quick thought in how the quality of program's can change quickly

[rehab_sports_dr]

As medical students are compiling their rank lists for the different programs, I just wanted to throw in my 2 cents on how quickly the reputation for programs can change. I think this is probably true for PM+R more than many other disciplines.

For example, for many medical students, the most important factor in deciding where to go is the relative strength of MSK training at those institutions. For most departments, the strength of the MSK training is function of only a few people, so that if a department adds one or two quality people (or loses 1-2 quality people), that can make an enormous impact on the quality of the training of the residents.

As an example, LIJ currently has one outstanding person in MSK (Jason Lipetz), so for residents interested in MSK training, the quality of their residency experience is mostly a function of Jason Lipetz. If they were to add a faculty member, though, it could substantially change the quality of the program to an even higher level.

Similarly, while most soon to be graduating fellows will be entering private practice, a few will choose to enter academia. When they do, that could have a big impact on the quality of training for the residents.

As a medical student, I am not sure what you do with this information. But is important that the program that you are ranking today could change in a significant way within a period of the next few months.

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[drusso]

Great post. That's why I think that the thing to emphasize is "balance" and "diversity" in a residency program. A good residency program makes you a well-rounded physiatrist.

Having said that it would be great if more physiatrists (especially those with strong MSK, Spine, and Pain training) stuck around the academic scene, but I don't see most academic departments making their recruitment a strong priority.

 

[Brooklyndo2.1]

Great post. That's why I think that the thing to emphasize is "balance" and "diversity" in a residency program. A good residency program makes you a well-rounded physiatrist.

Having said that it would be great if more physiatrists (especially those with strong MSK, Spine, and Pain training) stuck around the academic scene, but I don't see most academic departments making their recruitment a strong priority.

Wy do you think that is? the part about recruitment I mean

 

[rehab_sports_dr]

I am now in the process of being recruited for academic MSK positions. The big issue is that most departments have a pay scale that is set for all physiatrists.

In my ideal world, academic departments would pay MSK docs on a higher scale than other academics (similar to how internal medicine departments pay their GI and cardio docs more than their generalists).

But that is the limiting factor at this time.

 

[drusso]

I am now in the process of being recruited for academic MSK positions. The big issue is that most departments have a pay scale that is set for all physiatrists.

In my ideal world, academic departments would pay MSK docs on a higher scale than other academics (similar to how internal medicine departments pay their GI and cardio docs more than their generalists).

But that is the limiting factor at this time.

I've heard others have faced the *SAME* issue and it was usually a deal breaker for them. Some progressive academic practices have switched to paying their faculty based on (gasp) PRODUCTIVITY which would make a lot more sense for a MSK or "interventional" physiatrist. If you're generating more RVU's for your chairman than your colleagues, then you deserve to be paid more. However, there is something intensely feudal about academic physiatry practices that rewards face time and "loyalty" as instead of productivity per se.

 

[Gauss]

One thing that surprised me was the "research requirement". Every program seems to have one; some have higher objectives but you hear residents just brush it off. Well, of course my program started to hold the residents to the actual requirements now and we're all scratching our heads wondering why now? It doesn't change the quality of the program, but it really pisses me off filling out IRB crap or having to run SPSS rather than focusing on things I want to do and learn about.

 

[Disciple]

One thing that surprised me was the "research requirement". Every program seems to have one; some have higher objectives but you hear residents just brush it off. Well, of course my program started to hold the residents to the actual requirements now and we're all scratching our heads wondering why now? It doesn't change the quality of the program, but it really pisses me off filling out IRB crap or having to run SPSS rather than focusing on things I want to do and learn about.

The academics in PM&R are trying to improve the research focus of the field to get us to be taken seriously by the rest of the medical community.

 

[Disciple]

I've heard others have faced the *SAME* issue and it was usually a deal breaker for them. Some progressive academic practices have switched to paying their faculty based on (gasp) PRODUCTIVITY which would make a lot more sense for a MSK or "interventional" physiatrist. If you're generating more RVU's for your chairman than your colleagues, then you deserve to be paid more. However, there is something intensely feudal about academic physiatry practices that rewards face time and "loyalty" as instead of productivity per se.

