Procedure Volumes

[Jack Black]

Can any one give me an idea of the volume or number of procedures (not patients treated) a typical full time pain doc can expect to do in a year? I realize this can vary, but there must be a typical range a full-time interventional pain physician can reasonably expect to do on average annually.

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[mille125]

Can any one give me an idea of the volume or number of procedures (not patients treated) a typical full time pain doc can expect to do in a year? I realize this can vary, but there must be a typical range a full-time interventional pain physician can reasonably expect to do on average annually.

first of all...who are you and why do you want to know?

 

[PMR 4 MSK]

I'd hazard a guess of the 50th %ile being 20 - 30 per week, but the upper 95th % being 60+

 

[paindefender]

first of all...who are you and why do you want to know?

Take some zyprexa. Good for paranoia.

 

[lobelsteve]

Take some zyprexa. Good for paranoia.

Bad idea- too much weight gain.
Tequila is king.

 

[paindefender]

Can any one give me an idea of the volume or number of procedures (not patients treated) a typical full time pain doc can expect to do in a year? I realize this can vary, but there must be a typical range a full-time interventional pain physician can reasonably expect to do on average annually.

Weekly

< 20 remedial action needed
20-30 mimimum acceptable
30-40 good
40-50 very good
50-60 outstanding
60+ blokjok

 

[Tenesma]

you have to figure that each procedure is going to generate a follow-up (with probably 2-3 patients no-shows because their pain is better)... so if you are doing 60 procedures/week then you are seeing about 60 procedure follow-ups per week --- 1/3 will respond to intervention and no room for repeat, 1/3 will require further intervention, 1/3 will require non-interventional care... so you may be able to squeeze out 15-20 procedures out of those 60 follow-ups (at best). then you have to figure that your rate of procedures per consultation will hover between 1/3 to 1/2 (unless you have some kind of weird set-up where all you get are procedure referrals)... and let's say you are seeing 8 new patients a day (4 days a week), that would be about another 12-14 procedures... so now you are at 27-34 procedures per week... and then figure that you can maybe extract 1 procedure for every 5th follow-up (not procedure related)... so you would have to see about 125 non-procedure follow-ups per week...

so in order to generate 60 procedures per week (and i am not talking about trigger points and joint injections), you would have to see 32 new patients/week, 60 post-procedure follow-ups per week and 125 regular follow-ups.... plus your 60 procedures per week -- totals 277 patient encounters per week... which in my opinion is malpractice and just not doable... (55 encounters per day including 12 procedures per day)

so therefore the only way you can get to 60 procedures is to EITHER have a spine surgeon spoon feed you OR have a few nurse practitioners who unload all of the procedure-follow-ups and the more mundane follow-ups OR you are doing a series of 3 for every possible CPT code in the book... (the latter being unacceptable from my point of view).

i think anything >30 per week is reasonable, and will pay your bills...

 

[Jack Black]

Thanks to those of you who contributed. My goal is to simply get a general 'feel' for what can be reasonable in a typical full service, full time interventional pain practice. (And not one that is simply fed only from a spine surgeon or a block jock situation, but rather a well rounded pain practice in the typical community)

The thoughts shared are helpful and much appreciated. Thanks again to those who have contributed.

 

[Kwijibo]

Listen, You don't have to be a block jock to do more than 60 procedures a week. I agree with a lot of what you guys are saying, but you can do more than 60 procedures without sacrificing patient care.

I think the most important factor that has been left out of this whole equation is that our patients come back. Even when you treat that 30 yo w/acute radic, they get a flare up every now and then. That spinal stenosis patient is almost guaranteed to come back, you are married to the post lami, the RFA will be back sooner or later, as will the pre surgery patient for discogram.
So you take Tenesma's equation, and with a more mature practice you add 4-5 procedures a day on someone you injected 6 months ago, or a year ago or whatever.
That is what it great about our pain management. The patients come back.

