IV sedation as a GP: worth learning?

[crooked castle]

Seems that a lot of GPRs and some dental schools are teaching IV sedation. What are the advantages and is it worth learning to add to my skill set as a GP?

I don't know too much about real world application of IV sedation as a GP. Is there a high demand and how often would a GP really be doing this? Is it safe for a GP to be administering moderate/deep sedation WHILE performing dental treatment? I'm assuming that most GPs are learning this to cut out hiring an anesthesiologist...? Even if they do cut out the anesthesiologist to save $$$, isn't there a high malpractice insurance associated with this?

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[Dgeorg6]

I would also like to hear what other people think of this. I have been interested in this for a while now! I am planning on practicing rural dentistry and think IV Sedation would be very beneficial to my practice! This is of course in the very far future unfortunately lol

 

[Sublimazing]

I think being able to provide sedation for your patients is a great service...and it's just flat out a good time 🙂

But unless you are confident in your ACLS and ability to intubate it just seems like such a risk.

I would be interested to hear if sedation dentists can make it profitable for themselves though.

If it were me I'd def have an MD or someone trained do it for me and make it profitable by slamming through 4-6 cases a day...I am surprised more GPs don't use an anesthesiologist to treat kids...seems like such a gold mine.

Interested to hear from the sedation dentists though.

 

[Screwtape]

For what it's worth a dentist I shadowed had his IV sedation certification but said he never used it. Since he has to be in the same room (solo shop) at all times a patient is IV sedated it is a drag for the rest of his office at the time. However, he uses oral sedation (patient takes potent cocktail before procedure at home and is driven to and from appointment) for a few morning cases regularly. They are basically zonked out during the whole procedure, but he could still leave the room. This is just one example from a solo GP.

 

[Saddleshoes]

I think being able to provide sedation for your patients is a great service...and it's just flat out a good time 🙂

But unless you are confident in your ACLS and ability to intubate it just seems like such a risk.

I would be interested to hear if sedation dentists can make it profitable for themselves though.

If it were me I'd def have an MD or someone trained do it for me and make it profitable by slamming through 4-6 cases a day...I am surprised more GPs don't use an anesthesiologist to treat kids...seems like such a gold mine.

Interested to hear from the sedation dentists though.

Ding, Ding Ding! We have the answer!!!!
1. Your confidence in your ACLS and intubation ability needs to be provable in court too!
2. You will be paying a much higher liability insurance bill for the privilege of IV sedation in your office too.
3. You will need to invest a chunk of money into and maintain a crash cart too!

 

[OhioDMD]

I used to offer IV sedation in my office. Generally comes down to expense and volume as to whether you can offer the service to your patients.
Pros: It's a great service when administered properly. Generally a win-win for both the patient and doctor.
It can be very lucrative if done in volume.
It may allow you to provide services (impacted 3rds, implants, multiple extractions, perio surg)
that you may not be able to do comfortably
Cons: It's expensive for the doctor and the patient.
Malpractice will be high. Probably 3x non IV rate (check with the major carriers for an accurate quote)
Usually not reimbursed by insurance company. Therefore totally out of pocket for the patient.
Time consuming for the doc. Requires extra equipment and ongoing ACLS training to maintain the
certification.
IMHO you can market yourself as a sedation dentist in a large urban area. Employ an RN or better yet a CRNA to to monitor your patients through the procedure and recovery. Expect to have high advertising, personnel, and malpractice
expense. Be very proficient in the dentistry you plan to offer (cosmetics, surgery, perio, implants etc) so that you can provide the services patients generally want sedation. Also be aware of what your malpractice carrier will and will not cover in an office setting as it may realistically limit what services ( general by a physician or CRNA) that you can provide.

 

[crooked castle]

Thanks for the replies everyone!

@OhioDMD I take it that from a financial standpoint, this is a good service mainly because it's usually out of pocket and if done in high volume. So would it be better to just hire someone to run the anesthesia then if there isn't enough volume (so we dont have to worry about liability insurance either). If you don't mind my asking, why did you stop offering the service?

@Sublimazing says he would hire one for the day and work on multiple cases...how does payment work? are anesthesiologists paid hourly?

 

[OhioDMD]

@crooked castle It is my understanding that if it's your office and your patient you still have a liability exposure even though you may not be the one administering the IV. For example my coverage (medpro) will only cover me for IV sedation or general when preformed in an out-patient surgery center or hospital setting. It varies with the type of coverage you have (mine 3,000,000/5,000,000 with no implant placement, no IV or General occurence policy for less than 2,000 per year). My reason for stopping was purely financial. At the time (1981-1985)I was doing 2-4 patients per month as a solo general. Insurance was going to go to 12,000 per year (different carrier). I couldn't justify the additional expense for the number of patients at the time.

 

[ring99]

I feel like case selection is really important. If I were a dentist with an IV sedation permit, I would not want to be sedating an obese, diabetic 55 year old on Coumadin. I would sedate young people only (from like 20-30) with no to marginal health problems.

@OhioDMD Does it always have to be done at an accredited site? I thought it varied by state. I know Cali requires all offices that administer sedation to undergo accreditation.

@crooked castle I think it depends. Most are salaried and compensated very well in medicine

 

[Shunwei]

Ding, Ding Ding! We have the answer!!!!
1. Your confidence in your ACLS and intubation ability needs to be provable in court too!
2. You will be paying a much higher liability insurance bill for the privilege of IV sedation in your office too.
3. You will need to invest a chunk of money into and maintain a crash cart too!

IMHO opinion it is better to not do it as a GP. Having a certificate from a CE course or doing it on 10-20 patients in a residency still cover the catastrophic effects if a case goes wrong. Remember all you need is for one case to go wrong for your career to suffer. Just saying.

