Procedures non-fellowship trained physiatrists will NOT be able to do in the future

[joshmir]

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(First, a hearty thanks for all the advice given out in this forum; the efforts of all contributors is most appreciated.)

I have often heard that certain interventional procedures may not be reimbursed in the future by third party payors UNLESS a resident goes on to do a fellowship. If the fellowship is in Pain Management, it will have to be ACGME accredited. Right now, there is no such stipulation for spine fellowships (please correct me if I am wrong).

So my questions are:

1) Which procedures that non-fellowship trained physiatrists are ROUTINELY performing now (ie, they learned them in residency or from a seminar they payed for)...will NOT be reimbursed for by 3rd party payors in the future if the physiatrist is *not* fellowship trained?

2) If any of the residents were in the shoes of this fourth year interviewee, how much added value would you ascribe to being able to do "a lot of interventional procedures" as a resident?

I'm worried that if I truly wish to complement my practice with interventional procedures, I should go to the program most likely to help me get a fellowship...not the program which gives me the most training in these procedures as a resident....because I may not be able to DO them after residency without a fellowship (which I perceive as getting more and more competitive).

3) How likely is this ACGME/fellowship limitation (on WHO can bill for these procedures)? When will it likely to take place? And most importantly, *who* makes these decisions, and how do we follow the developments? There's a lot of hearsay out there.

I personally would love to do a fellowship, just worried about getting one in the future, and what my limitations will be if I can't. Sorry for the run on sentences...Thanks so much in advance for any advice!

 

[drusso]

Not straightforward questions. I welcome input/corrections from Stink, Rehabdoc, and others who might want to contribute...

Originally posted by joshmir


1) Which procedures that non-fellowship trained physiatrists are ROUTINELY performing now (ie, they learned them in residency or from a seminar they payed for)...will NOT be reimbursed for by 3rd party payors in the future if the physiatrist is *not* fellowship trained?

None that I'm aware of. Nonfellowship-trained physiatrists do EMGs, simple joint injections (SI, shoulder, knee, elbow, wrist, etc), trigger point injections, botox injections, spinal manipulation, among others and are reimbursed for them all. Some physiatrists do more complicated axial spine injections without having had a fellowship.

Originally posted by joshmir

2) If any of the residents were in the shoes of this fourth year interviewee, how much added value would you ascribe to being able to do "a lot of interventional procedures" as a resident?

I'm worried that if I truly wish to complement my practice with interventional procedures, I should go to the program most likely to help me get a fellowship...not the program which gives me the most training in these procedures as a resident....because I may not be able to DO them after residency without a fellowship (which I perceive as getting more and more competitive).

It helps to have exposure to interventional procedures, but I think that it is more important to have comprehensive rehabilitation training during your residency experience. You can train a monkey to put a needle in a joint, but understanding *WHY* to put a needle somewhere and more importantly *WHY NOT* to put a needle somwhere, that's a little more complicated. I would focus on getting comprehensive training for residency, then looking for specific procedurally-heavy fellowships later. Others may have different points of view.

Originally posted by joshmir
3) How likely is this ACGME/fellowship limitation (on WHO can bill for these procedures)? When will it likely to take place? And most importantly, *who* makes these decisions, and how do we follow the developments? There's a lot of hearsay out there.

I personally would love to do a fellowship, just worried about getting one in the future, and what my limitations will be if I can't. Sorry for the run on sentences...Thanks so much in advance for any advice!

Right now there are so many different people doing interventional pain management procedures (physiatrists, anesthesiologists, neurosurgeons, orthopedic surgeons, neurologists, rheumatologists, etc) that it is impossible to limit reimbursement by ACGME fellowship training status or not. Too many people would be up in arms. Are you going to tell a neurosurgeon that he can't do a discogram without a pain fellowship? How about an anesthesiologist doing a steriod epidural? An orthopod doing an SI injection? A neurologist a botox injection? All of these procedures have indications for the diagnosis and management of pain. It really comes down to whether you can get the training and prove your proficiency within your scope of practice.

As for "who makes these rules?" Well, we do. The why medicine is a PROFESSION. We, austensibly, regulate ourselves. That is why it is important to be active in organized medicine and your specialty college. That's why PASSOR developed its scope of practice document and why the American Academy of Pain Medicine works to advocate on just these very issues.

Right now, I'd concentrate on getting the best possible PM&R training you can--comprehensive and broadly-based. Your interests might change. You might decide to do sports, occ med, or neurorehab or spinal cord injury. Focus on procedurally-oriented fellowships later...

 

[Finally M3]

Interesting. I just had an interview at William Beaumont in Michigan, and the residency director was asking me why myself, and apparently the other interviewees thus far this year, were interested in pursuing fellowships for interventional procedures.

I told him about the possibility/worry that hospitals/insurance may require fellowship training in the future to perform procedures. Hospital requirements, he said, there wasn't really anything you could do but get the fellowship. As for insurance/professional guidelines for performing interventional procedures, he said that he hadn't heard anything on the horizon, and even if it occured, the 'grandfathering' window that would be put into place prior to implementation would cover the current class of applicants...

FWIW...😀