In my practice, I average 60-80 procedures per week. I see on average 10 new patients a day and 20 medication/follow ups. I do not write many medications for people that I cannot help with injections (shoulder pain, wrist pain, abdominal pain, etc.) unless they are referred/dumped from someone close.
Another thing, the druggies taking tons of narcotics rarely ever want to get injections. Most of them are petrified of the needle. So this way most follow ups could potentially be injections as well.
Included in those injections are everything from stim trials, pudendal nerve blocks, sympathetic blocks, AA block, RFA's etc and I don't work for anyone. No one gets a 'series of three' and patients wait three weeks for a follow up after first injection and a month after second most of the time.
The main factor in generating procedures is a good referral base. About half of the patients come to my office knowing that they are there for an injection. 1/4 are for spine pain workup, 1/4 for whatever else. You need to provide a good service. Patients that need surgery get it, need other testing and therapy get it, and patients and referrers appreciate it.

 

[Tenesma]

kwijibo - if you are doing 60-80 procedures per week - that means about 12-16 procedures per day, do you choose not to see certain % of them in follow-up? how do you document improvement/deterioration if you don't see them (is it based on phone interviews?)... curious.

 

[mille125]

kwijibo - if you are doing 60-80 procedures per week - that means about 12-16 procedures per day, do you choose not to see certain % of them in follow-up? how do you document improvement/deterioration if you don't see them (is it based on phone interviews?)... curious.

i am also curious

 

[Kwijibo]

i am also curious

Typical patient- Spinal Stenosis/herniation- L5 radic. Patient counselled at initial interview about their options.
1. live with the pain with pain meds/lyrica/cymbalta/chiro/pt/etc. each step you take in treatment algorithm is based on pain level w/o neuro deficits. no one is pushed into having an injection.
2. epidurals
3. surgery/laminectomy.

plan:
L4-5 transforaminal on the left. no lyrica, antidepressant, etc. Follow up in 3 weeks. If 80% or better patient told to call and cancel their appointment and reschedule for two weeks later. If minimal to no relief and severe pain, patient told they can call and move their appointment up.

If patients fail epidurals they are sent for surgical consultation. Most people do not want surgery but I still recommend they see a surgeon so that they know their options. I recommend surgery if injections not working and a laminectomy or better yet microdisc are a possibility.

If patient gets good relief with injection patient told to stretch it out if after third injection patient told to follow up in 6 weeks. If a patient has gotten a 'series of three' by me two weeks apart then they really needed it an likely ended up getting that disc/stenosis taken out.

So I lose patients all the time to surgery or not needing another injection. I am sure many of you readers may be adverse to sending patients for surgery, but the bottom line is that laminectomies and microdiscs work, and often work very well. This also means that I get 5 new patients a week or so from spine surgeons.

No mid level practioner(NP starting soon). MA rooms patient and collects basic data. Usually will print out med refill scripts to be signed for certain patients. New patients get basic data collected by MA. Patients can wait one hour easily and system needs improvement. Work every other saturday and see inpatients before and occasionally after office hours two-three days a week. Most patients are straightforward.

One reason this works because in my area people practice individually. Most spine surgeons do not have their salaried pain guy. There are minimal surgical centers so there are not minimally trained epidural specialist pain docs on every corner. The surgeons make enough money that they dont have to do injections themselves, although this is growing. This leads to better patients floating around, less multilevel disc disease axial back pain on 30 mg roxicodone q 4 hours. You Florida guys know what I'm talking about.

 

[painfree]

So how many MAs do you have, and how are you splitting your procedures with clinic time? One procedure room or two and how do you speed up this process ?
Also, how are you documentating your notes?


Thanks.

 

[Jcm800]

sounds like an impressive volume.

I however cant see that volume, probably to my detrement. I spend too much time with the patients. Lots of competition around me, and the patients are old and nice so you have to not rush them in and out. I still get the occasional dump and crazy seeker, but less and less. Im basically a geriatrician, which works for me.

I am limited by my space and staff set up, which i hope to someday improve... Most I can see is 20 patients a day. maybe 8 procedures in the morning, nothing fancy, just injections. Then patients in the afternoon maybe 2-5 new a day, i do that 3 days a week. Two afternoons i have block time in the OR where i do all of my "non-injections" except RF i do in the office, which is a nightmare from efficiency standpoint...

