New Pain Practice

[MetroPain]

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Starting a new pain practice out of Fellowship and am thinking about setting up in an area where there already are several established practices. am limited to the geographic area for personal reasons. any thoughts? also, how did other members initially choose their office space and location without any real referral source in the area? any thoughts would help. thanks.

 

[Mister Mxyzptlk]

You have a tough road ahead. I think your best chance of survival is to see if a local hospital will do a deal with a guaranteed first year income, office space discounts, and practice promotion, etc. Your second best chance is if there is a 3-week wait for an appointment with the other clinics and you manage to capture the impatient people.

Some thoughts:

Getting on plans could be hard because they might tell you they already have plenty of pain docs on the panel.

You are going to have to break existing referral patterns and who knows what kind of relationships they have, such as being partners in an ASC.

Who will do your call coverage? Most hospitals want that in writing from your call partner before granting privileges. The other guys could stonewall your privileges just by refusing to do that. Without hospital privileges you usually can't get ASC privileges. Where will you do your cases?

 

[Kwijibo]

Just don't expect to make money for a while and consider moonlighting. Relationships are made to be broken! You just have to figure out what it takes to do it.

 

[MetroPain]

Thanks for the feedback.

Yes I know that I have a lot going against me.

Also, the hospitals in the area are run by very large anesthesia groups with pre-existing pain practices, so I know it's going to be a difficult road. Although there are already a lot of pain docs in the area, there is still need out there, as I have interviewed with the major groups and they are really busy constantly looking for people.

Regading the referral pattern, yes, I do agree that it is going to be hard to break that pattern. I just don't know how to break them. Besides the usual of advertising and getting the word out there, I really don't know how I am going to get the referrals for the newbie in the area who is also fresh out of practice.

I do know one thing, that I want to be independent and not be reliant on a group and be an employee of their decisions. Groups had to start off as small individual practices sometime ago, right?

Anyway, any other suggestions would be very grateful, especially from those who have ventured out on their own in similiar waters. Thanks

 

[Mister Mxyzptlk]

I do know one thing, that I want to be independent and not be reliant on a group and be an employee of their decisions. Groups had to start off as small individual practices sometime ago, right?

And today's countries started out as tribes, but it's very hard to start a new country today when all the territory has been taken. Ask the Palestinians, the Kurds, the Chechnyans, and the people who saved their Confederate money.

The people you will be competing with are seasoned hospital politicians. If the anesthesia groups have their own pain docs and you are not welcome what do you think they will do when you apply for privileges (who did you say you would list as your call coverage on the staff application?).

And if you somehow get privileges what do you think will happen when you schedule a case? They will screw with you. If there is an emergency case you will be the first one bumped. They will find reasons to cancel your cases. If you have a complication they will be all over you.

You also have no idea whether you will be able to get on insurance panels. Do you think you can earn a living doing Medicare and Workers' Comp?

You are like a bloody fish swimming into a pool of sharks. "There seems to be room for more pain doctors" is an observation, not a plan.

 

[Doctodd]

you might be better off joining a group and then breaking away via some loophole in their contract or negotiating something. You will learn alot and meet alot of people during that time period. Or you might get lucky and join an honest group.

T

 

[Ligament]

You might as well kill yourself now MetroPain. 😀

And today's countries started out as tribes, but it's very hard to start a new country today when all the territory has been taken. Ask the Palestinians, the Kurds, the Chechnyans, and the people who saved their Confederate money.

The people you will be competing with are seasoned hospital politicians. If the anesthesia groups have their own pain docs and you are not welcome what do you think they will do when you apply for privileges (who did you say you would list as your call coverage on the staff application?).

And if you somehow get privileges what do you think will happen when you schedule a case? They will screw with you. If there is an emergency case you will be the first one bumped. They will find reasons to cancel your cases. If you have a complication they will be all over you.

You also have no idea whether you will be able to get on insurance panels. Do you think you can earn a living doing Medicare and Workers' Comp?