The problem is that that most academic PM&R programs bring in their revenue through high volume inpatient services with quick discharges. In the academic setting, for an MSK specialist to match a general inpatient Physiatrist, they need to have a high volume clinic (15 min. f/u) with lots of epidurals and EMGs (of course advanced interventional skills would help to lighten the needed volume of epidurals). But, as it now stands that's just not the PM&R way as Physiatrists like to do 30-45min. f/u with some injections and EMG only when necessary.

This happened to a former co-resident of mine who was hired on to start up an MSK clinic at an academic program. The starting salary for the typical starting general inpt attending was a standard 120-130K. Given the circumstances (as he didn't want to participate in the inpt coverage) he was low balled horribly (80K). He ended up eventually taking the position which left me just shaking my head.

 

[Disciple]

I am now in the process of being recruited for academic MSK positions. The big issue is that most departments have a pay scale that is set for all physiatrists.

In my ideal world, academic departments would pay MSK docs on a higher scale than other academics (similar to how internal medicine departments pay their GI and cardio docs more than their generalists).

But that is the limiting factor at this time.

Musculoskeletal medicine needs to become a defined specialty with a defined knowledge base and skill set (not just something alot of young Physiatrists like to do) if it is to become the PM&R equivalent of GI or Cardiology.

There is just too much variability. What is "musculoskeletal medicine" anyway? A little sports med, some general Orthopaedic knowledge, EMG for peripheral nerve entrapments and some basic injections skills?

I'm kidding by the way.

There needs to be much more sophistication if an analogy is to be made with the IM subspecialties. I would propose something along the lines of knowledge of complex spinal disorders, sports medicine, orthopaedic care, ABEM level skill in EMG, proficiency in diagnostic musculoskeletal ultrasound and guided injections, proficiency in imaging interpretation (plain films, MRI and CT) and of course a fairly deep repetoire of interventional techiniques.

The AAPMR has the right idea in creating a separate "spine" track for the next meeting and having Bogduk lecture. I guess we'll see what happens in the next few years.

 

[drusso]

What is "musculoskeletal medicine" anyway?

How about this for a definition, "What orthopods used to do well before solely focusing on surgery and what rheumatologists never did well at all!"

 

[Taus]

How about this for a definition, "What orthopods used to do well before solely focusing on surgery and what rheumatologists never did well at all!"

I always thought you guys were like PT's who could write prescriptions?

 

[Brooklyndo2.1]

I always thought you guys were like PT's who could write prescriptions?

sorta like we DO's are chiros who can write scripts?

 

[Ligament]

I'm a physiatrist completing an anesthesiology based pain fellowship, highly interventional. I really like to teach the residents.

I've talked to a couple academic PM&R programs about joining, but the salaries are SO low compared to what I could make in private practice it makes it almost impossible to consider them. Starting PM&R academic salary in my neck is $120-$150k/year, whereas doing interventional pain in the private world could easily yield me $300-$600k/year take home within a couple years of startup WITHOUT practicing like a *****. I think the academic PM&R world needs to wake up and realize that they will not attract interventional pain physicians with these types of lowball salaries. Some academic full time physiatrists may COLLECT as little as $300k/year of billings, whereas for pain docs COLLECTIONS can be as high as nearly $2million in a high volume practice...there needs to be an appropriate incentive...

 

[Brooklyndo2.1]

I have heard rumors that interventional procedures will not be reimburesed nearly as well as they are now in the comming few years (5 or so) ... any thoughts on this?

 

[Ligament]

Without a doubt reimbursement will be cut, however interventional pain procedures will always pay well, especially since there have been some moves to restrict pain fellowship spots with newer, tougher, ACGME pain fellowship requirements. The docs that will come out on top are the ones that have something to offer the patients other than ONLY injection therapy.

I have heard rumors that interventional procedures will not be reimburesed nearly as well as they are now in the comming few years (5 or so) ... any thoughts on this?

