Pain Physician Outlook

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nopainnogain21

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Hey all, new incoming pain fellow. Was curious for the seasoned docs out there, how worried should we be regarding the reimbursement cuts to B&B procedures? I know there is a shift from pain trained folks back to general anesthesia, but still seems like most pain jobs even in big cities start you at 300k + productivity. Sounds feasible to be making 400-500k still correct?
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The outlook from an insurance point of view is always bad.

The problems that drive referrals to us will always exist though, so the future is cash pay. Radiculopathy will still exist, even if insurance pays $50 for an ESI. My cash pay patients have no problem with $575 for an epidural.

For now, hospitals will pay generously due to their inflated SOS differential. Will that still exist in 10 years? No idea.
 
nopainnogain21 said:
Hey all, new incoming pain fellow. Was curious for the seasoned docs out there, how worried should we be regarding the reimbursement cuts to B&B procedures? I know there is a shift from pain trained folks back to general anesthesia, but still seems like most pain jobs even in big cities start you at 300k + productivity. Sounds feasible to be making 400-500k still correct?
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powermd said:
The outlook from an insurance point of view is always bad.

The problems that drive referrals to us will always exist though, so the future is cash pay.

For now, hospitals will pay generously due to their inflated SOS differential. Will that still exist in 10 years? No idea.
Click to expand...
Go hospital employment in a rural area and your belly will be full
 
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Outlook is bad for medicine in general with respect to reimbursement with continuous pressure for cheaper physicians nurses PAs etc. the fact that only a small fraction of cost is related to the people who actually care for the patients and most goes to pharmaceutical, equipment, management, supplies etc is irrelevant. The population et al. Won’t be happy til the percentage is 0.
 
powermd said:
The outlook from an insurance point of view is always bad.

The problems that drive referrals to us will always exist though, so the future is cash pay. Radiculopathy will still exist, even if insurance pays $50 for an ESI. My cash pay patients have no problem with $575 for an epidural.

For now, hospitals will pay generously due to their inflated SOS differential. Will that still exist in 10 years? No idea.
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SOS will be dead.
 
Doubtful the ceos will continue to need monkeys to do their bidding
 
4-500K sounds like a ton when you are just starting out. and it is. but once you have been doing this for a while, it doesnt seem that wonderful.

dont listen to the naysayers. the outlook is fine. ive been hearing about doom and gloom since medical school, but still make more every year, and we are working on 15+ years since fellowship. granted, i do work a bit harder each year....
 
Not to open the SOS bag of worms but I’m not sure any current hospital with the exception of the ones with huge amounts of charity support could survive in their current state without it. My current very large hospital system whose name you would definitely know has gone from 5-6% profit several years ago and is now struggling at a reported 1-2%. The massive restructuring required while fun to watch would likely be catastrophic to the rural hospital system in the US. Not arguing it’s correct or shouldn’t be cancelled but as HOPD I get paid around 6 rvus for an RFA, most of that money is siphoned off to keep the hospitals afloat.
 
Laryngospasm said:
Not to open the SOS bag of worms but I’m not sure any current hospital with the exception of the ones with huge amounts of charity support could survive in their current state without it. My current very large hospital system whose name you would definitely know has gone from 5-6% profit several years ago and is now struggling at a reported 1-2%. The massive restructuring required while fun to watch would likely be catastrophic to the rural hospital system in the US. Not arguing it’s correct or shouldn’t be cancelled but as HOPD I get paid around 6 rvus for an RFA, most of that money is siphoned off to keep the hospitals afloat.
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How much does your ceo bank per year. Maybe start chopping him/her down a bit and go from there
 
Dr. Ice said:
How much does your ceo bank per year. Maybe start chopping him/her down a bit and go from there
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I don’t disagree. The current state of our healthcare is a little like big government. Bloated and full of waste with all the people out of sight getting rich. I’d love to see it change.
 
SSdoc33 said:
4-500K sounds like a ton when you are just starting out. and it is. but once you have been doing this for a while, it doesnt seem that wonderful.

dont listen to the naysayers. the outlook is fine. ive been hearing about doom and gloom since medical school, but still make more every year, and we are working on 15+ years since fellowship. granted, i do work a bit harder each year....
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making more while the $/wRVU continues to go down. so working harder with more being taken off the top.
 
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CBT sessions before SIJ injections…it’s all gone to s***.
 
Dr. Ice said:
Go hospital employment in a rural area and your belly will be full
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Agreed. Rural hospital is a solid way to start out.

That said, things are always getting worse in pain (and every other medical specialty). I’ve only been out one year but even in that year we’re seeing RFA have more hoops to jump through. SCS getting harder to get approval for every year. Procedures denied for reasons that increasingly defy medical logic. The headaches with pain are still not anywhere enough to make doing something else a consideration; it’s still way better than being on 24 hour OB anesthesia call cutting for a non-indicated C-section at 4 in the morning on Christmas.
 
