Pre operative psych clearance for surgery

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CleanUp

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Hi y’all,

Does anyone know what the approximate cash price is for a preoperative psych clearance for surgery?

Think VHCOL area. Most patients have no psych hx.

Someone charged my patient $1500 and I thought that was a tad high.

I have used psychologists and psychiatrists in the past.

I am a different medical speciality so don’t know what a reasonable price would be. If it is 1500$ then so be it. I respect what y’all do.

TIA
 
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I charge $1000 for a non surgical second opinion consultation. It’s a record review, full evaluation with a written report. I’m in a MCOL area. VHCOL plus higher liability for surgery $1500 seems reasonable. Even in a patient without psych hx, they should be commenting on optimizing psych function post op.
 
$1500?!? And most patients with no psych history?!? What type of surgeries are we clearing folks for at that price? We used to do pre-op evals for gastric bypass when I was a resident, and I can assure you my eval was worth nowhere close to $1500 imo.
 
Your comment about "using" psychologists and psychiatrists tells me just how much value you put on this "clearance" despite your comment at the end there.

See here for a relevant thread about how most people here view this kind of stuff. It's rather annoying and if your patient can't find someone in network who is willing to do this, then they're gonna pay whatever the market will bear like any other cash practice/procedure/eval.

 
Your comment about "using" psychologists and psychiatrists tells me just how much value you put on this "clearance" despite your comment at the end there.

See here for a relevant thread about how most people here view this kind of stuff. It's rather annoying and if your patient can't find someone in network who is willing to do this, then they're gonna pay whatever the market will bear like any other cash practice/procedure/eval.

No offense was intended I assure you. It means I’ve worked with both psychologists and psychiatrists before. And I’m anesthesia so I’m well aware patients cannot be “cleared” but only optimized. By the way, I never force anyone to “clear” any of the patients.

The insurance company makes me get psych clearance or else I cannot perform the surgery. They are not my rules. They are 100% arbitrary and not created by physicians. But alas the system we are in
 
I don't do surgery clearance, but VHCOL cash private practices charge $750+ for a one hour psychiatric evaluation. I'd imagine surgery clearance requires more than 2 hours of work, so $1500 seems low to me. Perhaps these are psychologist rates. Or a psychiatrist just pocketing the $1500 and saying some version of, "Looks good to me."
 
I would also like to know what surgeries these are. Cosmetic surgeries? Organ transplants? Bariatric?
 
Maybe we don't label it with a conclusion before hand? Yea? "Clearance" is not what we you/we are doing here.

Know the population and know the work (the population, the standards, the question, and the professional position statements) before you do the work.

That said, this is not really rocket science either. Let us not reinvent the wheel. What's the question for each individual case? Let's not get carried away with any kind of "authority" here.
 
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I don't do surgery clearance, but VHCOL cash private practices charge $750+ for a one hour psychiatric evaluation. I'd imagine surgery clearance requires more than 2 hours of work, so $1500 seems low to me. Perhaps these are psychologist rates. Or a psychiatrist just pocketing the $1500 and saying some version of, "Looks good to me."

In what world is a patient with no psych history (like OP said most were) taking 2 hours of your time to "clear" before a surgery? This is wild.

"$1500 seems low." I cannot tell if you're trolling. $1500 to "clear" someone who most likely has no psych history and at worst has probably routine depression. What am I missing here? Are we talking about transgender top/bottom surgeries?

When we "cleared" patients for surgery in residency it was for bariatric surgery or to put them on a liver transplant list. Most of these patients also had no psych history and our eval was a glorified "are you sure you know what type of post-op care and diet this is going to entail? You have a plan in place for someone to take care of you?" We were given an hour but I don't remember any of them lasting over 30-45 min, even with attendings coming in to staff it.

Charging $1500 for that is a disgrace, imo.
 
In what world is a patient with no psych history (like OP said most were) taking 2 hours of your time to "clear" before a surgery? This is wild.