You are like a bloody fish swimming into a pool of sharks. "There seems to be room for more pain doctors" is an observation, not a plan.

 

[Spine Specialist]

Dude,

Competition is life. There will be always people out there to crush/kill your practice and not let you grow. The only way to beat the competition is to be creative. Be different than your competitors. Work hard, maintain quality and do the right thing. Show compassion to your patients. no matter what you will thrive. Practice is all about word of mouth. Your big sharks can do all the marketing and tricks in the world....if you are good you can win.
Think about google. It was started in a small garage. It is all about being creative with ideas. Think youtube. Yeah...coco-cola was a BIG SHARK...How Pepsi broke the record? You can also break the referral pattern.
Just think. You will get ideas. Oppurtunities never cease to exist. If you cant create a new country here....go to moon and create one.😉 Explore a new territory. There will be always room in the top for xtra-ordinary pain doctors.
Good Luck.

 

[drrinoo]

We'll have to hypnotize Dr. Gorback into writing 'I am optimist' on the black board 300 times.

For the moment, however, I need him to be a cynic.

If hospital privilege requests are denied for economic reasons (economic credentialling), are they reportable to the national data practitioner data bank?

 

[drrinoo]

also, does anyone know the role independent practice associations play in terms of enrolling in health insurance plans.

Do they carry the same influence as a large multispecialty group?

 

[Aether2000]

We have an IPA that negotiates rates for over 100 MDs across many practice specialties. The degree of their influence is not measurable since most of the negotiated rates are the same or only slightly higher than the posted rates...

How was the ASIPP annual meeting this year?

 

[Mister Mxyzptlk]

Rinoo:

Scratch a cynic and find a disillusioned idealist. Have you ever been in the private practice world? Some people play very rough where money and turf are concerned. I'm not making up these points. These are things I have seen. I just saw a physician-owned facility hound one of my colleagues off the medical staff using QA in order to force a sale of his shares.

Spine specialist:

Being a good doctor is not a unique approach. What makes you think the current docs are not kind, compassionate and enjoy excellent reputations?

If there are financial ties between the referrers and the pain docs (e.g., both are shareholders in an ASC) it doesn't matter how good you are or how nice you are. To use your analogy, if Yahoo somehow put money into people's pockets if they used their web site, Google would have died a quick death. And if Yahoo could have blocked Google's access to the Internet like these guys can block getting hospital privileges, ditto.

Starting a new practice in a highly competitive area is not the same as building a better mousetrap in a free and open market. Medicine is anything but that.

 

[Spine Specialist]

Gorback,

I respect your experience in the private practice world. I completely agree it is a cut-throat competitive world. But, i also sincerely believe there is no power in the world which is stronger than someone's will to survive and excel. If metropain has a will he can certainly find a way. That is my point.

The biggest things are always the easiest to do because there is no competition.
- William Van Horne

 

[Mister Mxyzptlk]

"Where there's a will there's a way" is not really a "point"; it's just wishful thinking. I don't recall ever seeing that law of nature written down anywhere, and history is replete with counter-examples, both large and small. Being talented and driven does not guarantee success. Robert E. Lee was one of the greatest leaders who ever lived. He had phenomenal willpower but he succumbed to overwhelming opposition from lesser men who simply had more resources.

It's POSSIBLE metro can survive, but if the current occupants line up against him it is IMPROBABLE. I think it's a gross disservice to him to provide encouragement based on something Grandma embroidered on a pillow. It's one thing to build castles in the air, but don't try to live in them unless you put in a foundation.

The converse of your philosophy is that if he fails, it means he either wasn't up to the task or just didn't try hard enough. I'm not comfortable with that.

 

[Spine Specialist]

"Where there's a will there's a way" is not really a "point"; it's just wishful thinking. I don't recall ever seeing that law of nature written down anywhere, and history is replete with counter-examples, both large and small. Being talented and driven does not guarantee success. Robert E. Lee was one of the greatest leaders who ever lived. He had phenomenal willpower but he succumbed to overwhelming opposition from lesser men who simply had more resources.