 

[crooked castle]

Very true about case selection @ring99. To clarify, I was asking about a GP paying a dental anesthesiologist (how much would I have to pay him: is it based on per hour? approx how much $). I would be bringing him into my private practice setting (or perhaps in outpatient if I obtain hospital privileges).

A case going awry is what I'm most nervous about @Shunwei! But I guess this would go hand in hand with experience and case selection. Would it better to learn this in a GPR/dental school vs CE?

Would it be worth learning IV sedation now if given the opportunity, even if I don't plan on using it for quite a while? I would probably plan to offer IV in the future but have an anesthesiologist with me for the first few years (to gain some experience for myself too) when I have a few cases here and there. If it turns out there is a high enough volume and demand for this service perhaps it would justify running these cases on my own from a financial standpoint?

 

[Sublimazing]

Thanks for the replies everyone!

@OhioDMD I take it that from a financial standpoint, this is a good service mainly because it's usually out of pocket and if done in high volume. So would it be better to just hire someone to run the anesthesia then if there isn't enough volume (so we dont have to worry about liability insurance either). If you don't mind my asking, why did you stop offering the service?

@Sublimazing says he would hire one for the day and work on multiple cases...how does payment work? are anesthesiologists paid hourly?

There are a few options.

Get a physician, get a CRNA, get a DA...there are pros and cons all of them...most go with an MD

These guys do either hourly (500-900 per hour) versus charge per case (which can really vary I've seen 750 upto a couple thousand)

Usually the patient is billed seperately by the anesthesiologist/anesthetist

 

[crooked castle]

@Sublimazing Dang that's expensive! I think this would only make sense if doing more expensive procedures/tx plans. I mean, imagine if this was just for a few restorations/extractions...I could possibly be losing money, in addition to having to pay for some liability insurance (even if I am not the one running the IV). Perhaps like @OhioDMD was saying, depending on insurance coverage, I would have to take the patient to outpatient hospital setting where they could cover my IV sed. I don't want to make this sound like it's all about the money; I do want to offer this service for patients who need it, but we also got to take care of ourselves!

PS: I found another informative thread for those interested in more on this topic
http://forums.studentdoctor.net/threads/iv-sed-in-a-gp-office.758027/

 

[Sublimazing]

@Sublimazing Dang that's expensive! I think this would only make sense if doing more expensive procedures/tx plans. I mean, imagine if this was just for a few restorations/extractions...I could possibly be losing money, in addition to having to pay for some liability insurance (even if I am not the one running the IV). Perhaps like @OhioDMD was saying, depending on insurance coverage, I would have to take the patient to outpatient hospital setting where they could cover my IV sed. I don't want to make this sound like it's all about the money. I do want to offer this service for patients who need it, but we also got to take care of ourselves!

PS: I found another informative thread for those interested in more on this topic
http://forums.studentdoctor.net/threads/iv-sed-in-a-gp-office.758027/

The PATIENT pays...not you...but it can be difficult to convince a patient to shell out a thousand on top of the dental work

Insurance almost never covers for a DA, but will often for an MD in a private practice setting...no clue about crnas

In many states dentists prefer to use the hospital...it can be cheaper/free for pediatric patients, the dentist doesn't have to worry about the medical implications of anesthesia, legally you are FAR better covered, and I think a lot of dentists like to play surgeon for the day (and i dont blame them, i did it in my gpr and it's downright fun)

There are a lot of options...it seems geogrpahy has the greatest influence on how dentists handle sedation

 

[Silent Cool]

I've actually looked into this topic quite a bit and here is what I can tell you:

A CRNA will cost the patient about $400 per hour. There are a number of CRNA independent contractors out there offering this service.

A DA will cost more--probably about $600 per hour.

I think an MD is in that ball park as well.

Typically, each 15 minute increment after the first hour is billed at about $50.

IMO, you should not be doing the sedation and the dentistry at the same time. I think that taking an IV sedation course is useful to understand it and have familiarity with it, but ideally someone like a CRNA, DA, MDA should be hired to manage the anesthesia.

Dental insurance typically does not cover this, so the patient usually pays out of pocket. The exception I believe is for Pedo, hence the high demand for Pedo sedation out there. I have seen many Pedo offices that contract with either a CRNA or a DA to provide sedation.

Here are a few:
http://www.sleepyanesthesia.com/
http://www.andreafonnerdds.com/site/Welcome.html
http://www.drtarg.com/

 

[Sublimazing]

I've actually looked into this topic quite a bit and here is what I can tell you:

A CRNA will cost the patient about $400 per hour. There are a number of CRNA independent contractors out there offering this service.

A DA will cost more--probably about $600 per hour.

I think an MD is in that ball park as well.

Typically, each 15 minute increment after the first hour is billed at about $50.

IMO, you should not be doing the sedation and the dentistry at the same time. I think that taking an IV sedation course is useful to understand it and have familiarity with it, but ideally someone like a CRNA, DA, MDA should be hired to manage the anesthesia.

Dental insurance typically does not cover this, so the patient usually pays out of pocket. The exception I believe is for Pedo, hence the high demand for Pedo sedation out there. I have seen many Pedo offices that contract with either a CRNA or a DA to provide sedation.

Here are a few:
http://www.sleepyanesthesia.com/
http://www.andreafonnerdds.com/site/Welcome.html
http://www.drtarg.com/

Insurance will not cover a DA doing it even for pedo in any scenario I have ever seen, but I think it will for an MD

And the circus vaporizer that Targ uses is terrifying...like something the Joker would have