"$1500 seems low." I cannot tell if you're trolling. $1500 to "clear" someone who most likely has no psych history and at worst has probably routine depression. What am I missing here? Are we talking about transgender top/bottom surgeries?

When we "cleared" patients for surgery in residency it was for bariatric surgery or to put them on a liver transplant list. Most of these patients also had no psych history and our eval was a glorified "are you sure you know what type of post-op care and diet this is going to entail? You have a plan in place for someone to take care of you?" We were given an hour but I don't remember any of them lasting over 30-45 min, even with attendings coming in to staff it.

Charging $1500 for that is a disgrace, imo.
Wegovy will do away with most all this within the next 5 years for 90% of (former) cases. Mark my words!

Also, can we stop saying "Wild," please? This is not what that word means. Internet words are not real words! Stop saying this!
 
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Didn’t mean to ruffle feathers here
Spinal cord stimulators.
So interventional pain? I could see this requiring a longer evals even for patients with “no psych history”. Patients with chronic pain frequently have underlying psych issues and peeling that back may take more time. That said, even if there is psych history, it’s probably irrelevant to these procedures unless they’re delusional that docs implanted a mind control device or are so severely depressed they can’t care for themselves. Either way, you’re going to see seemingly high prices partially because these are such pointless evals that are “required”.

In what world is a patient with no psych history (like OP said most were) taking 2 hours of your time to "clear" before a surgery? This is wild.

"$1500 seems low." I cannot tell if you're trolling. $1500 to "clear" someone who most likely has no psych history and at worst has probably routine depression. What am I missing here? Are we talking about transgender top/bottom surgeries?

When we "cleared" patients for surgery in residency it was for bariatric surgery or to put them on a liver transplant list. Most of these patients also had no psych history and our eval was a glorified "are you sure you know what type of post-op care and diet this is going to entail? You have a plan in place for someone to take care of you?" We were given an hour but I don't remember any of them lasting over 30-45 min, even with attendings coming in to staff it.

Charging $1500 for that is a disgrace, imo.
Sure, but when they’re stupid/pointless evals that are a “required” waste of time people are going to charge a premium. I don’t see this as any different from docs who charge $2k+ for an ADHD eval where they do a basic screener and just run through DSM criteria without doing any actual cognitive batteries or really going in depth with an ACE-PLUS or DIVA. Or psychological testing for “diagnostic clarification” when all that’s done is a SCID-5.
 
So interventional pain? I could see this requiring a longer evals even for patients with “no psych history”. Patients with chronic pain frequently have underlying psych issues and peeling that back may take more time. That said, even if there is psych history, it’s probably irrelevant to these procedures unless they’re delusional that docs implanted a mind control device or are so severely depressed they can’t care for themselves. Either way, you’re going to see seemingly high prices partially because these are such pointless evals that are “required”.


Sure, but when they’re stupid/pointless evals that are a “required” waste of time people are going to charge a premium. I don’t see this as any different from docs who charge $2k+ for an ADHD eval where they do a basic screener and just run through DSM criteria without doing any actual cognitive batteries or really going in depth with an ACE-PLUS or DIVA. Or psychological testing for “diagnostic clarification” when all that’s done is a SCID-5.
So I think because it's pain, and because it's spine, there is likely more medicolegal liability involved for everyone involved. Because not infrequently, the person getting one of these, is not going to be cured, and spinal pain from worse --> better but still spinal pain, can still be pretty bad. There will be gladness, there will be disappointment. And that's just your well adjusted person with minimal psych issues playing into their chronic pain.

I was just doing a nominal review (Google) and it seems that when it comes to spinal surgery and outcome, having a good result is 100% related to having selected the right candidate for surgery. A significant portion of the folks having a piss poor outcome, it seems they may never have been appropriate for the procedure based on psychological/psychiatric factors.

Given what destroying someone's back through surgery who may never have benefited from it to begin with, is, it is therefore crucial to carefully select the surgical candidate; and specifically for spine/back pain, more important than for many procedures.