It's POSSIBLE metro can survive, but if the current occupants line up against him it is IMPROBABLE. I think it's a gross disservice to him to provide encouragement based on something Grandma embroidered on a pillow. It's one thing to build castles in the air, but don't try to live in them unless you put in a foundation.

The converse of your philosophy is that if he fails, it means he either wasn't up to the task or just didn't try hard enough. I'm not comfortable with that.

You are right, gorback.

 

[lucyz02]

goback- while this person has solicited advise in setting up a pain practice you have definitely dissuaded him/her of that. Are you then suggesting for all these new grads that don't want to practice in the sticks that their only option is to join a group? Hypothetically then, should fellowships then advertise "interventions pain for rural/underserved medicine".... you have allot more experience than myself ....but it seems a bit impractical when there are solo practicioners in the cities who obviously got there somehow???? Probably more than one surgery center, they can't all be under than guard?

 

[Tenesma]

as a solo guy breaking into a big market you will not make any money for a few years - so be ready to moonlight or do part-time work at a nursing home... then hopefully after 4-5 years, you will slowly start growing a practice because of relationships and word-of-mouth... that is only likely if you can outshine any financial relationships in the community that pre-date your arrival...

bottom line - if you need to be in a metropolitan area because of family reasons, then find a suburb that is about 30-50 minutes out-of-town where there is a little commuity hospital and setup shop either in that hospital or next to it... work your ass off for 5 years and then spread into the metropolitan area slowly....

the primary issue is getting credentialed with insurance companies - all of them except for medicare/medicaid/work. comp/auto require that you have privileges at a hospital.... and if there is competition i can guarantee you that you will never get privileges. In fact some anesthesia groups have exclusivety at a lot of hospitals, so they will shoot your application down even before you get it submitted.... no privileges no insurance credentials...

so go suburban/rural - plus you will make more money because the HMOs don't always reach out to the suburban areas.... unless of course your metro area is LA or NYC - then you have no chance in hell....

 

[Mister Mxyzptlk]

goback- while this person has solicited advise in setting up a pain practice you have definitely dissuaded him/her of that. Are you then suggesting for all these new grads that don't want to practice in the sticks that their only option is to join a group? Hypothetically then, should fellowships then advertise "interventions pain for rural/underserved medicine".... you have allot more experience than myself ....but it seems a bit impractical when there are solo practicioners in the cities who obviously got there somehow???? Probably more than one surgery center, they can't all be under than guard?

If you had seen any of my other posts in response to startup questions you'd know that this is not my blanket advice. In other situations I have offered different opinions. I once spent 3 hours sitting in a coffee shop kicking around ideas with one of the fellows in this forum on how to enter his target market. What made that different is that he had done extensive research (talking to me being yet another part of his research) and had developed several strategies. I was just trying to help him on the pros and cons of his different options.

There are various ways to make a startup happen, and they have been discussed in other threads. But you have to do your homework and have a game plan before you take the plunge (especially if you have a family depending on you). In this instance I see no such research being conducted and I see no plan of action other than just showing up. Given the information provided it looks like just moving in and hanging up a shingle would be a disaster.

The fact that there are solo practitioners in urban areas (I am one) does not mean they just waltzed in after graduating and set up shop. As previously discussed, the barriers against such a strategy are significant in a mature market. Sometimes there are pockets of opportunity even in a seemingly saturated market but unless you know the landscape just showing up somewhere is ill-advised.

 

[Disciple]

I hear it's ten times worse starting solo in specialties like Cardiology.

 

[lucyz02]

I can't speak for metro but this sounds like his intial steps to "research" as I doubt anyone (atleast with any intuition) would just roll into to town and expect patients to be lining up at the door.

To break into the urban environment would you reccomend joining up with a group intially?

How/Where can one find out ahead of time about this potential creditialling barracade?