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Dr. Ice said:
What do you guys define as “more work”

Not being antagonistic, I’m just curious
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More patients in clinic
More prior auths
More searching for pharmacies that have the meds
More inbox messages
More denials
More documentation
More requests to appeal the denial
More peer to peers
Lower reimbursements
Supplies cost more
Staff costs more
Rent costs more
 
Dr. Ice said:
What do you guys define as “more work”

Not being antagonistic, I’m just curious
Click to expand...

Being told we need to go from 35 patient contact hours to 36 hours. Having our comp tied to benchmark percentiles instead of total wrvus (benchmarks increase every year so in order to make the same you need to figure out how to generate more wrvus), having metrics become more difficult to achieve every year so you need to do more of each metric etc.
 
SSdoc33 said:
4-500K sounds like a ton when you are just starting out. and it is. but once you have been doing this for a while, it doesnt seem that wonderful.

dont listen to the naysayers. the outlook is fine. ive been hearing about doom and gloom since medical school, but still make more every year, and we are working on 15+ years since fellowship. granted, i do work a bit harder each year....
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you are going in the wrong direction....
 
BobBarker said:
“Ok, my friend. You guys are just going to pay me for another block. And I’m going to do it at the hospital out of spite. Which will cost the insurance company $1500. Then I’m going to end up doing the RFA anyways.”
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the reviewers are subcontractors. they dont care if aetna has to pay more
 
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See? These are the games they play.

Just wait until they deny it since
1. Patient was given fent
2. Patient was given prop (no analgesic properties for the non anesthesia folk)
3. Patient took an opioid before coming in.

You can win but again it takes time and mental energy to jump through all these hoops. Even if you do all local they still play games it is ridiculous.
 
BobBarker said:
“Ok, my friend. You guys are just going to pay me for another block. And I’m going to do it at the hospital out of spite. Which will cost the insurance company $1500. Then I’m going to end up doing the RFA anyways.”
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"Not so fast. Since the second bupi block wasnt done according to guidelines, we are not going to pay for it"
 
Ducttape said:
oh yes, no sedation for MBB.

i would argue tho having to give fentanyl and/or propofol for an MBB is a contraindication for an RFA.
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Still don't get the idea of sedation for procedures in general. I know people were posting before that there are some areas of the country where it's common to do B&B procedures with sedation but at this point I've given versed and fent during only 1 clinic procedure and that was for a stim trial.

The apparent regional differences in practice patterns are wild.
 
I’m guessing there is a distinct difference between sedation at surgery centers and HOPD. For all the crap we HOPD get at least a lot of us don’t do needless sedation.
 
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TIVAndy said:
I just had a peer to peer denial of rfa. Reason was that I used bupivacaine for both mbbs. They wanted one bupi one lido. I said F u.
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Which review company is this, and do their own guidelines say you need a different local for block #2?
AFAIK Evicore, Carelon, Evolent/Magellan/RadMD/WTF and Cohere do not specify.
 
BoardingDoc said:
Still don't get the idea of sedation for procedures in general. I know people were posting before that there are some areas of the country where it's common to do B&B procedures with sedation but at this point I've given versed and fent during only 1 clinic procedure and that was for a stim trial.

The apparent regional differences in practice patterns are wild.
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Very common in my area for people to have "MAC" by a CRNA at the practice-owned surgery center for everything - ie, propofol for ESIs 😱

I give versed for RFAs, use versed/ketamine for kyphos, and pretty much never give sedation otherwise. Some people have found that they prefer "getting knocked out" for their procedures, and I welcome them to find other doctors who will do that.
 
clubdeac said:
I just got denied a repeat RFA after the patient got 80% relief x 3 yrs from the last RFA bc of no recent PT 🤦🏻‍♂️ these people are dirt bags
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For us down in GA, after 2 years they ask for repeat double Dx blocks. Waste of time and money. wrvu so really doesn't mean much for me- but stupid and bad for patients. Nice opportunity to see the patient, ask about new symptoms, and give them new CA dx. See pic thread.
 
drusso said:
HOPD rape of the facility fee.
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i dont think that sedation fees are that much of a money-making item compared to the facility fee itself. in terms of time efficiency, sedation significantly increases this.


any financially constrained institution - which is to say all of them after covid - would have determined that sedation for routine cases is not cost effective.
 
lobelsteve said:
For us down in GA, after 2 years they ask for repeat double Dx blocks. Waste of time and money. wrvu so really doesn't mean much for me- but stupid and bad for patients. Nice opportunity to see the patient, ask about new symptoms, and give them new CA dx. See pic thread.
Click to expand...
same thing in upper midwest here, but recently they stopped requiring repeat mbb's, just started approving repeat rfa > 2 years
 
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