It's understandable from a medical standpoint all involved, the surgeon and the evaluating psychiatrist, do their due diligence here.

It seems usually with these things, the insurance companies want them, and I would say, some for good reason, or good enough reason.

And all of the above ends up being a reason the surgeon ends up wanting it too.

Arguably, at this point whoever you are bringing into this loop, is also just being exposed to medicolegal liability. And yes, that should be compensated.

Ugh, we hear it from every doc that gets sued. Yes, accept it as a fact of practice, don't let it destroy you emotionally, but it can be time-consuming (and that is not compensated) and stressful.

So more than a waste of time (we waste time and don't get compensated at all for it all the time) this represents an opportunity to be compensated on the front end, for what on the back end could be a hassle on a level where $1500 IS trivial compensation.

Residents are almost completely insulated from how awful this kind of thing can be, and so that perspective on what it should cost I think misses the whole picture.

You don't really know until you do the eval what you are looking at, either. You could bill based on difficulty/time, but hard to see how one could really argue that.
 
I've never done this type of evaluation but I've had surgeons when I do CL put consults for "psych clearance". I never understood it and when I clarified, 99% of the time the consults were canceled. What was the procedure???
 
Here’s what will really scratch heads - why do spinal cord stimulators require a psych evaluation by insurance companies but fusions, ACDFs, laminectomies, etc do not? Seems arbitrary.
L
 
So interventional pain? I could see this requiring a longer evals even for patients with “no psych history”. Patients with chronic pain frequently have underlying psych issues and peeling that back may take more time. That said, even if there is psych history, it’s probably irrelevant to these procedures unless they’re delusional that docs implanted a mind control device or are so severely depressed they can’t care for themselves....
These are required by the device manufacturer, whose financial interest is selling as many devices as possible. That should tell you something. The literature clearly demonstrates that psychological factors predict pain reports and surgical outcome.
 
Here’s what will really scratch heads - why do spinal cord stimulators require a psych evaluation by insurance companies but fusions, ACDFs, laminectomies, etc do not? Seems arbitrary.
L
Here’s your answer:

These are required by the device manufacturer, whose financial interest is selling as many devices as possible. That should tell you something. The literature clearly demonstrates that psychological factors predict pain reports and surgical outcome.
Sure, but being required by the device manufacturer is still dumb. I get what you’re saying, but I think we all would likely agree that short of something I mentioned above (specific delusions/psychosis) these evals are silly.
 
was just doing a nominal review (Google) and it seems that when it comes to spinal surgery and outcome, having a good result is 100% related to having selected the right candidate for surgery. A significant portion of the folks having a piss poor outcome, it seems they may never have been appropriate for the procedure based on psychological/psychiatric factors.
Sure, but do you think psychiatrists or psychologists doing these evals know how to determine who these candidates are? Quick answer is that in general we don’t. The people doing these evals are typically not psychs with significant training in pain interventions or treatment, the vast majority of us are not. Most psychiatrists and psychologist will receive no real training in this at all and these encounters are just general psych evals to “clear” a patient for surgery.

So unless OP is sending patients with a specific form of questions to be answered (which I can guarantee you he’s not if this is being required by insurance), then these evals are just further unnecessary bloat in the system.
 
I'll just say this seems messy. At least with organ transplants or bariatric you kind of what the person is being asked to do after the procedure and you know that someone with florid psychosis isn't going to be able to. What exactly is the patient expected to do after a spinal cord stimulator insertion? Keep the wound area clean until it heals? It just seems like they might be expecting you to predict the success of the pain relief here and you don't have a crystal ball.
 
Here’s your answer:


Sure, but being required by the device manufacturer is still dumb. I get what you’re saying, but I think we all would likely agree that short of something I mentioned above (specific delusions/psychosis) these evals are silly.
I would disagree, and so would the literature and tests. 31-64% of chronic pain patients meet criteria for a personality disorder. Childhood abuse/neglect is associated with a 45% increased risk to report chronic pain, with that rate increasing up to 95% if the person experiences more than 4 ADEs.