Lastely, once one starts up what are good marketing techniques?

 

[Tenesma]

marketing techniques:

meet every doctor face to face if possible
become friends with every office manager if possible
shower the referral coordinators at those offices with love and TLC

then join every committee at your hospital possible
join the Rotary Club
join the Yacht Club
basically be everywhere - be available ALL the time

trouble shoot problems/delays in your practice on a regular basis

when you get a referral from a new doctor make sure you spend about 1 hour with that patient and make them feel like a MILLION bucks so that they report back nice things to the new referring doc...

get drug reps to sponsor dinners where you can talk about pain

do CMEs on pain at your local hospitals

basically your face, your name and your commitment to those patients has to be everywhere ---

then work hard for 3-6 months and then repeat --- within about 2 years you should have a rock solid practice

also it pays big time to become best buds with the local spine guys and their wives - organize play dates for your kids with theirs - etc...

 

[MetroPain]

Thank you for all the advice.

Gorback:

Thanks gor all the honesty. I do think that you are right on several levels, however, I do not want to join a group and be an employee. As for the research, yes, i feel like that i have done a lot of research into the area of practice. I already do have full hospital priveleges for a hospital that I moonlight for , including anesthesia and unrestricted pain management priveleges. I do have a solo pain practioner willing to cover my calls as long as i do the same for him, so i think that issue is covered.

As for the comp and other groups cutting me out with built-in referral systems (asc partners), i also have thought of that issue, but i think that i can get a different niche with referrers by buddying up with more of the primary care docs. a lot of the spine groups in the area, no longer refer to pain practices or anesthesia groups, they have gotten bright and are hiring new grads (primarily pmr grads - i think because they are willing to accept a lower salary compared with anesthesia trained grads because of the recent job market and salary for anesthesia) for their pain practices, thereby keeping all the patients in-house.

I know that it is a cut-throat world out there, and i have discussed and contemplated this issue for a while and even hired practice consultants to discuss their professional opinions. All in all, I know that it will be very very difficult to get started in a already saturated and competitive market. However, primary care docs, dentists, chiropractors, etc. do it all the time, and there are practioners who are successful in what i feel is even a more difficult market than pain management, at least presently.

I know that its an uphill climb, but i am willing to take that risk and challenge, to hopefully set a successful future for myself. I am willing to do what other people have mentioned including cme lectures, drug rep dinners, lectures, etc. I have already scheduled several educational sessions. I am also contemplating, setting up 2 locations, one in the urban area and then another in a more rural area to see which one i can generate more refferals and volume and to try to get my name out there quicker.

otherwise, i appreciate all the advice and honesty. this is exactly what i want and need. before i really take the financial plunge, i want to try to put most of the cards in my hand although i know that there is alot of risk.

thanks for all the feedback.

 

[Spine Specialist]

I know that its an uphill climb, but i am willing to take that risk and challenge, to hopefully set a successful future for myself.

Rock on dude.👍




I believe that one of life's greatest risks is never daring to risk.
- Oprah Winfrey

 

[lonelobo]

Thank you for all the advice.

Gorback:

Thanks gor all the honesty. I do think that you are right on several levels, however, I do not want to join a group and be an employee. As for the research, yes, i feel like that i have done a lot of research into the area of practice. I already do have full hospital priveleges for a hospital that I moonlight for , including anesthesia and unrestricted pain management priveleges. I do have a solo pain practioner willing to cover my calls as long as i do the same for him, so i think that issue is covered.

As for the comp and other groups cutting me out with built-in referral systems (asc partners), i also have thought of that issue, but i think that i can get a different niche with referrers by buddying up with more of the primary care docs. a lot of the spine groups in the area, no longer refer to pain practices or anesthesia groups, they have gotten bright and are hiring new grads (primarily pmr grads - i think because they are willing to accept a lower salary compared with anesthesia trained grads because of the recent job market and salary for anesthesia) for their pain practices, thereby keeping all the patients in-house.