 

[Taus]

sorta like we DO's are chiros who can write scripts?

Exactly!

On a serious note...
This is some awesome advice on this thread...thank you to the vets for discussing this here. I'm gonna really try to keep my ear to the ground about programs over the next year and a half before I enter the match.

 

[lobelsteve]

The problem is that that most academic PM&R programs bring in their revenue through high volume inpatient services with quick discharges. In the academic setting, for an MSK specialist to match a general inpatient Physiatrist, they need to have a high volume clinic (15 min. f/u) with lots of epidurals and EMGs (of course advanced interventional skills would help to lighten the needed volume of epidurals). But, as it now stands that's just not the PM&R way as Physiatrists like to do 30-45min. f/u with some injections and EMG only when necessary.

This happened to a former co-resident of mine who was hired on to start up an MSK clinic at an academic program. The starting salary for the typical starting general inpt attending was a standard 120-130K. Given the circumstances (as he didn't want to participate in the inpt coverage) he was low balled horribly (80K). He ended up eventually taking the position which left me just shaking my head.

My PA makes over 80k. I guess that's why I am not a MSK, or Fizz-e.

 

[lobelsteve]

I have heard rumors that interventional procedures will not be reimburesed nearly as well as they are now in the comming few years (5 or so) ... any thoughts on this?

Our reimbursement rates went up roughly 5% from Medicare 2006 to 2007.

The sky is always falling!

If it actually does, have eggs in many baskets. If it doesn't, have eggs in many baskets.

 

[Brooklyndo2.1]

Our reimbursement rates went up roughly 5% from Medicare 2006 to 2007.

The sky is always falling!

If it actually does, have eggs in many baskets. If it doesn't, have eggs in many baskets.

muchos quevos

yo comprende?

 

[rehab_sports_dr]

Based on my limited experience with contact negotiations thus far, most departments have some productivity factor built into their bonus system, but their is enormous variability in how big that bonus is. Some departments are similar to a private practice, where the bonus can approach the size of your base salary, whereas in other departments the bonus is a much smaller amount (in the range of ~10% of your base salary).

Other aspects of an academic position cotnract differ from private practice. for example, they have some mechanism for compensating you for academic activities like teaching, supervising, publications, etc. This is important, because it is one of the main reasons (for me, anyway), that I am going into academics instead of private practice.

 

[Disciple]

I think the academic PM&R world needs to wake up and realize that they will not attract interventional pain physicians with these types of lowball salaries...

Most PM&R departments probably don't have enough money to pay fair salaries to MSK docs.

One of my former co-residents is one of Slipman's fellows this year. From what he tells me, that is how you make yourself productive/profitable in the academic setting. 50 injections a day, or whatever huge number he does, plus all that research.

 

[Disciple]

Based on my limited experience with contact negotiations thus far, most departments have some productivity factor built into their bonus system, but their is enormous variability in how big that bonus is. Some departments are similar to a private practice, where the bonus can approach the size of your base salary, whereas in other departments the bonus is a much smaller amount (in the range of ~10% of your base salary).

Other aspects of an academic position cotnract differ from private practice. for example, they have some mechanism for compensating you for academic activities like teaching, supervising, publications, etc. This is important, because it is one of the main reasons (for me, anyway), that I am going into academics instead of private practice.

Typically, the productivity bonus is a percentage of collections above your base salary.

You have to remember, academic centers see alot of Medicare and Medicaid. In keeping with PM&R tradition/philosophy, how much are you going to be collecting seeing 8-12 Medicare/Medicaid patients per day with a couple of single level/side ESIs and an EMG.

 

[axm397]

Most PM&R departments probably don't have enough money to pay fair salaries to MSK docs.

One of my former co-residents is one of Slipman's fellows this year. From what he tells me, that is how you make yourself productive/profitable in the academic setting. 50 injections a day, or whatever huge number he does, plus all that research.

Slipman has a very unique and profitable arrangement w Penn. Don't think new grads can even consider getting a similar arrangement.