Psychologically, there is a reason some people get a papercut and act like they're dying compared to a farmer who says that his left arm kinda hurts. I wouldn't want to be the surgeon who is dealing with a patient with Histrionic Personality Disorder post op.
 
Sure, but do you think psychiatrists or psychologists doing these evals know how to determine who these candidates are? Quick answer is that in general we don’t. The people doing these evals are typically not psychs with significant training in pain interventions or treatment, the vast majority of us are not. Most psychiatrists and psychologist will receive no real training in this at all and these encounters are just general psych evals to “clear” a patient for surgery.

So unless OP is sending patients with a specific form of questions to be answered (which I can guarantee you he’s not if this is being required by insurance), then these evals are just further unnecessary bloat in the system.
Totally fair. Just pointing out, there is a legitimate medical need here, even if the surgeon and psychiatrist and field in general haven't figured out how to fully articulate or assess it.

Couple reality with the the legal risk aspect... then yeah it's busy work to satisfy the latter by "pretending" to do the former.

Still makes sense to me on some level, but yes it is bloat. Still makes sense it is expensive. As you're pointing out, you're expecting a doctor to wade into ill defined territory that could be expensive to the doctor.
 
These are required by the device manufacturer, whose financial interest is selling as many devices as possible. That should tell you something. The literature clearly demonstrates that psychological factors predict pain reports and surgical outcome.
My theory here, if there are enough problems with the device/failures to demonstrate benefit, the FDA can pull the approval. So even if your interest is selling the device, it's not like you want it done in a way that the device comes to be seen as ineffective. So you do want to keep it out of people who are likely not to benefit.

These devices really aren't benign and have high rates of serious complications (relative to many things we do).

It's also expensive so if insurance companies have a reason to deny... surgeon also want to operate and make money, but in this case where insurance may deny, that may be letting them off the hook in denying a poor candidate without being the bad guy.
 
Here’s what will really scratch heads - why do spinal cord stimulators require a psych evaluation by insurance companies but fusions, ACDFs, laminectomies, etc do not? Seems arbitrary.
L
My perusal suggests that these have a higher rate of success than the implants. The implants by definition, you have differentiated (through the procedures) the patients who have failed every single intervention for back pain. I didn't pull a citation but the last thing I saw was 65-95% improvement for many of the various procedures you listed. Presumably they help people who can be helped by them. The spinal cord implant candidate, not so much. And the last thing I just saw suggests it's only 50% for these devices, and that it may be no better than placebo.

I dunno, the back pain issue is a problematic to say the least, but these patients are the worst of the worst and this is a hail Mary, compared to all before it.
 
I would disagree, and so would the literature and tests. 31-64% of chronic pain patients meet criteria for a personality disorder. Childhood abuse/neglect is associated with a 45% increased risk to report chronic pain, with that rate increasing up to 95% if the person experiences more than 4 ADEs.

Psychologically, there is a reason some people get a papercut and act like they're dying compared to a farmer who says that his left arm kinda hurts. I wouldn't want to be the surgeon who is dealing with a patient with Histrionic Personality Disorder post op.
I get that 100%, but have you looked at the evals that are getting signed off? I went to a residency where psychiatry actually rotated through our pain clinic. Most of these evals are the generic assessment and DON'T assess for personality disorders. So while I do agree with you that's what should be happening (just like pre-op bariatric evals should include assessments for eating disorders), this isn't what is being done in practice.

Totally fair. Just pointing out, there is a legitimate medical need here, even if the surgeon and psychiatrist and field in general haven't figured out how to fully articulate or assess it.

Couple reality with the the legal risk aspect... then yeah it's busy work to satisfy the latter by "pretending" to do the former.