I know that it is a cut-throat world out there, and i have discussed and contemplated this issue for a while and even hired practice consultants to discuss their professional opinions. All in all, I know that it will be very very difficult to get started in a already saturated and competitive market. However, primary care docs, dentists, chiropractors, etc. do it all the time, and there are practioners who are successful in what i feel is even a more difficult market than pain management, at least presently.

I know that its an uphill climb, but i am willing to take that risk and challenge, to hopefully set a successful future for myself. I am willing to do what other people have mentioned including cme lectures, drug rep dinners, lectures, etc. I have already scheduled several educational sessions. I am also contemplating, setting up 2 locations, one in the urban area and then another in a more rural area to see which one i can generate more refferals and volume and to try to get my name out there quicker.

otherwise, i appreciate all the advice and honesty. this is exactly what i want and need. before i really take the financial plunge, i want to try to put most of the cards in my hand although i know that there is alot of risk.

thanks for all the feedback.

a lot of the spine groups in the area, no longer refer to pain practices or anesthesia groups, they have gotten bright and are hiring new grads (primarily pmr grads - i think because they are willing to accept a lower salary compared with anesthesia trained grads because of the recent job market and salary for anesthesia) for their pain practices, thereby keeping all the patients in-house.


Maybe the reason more PM&R grads are being hired is because of what they have to offer
(EMG, more thorough musculoskeletal training)

 

[MetroPain]

Lone:

I did not mean to put down PMR. I do feel that they have far superior training for Musc/Skel, emg, etc. However, considering the high demand market right now for anesthesiologists, a lot of new grads, including myself, expect to be compensated higher than PMR docs (at least that the way that it is in my practice location) just for anesthesia work which may also include pain.

 

[Mister Mxyzptlk]

This sounds more viable now, although you still have an uphill battle.

I think your plan to do an end-run around the spine surgeons is a good one. The vast majority of my referral sources are PCPs. You get a pool of 50 or so, each sending a few, and you will be in good shape. Plus, if one gets mad at you, there are 49 left. If you alientate one of the 6 surgeons that's a bigger % loss.

The hard part is breaking the reflex referral of back pain to a surgeon first. The smart PCPs will pick up on the fact that you can do the same workup, especially if they receive good detailed reports back that reflect your attention to detail and good decision-making (but you might have to point it out to the slower ones over lunch). I think PCPs generally want their patients to avoid surgery so if you show you can reduce that it will go well for you. If you're successful you will control who the pts see for surgery and that can be leveraged with surgeons.

Fish around with the neurologists too, although they may be connected to the surgeons for EMGs. Of course, if they have a PMR person in-house doing EMGs the neurologists may not have much of a tie-in with the surgeons. If you start sending EMGs they may be very open to mutual referrals.

 

[Disciple]

We have an IPA that negotiates rates for over 100 MDs across many practice specialties. The degree of their influence is not measurable since most of the negotiated rates are the same or only slightly higher than the posted rates...

If I were to become credentialed with plans through an IPA, and then move to another city within the same state later on, would I be able to carry over that credentialing or have an easier time with credentialing in my new location?

 

[Disciple]

the primary issue is getting credentialed with insurance companies - all of them except for medicare/medicaid/work. comp/auto require that you have privileges at a hospital.... and if there is competition i can guarantee you that you will never get privileges. In fact some anesthesia groups have exclusivety at a lot of hospitals, so they will shoot your application down even before you get it submitted.... no privileges no insurance credentials...

The area I'm practicing in is pretty saturated and has a good number of solo PM&R pain docs who get their privileges through the rehab units of vaious hospitals, and I'm assuming get insurance credentialling done that way.

Any comments?

 

[Doctodd]

not sure if already mentioend, but the way around the roadblocks from the anesthesia group is to get priviledged as a PM+R doc and then do pain.

T

 

[Mister Mxyzptlk]

not sure if already mentioend, but the way around the roadblocks from the anesthesia group is to get priviledged as a PM+R doc and then do pain.