 

[catwhisperer]

Neither Dr Lipetz or any other musculoskeletal physiatrist could possibly protect the LIJ Rehab Department or residency program from its malevolent Chair, who is a neurologist. He is hostile to PM&R; and he has stated publically that he sees "no reason for PM&R as a specialty". He prevented LIJ's Former Rehab Department Chairman from ever having consultation privileges at Northshore several years ago. This precipitated the former LIJ Rehab Department Chairman's departure from LIJ several years ago and subsequent appointment at Kessler.

 

[drvlad2004]

Neither Dr Lipetz or any other musculoskeletal physiatrist could possibly protect the LIJ Rehab Department or residency program from its malevolent Chair, who is a neurologist. He is hostile to PM&R; and he has stated publically that he sees "no reason for PM&R as a specialty". He prevented LIJ's Former Rehab Department Chairman from ever having consultation privileges at Northshore several years ago. This precipitated the former LIJ Rehab Department Chairman's departure from LIJ several years ago and subsequent appointment at Kessler.

Because the LIJ PM&R program is under the neurology dept, the residency program has been very limited and under-established especially in musculoskeletal and outpatient. The program directors and chairmen have changed frequently over the years.

 

[Disciple]

Slipman has a very unique and profitable arrangement w Penn. Don't think new grads can even consider getting a similar arrangement.

I fully realize that he is probably more valuable to the surgeons and the spine center than the PM&R department, is able to go through a high volume of patients with the fellows and is handsomely compensated by Arthrocare for his work regarding Nucleoplasty.

Just making a point that seeing a few clinic patients, doing occasional epidurals and EMGs isn't going to cut it if you plan on being productive and pulling your weight in your department as an academic MSK doc.

 

[RuNnR]

do any of yall think there are programs that have changed for better and worse (maybe Tufts) that you wouldn't recommend?

Ones that keep changing for better (maybe harvard, hopkins, Emory)?

thanks!!

 

[catwhisperer]

I have heard rumors that interventional procedures will not be reimburesed nearly as well as they are now in the comming few years (5 or so) ... any thoughts on this?

Absolutely true, the government policy wonks who govern Medicare and Medicaid have noted that the number of interventional spine procedures performed by physiatrists has increased by over 70%, while the number of admissions for inpatient rehab has declined by almost 40%. Count on reimbursement for interventional procedures being slashed by Medicare and Medicaid, and the private insurers will soon follow suit and decrease their reimbursement as well.

 

[drusso]

Absolutely true, the government policy wonks who govern Medicare and Medicaid have noted that the number of interventional spine procedures performed by physiatrists has increased by over 70%, while the number of admissions for inpatient rehab has declined by almost 40%. Count on reimbursement for interventional procedures being slashed by Medicare and Medicaid, and the private insurers will soon follow suit and decrease their reimbursement as well.

I don't think that you understand how the process works. The Feds don't change reimbursement for specific procedures.

Physicians bill their services using codes developed by a seventeen member committee known as the CPT Editorial Panel. The AMA nominates eleven of the members while the remaining seats are nominated by the Blue Cross Blue Shield Association, the Health Insurance Association of America, CMS, and the American Hospital Association. The CPT Committee issues new codes twice each year.

A separate committee, the Relative Value Update Committee (the RUC), determines the Resource Based Relative Value for each new code and revalues all existing codes at least once every five years. The RUC has 29 members, 23 of whom are appointed by major national medical societies. The six remaining seats are held by the Chair (an AMA appointee), an AMA represenative, a represenative from the CPT Editorial Panel, a representative from the American Osteopathic Association, a representative from the Health Care Professions Advisory Committee and a representative from the Practice Expense Review Committee.

The RBRVS for each CPT code is determined using three separate factors: physician work, practice expense, and malpractice expense. The RUC examines each new code to determine a relative value unit (RVU) by comparing the physician work of the new code to the physician work involved in existing codes.