Still makes sense to me on some level, but yes it is bloat. Still makes sense it is expensive. As you're pointing out, you're expecting a doctor to wade into ill defined territory that could be expensive to the doctor.
To be clear, I'm not saying that pre-op evals can't be beneficial. There are certain procedures where diagnoses should be ruled out (body dysmorphia for cosmetic surgeries, BED for bariatric, SUDs for pre-transplant evals, etc), but these concerns are NOT what insurance companies are asking or even what many surgeons are asking for. More often than not they're just asking for someone to check some boxes to be a meat shield/barrier for liability if things go south. That's part of why these evals are so expensive. If I'm going to take on liability, I better be getting paid d*** well to do so.
 
I get that 100%, but have you looked at the evals that are getting signed off? I went to a residency where psychiatry actually rotated through our pain clinic. Most of these evals are the generic assessment and DON'T assess for personality disorders. So while I do agree with you that's what should be happening (just like pre-op bariatric evals should include assessments for eating disorders), this isn't what is being done in practice.


To be clear, I'm not saying that pre-op evals can't be beneficial. There are certain procedures where diagnoses should be ruled out (body dysmorphia for cosmetic surgeries, BED for bariatric, SUDs for pre-transplant evals, etc), but these concerns are NOT what insurance companies are asking or even what many surgeons are asking for. More often than not they're just asking for someone to check some boxes to be a meat shield/barrier for liability if things go south. That's part of why these evals are so expensive. If I'm going to take on liability, I better be getting paid d*** well to do so.
In that case, I absolutely agree with you.
 
To be clear, I'm not saying that pre-op evals can't be beneficial. There are certain procedures where diagnoses should be ruled out (body dysmorphia for cosmetic surgeries, BED for bariatric, SUDs for pre-transplant evals, etc), but these concerns are NOT what insurance companies are asking or even what many surgeons are asking for. More often than not they're just asking for someone to check some boxes to be a meat shield/barrier for liability if things go south. That's part of why these evals are so expensive. If I'm going to take on liability, I better be getting paid d*** well to do so.

Thus my comment about the little slipup up there about "using" psychologists or psychiatrists for this stuff. That's how this is viewed by the proceduralist and patient in many of these cases....just check my box I don't care who does it.
 
There are certain procedures where diagnoses should be ruled out (body dysmorphia for cosmetic surgeries, BED for bariatric, SUDs for pre-transplant evals, etc)

Ok, this is understandable but

More often than not they're just asking for someone to check some boxes to be a meat shield/barrier for liability if things go south.

What exactly are we worried about being sued for here, for a spinal cord stimulator? I feel like we're grasping at straws to come up with zebra cases of how we'd be getting sued for a spinal surgery we didn't perform. Who is the one doing the suing? Patient suing us for "clearing" them? Family suing us because we "cleared" someone for surgery who later kills themselves and they argue they only killed themselves because the surgery went poorly and they should have never been cleared? Maybe I'm naive but these seem pretty unlikely.

I wouldn't want to be the surgeon who is dealing with a patient with Histrionic Personality Disorder

Are people getting sued for a missed diagnosis of histrionic personality disorder? Is this a thing that actually happens?
 
Ok, this is understandable but



What exactly are we worried about being sued for here, for a spinal cord stimulator? I feel like we're grasping at straws to come up with zebra cases of how we'd be getting sued for a spinal surgery we didn't perform. Who is the one doing the suing? Patient suing us for "clearing" them? Family suing us because we "cleared" someone for surgery who later kills themselves and they argue they only killed themselves because the surgery went poorly and they should have never been cleared? Maybe I'm naive but these seem pretty unlikely.



Are people getting sued for a missed diagnosis of histrionic personality disorder? Is this a thing that actually happens?
The surgeon is the one getting sued, bringing in the psychiatrist is meant to spread the liability a bit, and have back up about something that a failed spinal implant patient could claim as low hanging fruit, that they had a poor result because they weren't properly ruled out or assessed as a candidate for the surgery. As said, psychiatric factors are proven to be relevant. And surgeons under no circumstances can claim expertise in that area. So the only way to close that loophole is with an eval by the relevant expert. This has value, even if we argue that expert is not even able to make that assessment. I'll explain.