Unless you practice where Disciple is and there are PM&R docs established all over the place.

 

[Disciple]

Wanted to resurrect this thread as I'm experiencing alot of what Gorback has posted above.


And I'm part of group!


Couple of questions:

1. Has anybody had to create an in-office procedure suite, not due to professional fee differentials, but out of necessity? (i.e. rival groups controlling credentialing committee's at ASCs and blocking privileges).

2. What about thinking outside the box if you're being blocked from insurance plans, and say, partnering with a Chiropractor? Good source of direct to patient marketing and referrals for spine patients?


Any input is appreciated.

 

[lobelsteve]

Wanted to resurrect this thread as I'm experiencing alot of what Gorback has posted above.


And I'm part of group!


Couple of questions:

1. Has anybody had to create an in-office procedure suite, not due to professional fee differentials, but out of necessity? (i.e. rival groups controlling credentialing committee's at ASCs and blocking privileges).

2. What about thinking outside the box if you're being blocked from insurance plans, and say, partnering with a Chiropractor? Good source of direct to patient marketing and referrals for spine patients?


Any input is appreciated.

\

\

I have experience with DC's. None of it good.

PM me.

 

[2win]

Starting a new pain practice out of Fellowship and am thinking about setting up in an area where there already are several established practices. am limited to the geographic area for personal reasons. any thoughts? also, how did other members initially choose their office space and location without any real referral source in the area? any thoughts would help. thanks.

I can tell you from my experience that it is extremely difficult to estabish a pain practice on your own. You need connections and you have to be ready to invest (not to make 😉 money in the first years. IMO in this market enviroment it is a not viable option. glty

 

[Tenesma]

it is totally doable, but you are going to be poor for 6-18 months...

so if you want to set-up shop, i'd make sure you have other avenues for guaranteed income (do some per-diem anesthesia, work part-time at a nursing home - whatever it takes to put food on the table)...

if you can offer a better product/service and break into the referral patterns you will eventually succeed

then again, i have seen some people try hard, spend a TON of money, and not get anywhere... you REALLY need to know the market you are going into, or have the back-up of a hospital.

 

[mille125]

it is totally doable, but you are going to be poor for 6-18 months...

so if you want to set-up shop, i'd make sure you have other avenues for guaranteed income (do some per-diem anesthesia, work part-time at a nursing home - whatever it takes to put food on the table)...

if you can offer a better product/service and break into the referral patterns you will eventually succeed

then again, i have seen some people try hard, spend a TON of money, and not get anywhere... you REALLY need to know the market you are going into, or have the back-up of a hospital.

or you can get an income guarantee with a local hospital...you usually have better luck with community hospitals...this brings its own set of issues but at least you are not poor and not hundreds of thousands in the hole to start...starting a pain practice from scratch like any business opportunity takes guts..however if done right it can be very gratifying and can open doors that would never be open otherwise...personally i wouldnt have it any other way...everything in life is a risk..

 

[Disciple]

if you can offer a better product/service and break into the referral patterns you will eventually succeed.

I've been able to do this to a certain degree as some of the paincare done in my community is, for lack of a better word, "sloppy".

It's the anticompetitive business practices by established groups that I have not found an answer to yet.

 

[lobelsteve]

I've been able to do this to a certain degree as some of the paincare done in my community is, for lack of a better word, "sloppy".

It's the anticompetitive business practices by established groups that I have not found an answer to yet.

That is where a letter to the editor of your local paper (revewed first by your attorney) to expose the dark side of medicine can be quite useful.

 

[Jcm800]

The area I'm practicing in is pretty saturated and has a good number of solo PM&R pain docs who get their privileges through the rehab units of vaious hospitals, and I'm assuming get insurance credentialling done that way.

Any comments?

I was actually crednetialled at a hospital through the Medicine department...crazy. Anesthesia would not let me (i am an anesthesiologist) but somehow i was able to do it through internal medicine...

wierd.