suspect many are "cured" quite quickly after they can't afford the payments.

Thats not including the UDS benefits that come into play or the percentage from the counseling.

Multiply that by 100 patients (or 275 soon). Not a bad gig for about 20 hours a week of time.

I know of a pulmonologist who switched to primary care and suboxone clinic and gave up his pulmonology practise.
 
I know of a pulmonologist who switched to primary care and suboxone clinic and gave up his pulmonology practise.

He did it because he wanted to save us from the opioid crisis and is a humanitarian. Why else would he change over? He knew he could do the most good for society at a Suboxone clinic!
 
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