The issue with some of the medmal stuff, is that while things have to appear to make sense on some surface lay person assessment, it doesn't have to make medical sense in the way it does to us.

"My client had a poor result. They did not experience significant pain relief, and they had a complication of infection. Patients with certain psychiatric factors have been shown not to have benefit from the surgery. Dr. Surgeon did not discuss this with the patient, nor did they assess for the presence of these factors in selecting my client for this procedure."

So, unfortunately the above makes sense to most people. But just sending the patient to psychiatry doesn't meaningfully address the above you argue!!!

"My client, Dr. Surgeon, discussed the risks and benefits of the procedure. The patient was referred to psychiatry and assessed, whereupon both Surgeon and Psychiatrist in consultation agreed that the patient was a candidate for surgery. However outcomes cannot be guaranteed...."

So much of it is rebutting certain arguments, and when it comes to medical opinions, there is power in numbers.

Someone might come back and try to then argue about how the psychiatrist came to their opinion, but at this point the "gotcha" of, "psychiatry is relevant and you didn't consult psych," has been eliminated. Actually getting into the weeds of whether or not what the psych did has validity, tends to be a bit beyond what most folks are going to follow.

So the psych eval isn't about helping the psychiatrist in the event of a lawsuit. The opposite, really.

"Human liability shield" or whatever Stagg said is a great formulation of this.

Given the above, that's why we're saying, this shouldn't come cheap.

Lmao. You know the saying, if an intervention has no chance of benefit, and only risk of harm, then exposing someone to it, is only exposing them to risk of harm without any benefit. That's basically what an eval like this is, IF as stated there's really no good way to do it.

If you do something that you don't think is really going to help the patient, and just opens you up to lawsuit, in the hopes it helps another professional in case of lawsuit... the only way to balance that scale is money.
 
If it makes anyone feel better, sidestepping costly lawsuits is part and parcel of delivering care. If we assumed the implants might benefit some patients (setting aside the controversy), then you're going to want to manage the medicolegal risk so you can offer it to those who might benefit, despite the risks.

Obviously we don't want a reality where the surgeon should have gotten an assessment and didn't, and we want assessments to actually have validity. Does this whole process do exactly that? Probably sometimes it does good. Always? Eh
 
Here’s your answer:


Sure, but being required by the device manufacturer is still dumb. I get what you’re saying, but I think we all would likely agree that short of something I mentioned above (specific delusions/psychosis) these evals are silly.
I respectfully disagree. If the manufacturers want these in everyone then it’s in their financial interest to forgo an expensive step that delays or prohibits the implantation of their device.
 
I respectfully disagree. If the manufacturers want these in everyone then it’s in their financial interest to forgo an expensive step that delays or prohibits the implantation of their device.
Is it the device manufacturers requiring this eval or insurance? You said insurance in an earlier post, and they love putting up any barriers they can to avoid paying for expensive procedures.
 
I mean no case involving this is actually going to trial, but I guess I could (maybe?) see one settling for below reportable amounts. I do agree that people are grasping to find how the psychiatrists would be liable (or even where an insurance company would agree to settle) for anything. The bigger issue for me is that I do kind of care about my work and I'm not sure what my work would be here for spinal cord stimulators in specific. Again, I get bariatric and organ transplants and I do think we might have some limited role in that, but spinal cord stimulators?
 
From a psychiatric lens these evals likely aren't necessary in patients with no psych complaints, but I agree this needs to be viewed more from a medicolegal and layperson lens. Having a psych eval done prior to the surgery *looks* like a thoughtful step. Most of these cases I see are straightforward patients with no past psych history, no active psych complaints, and therefore not meeting criteria for any psych disorder. I don't have an issue "clearing" these patients, nor do I see much liability in this. This seems like a simple/pointless consultation, but it does serve as documentation (should it ever be needed) that the patient getting the surgery wasn't doing so while in a manic/psychotic/etc state.
 