I cant see patients for follow up knowing they will require a procedure then bring them back for the procedure. For example... I see the new consult on day1. shedule for whatever later that week, or more likely the following week. Do prcedure on say day 8 of meeting them, have them return in 3-4 weeks, planning as if I will repeat if needed. If they do not, thats the follow up. I just cant make the 70 year old person come in to tell me they want another injection, and then have them come back in a week to have it done...

Im a sucker i guess. What do most people do regarding this?

I got a lot to learn, and I need to speed up, but hey, the patients like me, and I never worry that Im running them through a circuit, like most guys in my area...

not that anyone asked.

Typical patient- Spinal Stenosis/herniation- L5 radic. Patient counselled at initial interview about their options.
1. live with the pain with pain meds/lyrica/cymbalta/chiro/pt/etc. each step you take in treatment algorithm is based on pain level w/o neuro deficits. no one is pushed into having an injection.
2. epidurals
3. surgery/laminectomy.

plan:
L4-5 transforaminal on the left. no lyrica, antidepressant, etc. Follow up in 3 weeks. If 80% or better patient told to call and cancel their appointment and reschedule for two weeks later. If minimal to no relief and severe pain, patient told they can call and move their appointment up.

If patients fail epidurals they are sent for surgical consultation. Most people do not want surgery but I still recommend they see a surgeon so that they know their options. I recommend surgery if injections not working and a laminectomy or better yet microdisc are a possibility.

If patient gets good relief with injection patient told to stretch it out if after third injection patient told to follow up in 6 weeks. If a patient has gotten a 'series of three' by me two weeks apart then they really needed it an likely ended up getting that disc/stenosis taken out.

So I lose patients all the time to surgery or not needing another injection. I am sure many of you readers may be adverse to sending patients for surgery, but the bottom line is that laminectomies and microdiscs work, and often work very well. This also means that I get 5 new patients a week or so from spine surgeons.

No mid level practioner(NP starting soon). MA rooms patient and collects basic data. Usually will print out med refill scripts to be signed for certain patients. New patients get basic data collected by MA. Patients can wait one hour easily and system needs improvement. Work every other saturday and see inpatients before and occasionally after office hours two-three days a week. Most patients are straightforward.

One reason this works because in my area people practice individually. Most spine surgeons do not have their salaried pain guy. There are minimal surgical centers so there are not minimally trained epidural specialist pain docs on every corner. The surgeons make enough money that they dont have to do injections themselves, although this is growing. This leads to better patients floating around, less multilevel disc disease axial back pain on 30 mg roxicodone q 4 hours. You Florida guys know what I'm talking about.

 

[Tenesma]

IF i suspect that patient may need further injections (either diagnostic or therapeutic) then i will have them call my RN within 7 days of procedure - if they are doing fine, then keep f/u - if they have new/different symptoms then come in for f/u right away - if their sx are unchanged, then we schedule them for procedure...

 

[PMR 4 MSK]

I stopped scheduling procedural patients for follow-up after the injections - I used to have them come in 1 week post-injection. I found at least 50% were doing so much better that they did not need to come in, and most of the rest could be handled via phone - I already knew what the next step would be should the ESI, MBB, whatever not work.

This freed up much of my clinic - so much so that in 2 months, I got my new pt wait time down from 2 months to 2 weeks.

 

[dc2md]

Are you guys billing for the phone conversations? Can you do that if only the nurse speaks to them?

 

[PMR 4 MSK]

Are you guys billing for the phone conversations? Can you do that if only the nurse speaks to them?

I don't - no one pays for it anyway.

 

[brori]

Never have billed for a phone call (would feel cheap). However, I suppose that if I had a phone conversation for more than 15 minutes with lots of questions, I would bill for it (would be interesting to see if it would get paid)

 

[mille125]

Never have billed for a phone call (would feel cheap). However, I suppose that if I had a phone conversation for more than 15 minutes with lots of questions, I would bill for it (would be interesting to see if it would get paid)

you wont