Okay then does every non-emergent surgery or other medical intervention get a psych eval to make sure the patient isn't manic? I'm just not seeing the benefit to spinal cord stimulators in specific beyond that pain and mental health are tightly intertwined. That doesn't exactly explain what a psychiatrist's role is here though. If they're depressed, are you going to say no, not cleared, they're less likely to successfully respond?
 
From a psychiatric lens these evals likely aren't necessary in patients with no psych complaints, but I agree this needs to be viewed more from a medicolegal and layperson lens. Having a psych eval done prior to the surgery *looks* like a thoughtful step. Most of these cases I see are straightforward patients with no past psych history, no active psych complaints, and therefore not meeting criteria for any psych disorder. I don't have an issue "clearing" these patients, nor do I see much liability in this. This seems like a simple/pointless consultation, but it does serve as documentation (should it ever be needed) that the patient getting the surgery wasn't doing so while in a manic/psychotic/etc state.

I think everyone who keeps replying like this reinforces the de-valuation of our time in these cases and needs to know what the actual CMS guidelines say about this. This not supposed to be a "straightforward" evaluation and not even supposed to be one that you just refer out to some random person in the community.


Selection of patients for implantation of spinal cord stimulators is critical to success of this therapy. SCS therapy should be considered as a late option after more conservative attempts such as medications, physical therapy, psychological therapy or other modalities have been tried.

Patients must have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. (Such screening must include psychological, as well as physical evaluation). Documentation of the history and careful screening must be available in the patient chart if requested. Patients being selected for a trial

  • Must not have active substance abuse issues.
  • Must undergo proper patient education, discussion, and disclosure including an extensive discussion of the risks and benefits of this therapy.
  • Must undergo appropriate psychological screening
 
That CMS info does not describe at all what "psychological screening" for this device would entail. I went down a rabbit hole and couldn't find anything. Some literature about it says that MMPIs are helpful? This would typically be outside our scope.
 
I think everyone who keeps replying like this reinforces the de-valuation of our time in these cases and needs to know what the actual CMS guidelines say about this. This not supposed to be a "straightforward" evaluation and not even supposed to be one that you just refer out to some random person in the community.


Selection of patients for implantation of spinal cord stimulators is critical to success of this therapy. SCS therapy should be considered as a late option after more conservative attempts such as medications, physical therapy, psychological therapy or other modalities have been tried.

Patients must have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. (Such screening must include psychological, as well as physical evaluation). Documentation of the history and careful screening must be available in the patient chart if requested. Patients being selected for a trial

  • Must not have active substance abuse issues.
  • Must undergo proper patient education, discussion, and disclosure including an extensive discussion of the risks and benefits of this therapy.
  • Must undergo appropriate psychological screening

Having a psychiatrist assess for the presence of an active mental illness does not "de-value" our time. A full psychiatric eval should be enough to rule out everything short of personality disorders. If a patient doesn't have a psych illness then they don't have a psych illness. How is that not straightforward?
 
It devalues our time because there isn't a clear issue here specific to the surgery, at least not one I can find anywhere. Assuming we should be assessing for the presence of an active mental illness in just everyone does devalue our time and effort.
 
Having a psychiatrist assess for the presence of an active mental illness does not "de-value" our time. A full psychiatric eval should be enough to rule out everything short of personality disorders. If a patient doesn't have a psych illness then they don't have a psych illness. How is that not straightforward?

It's an issue that comes up all the time with all kinds of random psychiatry "referrals" and people wanting a "full evaluation" without it being clear what that actually means when what they actually want you to do is just say "yeah the patient can have the surgery or procedure".

It's either a thorough structured assessment that's then actually worth time and money or it's not. I would not say that a typical psychiatric patient intake would be thorough or structured enough for what's typically done for these...for instance:


The stuff you want to see starts on page 60. Quite a bit more in depth than most psych H+P I've seen.

If you look at some of the psychology groups that do these they tell patients to estimate several hours just for the interview and scales themselves, not to mention actually writing the note/report.
 
Is it the device manufacturers requiring this eval or insurance? You said insurance in an earlier post, and they love putting up any barriers they can to avoid paying for expensive procedures.

It is almost always insurance
It's an issue that comes up all the time with all kinds of random psychiatry "referrals" and people wanting a "full evaluation" without it being clear what that actually means when what they actually want you to do is just say "yeah the patient can have the surgery or procedure".

It's either a thorough structured assessment that's then actually worth time and money or it's not. I would not say that a typical psychiatric patient intake would be thorough or structured enough for what's typically done for these...for instance:


The stuff you want to see starts on page 60. Quite a bit more in depth than most psych H+P I've seen.

If you look at some of the psychology groups that do these they tell patients to estimate several hours just for the interview and scales themselves, not to mention actually writing the note/report.

Interesting that that document is very much against a model that looks anything like 'clearance'. But yes this is way more than a standard H&P.
 
It's an issue that comes up all the time with all kinds of random psychiatry "referrals" and people wanting a "full evaluation" without it being clear what that actually means when what they actually want you to do is just say "yeah the patient can have the surgery or procedure".

It's either a thorough structured assessment that's then actually worth time and money or it's not. I would not say that a typical psychiatric patient intake would be thorough or structured enough for what's typically done for these...for instance:


The stuff you want to see starts on page 60. Quite a bit more in depth than most psych H+P I've seen.

If you look at some of the psychology groups that do these they tell patients to estimate several hours just for the interview and scales themselves, not to mention actually writing the note/report.
I am a different medical speciality so don’t know what a reasonable price would be. If it is 1500$ then so be it. I respect what y’all do

So I read through the psychological assessment portion of this and this is not a typical surgical clearance. What they are considering standard is a specialized eval using specific psychological batteries performed by a forensic psychiatrist/psychologist. This is not something most psychologists or psychiatrists are qualified to do and those qualified can charge a very high premium.

If your patient was only charged $1500 then it sounds like either it was someone doing a general eval who doesn’t actually know what they’re doing or is maybe someone new trying to build a referral base. Frankly, you’d be lucky to find a forensics doc charging less than $500/hr and often times much more. I would not be surprised if this would normally cost 2-3x what your patient was charged.
 
Wegovy will do away with most all this within the next 5 years for 90% of (former) cases. Mark my words!

Also, can we stop saying "Wild," please? This is not what that word means. Internet words are not real words! Stop saying this!
The skibidi rizz kids are going to drive you crazy
 
It's an issue that comes up all the time with all kinds of random psychiatry "referrals" and people wanting a "full evaluation" without it being clear what that actually means when what they actually want you to do is just say "yeah the patient can have the surgery or procedure".

It's either a thorough structured assessment that's then actually worth time and money or it's not. I would not say that a typical psychiatric patient intake would be thorough or structured enough for what's typically done for these...for instance:


The stuff you want to see starts on page 60. Quite a bit more in depth than most psych H+P I've seen.

If you look at some of the psychology groups that do these they tell patients to estimate several hours just for the interview and scales themselves, not to mention actually writing the note/report.

These authors are psychologists who created a biopsychosocial battery test for pain patients so I feel like there might be a little bias in the way they view how this should be done. It was also interesting to read them argue against the "psych clearance" model concept. I do agree this is definitely more in depth than a regular psych H&P, though ultimately the reason for a psych clearance request is because of insurance so they get to decide what they'll accept. If insurance accepts a regular psychiatry H&P, then I'll have no issues providing a psychiatry eval. If insurance wants some specific psychological battery tests, then the SCS team should go find a psychologist to do it.

It's also worth noting that the only true "red flags or exclusionary risk factors" these authors themselves list are things that a regular psych H&P would/should be assessing for ("dangerousness to self and others, psychosis, drug addiction, and other forms of severe psychopathology").
 
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