The practice expense, determined by the Practice Expense review Committee, consists of the direct expenses related to supplies and non-physician labor used in providing the service, and the pro rata cost of the equipment used. In addition, there is an amount included for the indirect expenses.

In the development of the RBRVS, the physician work (including the physician's time, mental effort, technical skill, judgement, stress and an amortization of the physician's education), the practice expense and the malpractice expense are factored into the result. The calculation of the fee includes a geographic adjustment. The RBRVS does not include adjustments for outcomes, quality of service, severity, or demand.

Every year Congress approves an equation that is used to generate a conversion factor. The conversion factor multiplied by the RVU assigned to every CPT code generates a dollar amount that is paid to the physician. If the conversion factor is lowered it effects all physicians. The codes and their resulting RVU's are in constant flux based upon which stake holders are on the RUC

 

[Brooklyndo2.1]

I don't think that you understand how the process works. The Feds don't change reimbursement for specific procedures.

Physicians bill their services using codes developed by a seventeen member committee known as the CPT Editorial Panel. The AMA nominates eleven of the members while the remaining seats are nominated by the Blue Cross Blue Shield Association, the Health Insurance Association of America, CMS, and the American Hospital Association. The CPT Committee issues new codes twice each year.

A separate committee, the Relative Value Update Committee (the RUC), determines the Resource Based Relative Value for each new code and revalues all existing codes at least once every five years. The RUC has 29 members, 23 of whom are appointed by major national medical societies. The six remaining seats are held by the Chair (an AMA appointee), an AMA represenative, a represenative from the CPT Editorial Panel, a representative from the American Osteopathic Association, a representative from the Health Care Professions Advisory Committee and a representative from the Practice Expense Review Committee.

The RBRVS for each CPT code is determined using three separate factors: physician work, practice expense, and malpractice expense. The RUC examines each new code to determine a relative value unit (RVU) by comparing the physician work of the new code to the physician work involved in existing codes.

The practice expense, determined by the Practice Expense review Committee, consists of the direct expenses related to supplies and non-physician labor used in providing the service, and the pro rata cost of the equipment used. In addition, there is an amount included for the indirect expenses.

In the development of the RBRVS, the physician work (including the physician's time, mental effort, technical skill, judgement, stress and an amortization of the physician's education), the practice expense and the malpractice expense are factored into the result. The calculation of the fee includes a geographic adjustment. The RBRVS does not include adjustments for outcomes, quality of service, severity, or demand.

Every year Congress approves an equation that is used to generate a conversion factor. The conversion factor multiplied by the RVU assigned to every CPT code generates a dollar amount that is paid to the physician. If the conversion factor is lowered it effects all physicians. The codes and their resulting RVU's are in constant flux based upon which stake holders are on the RUC

So Im just looking for education here...how then do some specialty procedures become "hot" due to reimbursement rate...
as an example, I would think that omt would be "worth" more since there is extra training/skill involved, as is true of injections....
if im wrong tell me how/why...
ps... I used omt as something im familiar with that requires a lot of skill to do well, thats all. (and wish it reimbursed better)

 

[drusso]

So Im just looking for education here...how then do some specialty procedures become "hot" due to reimbursement rate...
as an example, I would think that omt would be "worth" more since there is extra training/skill involved, as is true of injections....
if im wrong tell me how/why...
ps... I used omt as something im familiar with that requires a lot of skill to do well, thats all. (and wish it reimbursed better)

Again, several factors: Technical, cognitive, etc. Previously the technical factor in the codes have been more highly valued. There is also "drift." Usually, newer procedures get artificially higher RVU's in the beginning and then there is sort of downward drift as more physicians become expert and experienced with a given procedure, complications are better understood, efficacy is established, etc.

It also depends upon who is actually sitting on the committee and what their individual biases and knowledge are about the procedures. You'll note that the AOA sends one representative to the RUC. That representative needs to advocate for *all* procedures that DO's perform not just OMT. Thus, it may be a higher priority to advocate for higher physician reimbursement for skin biopsies or pap smears than OMT.

 

[Brooklyndo2.1]

Again, several factors: Technical, cognitive, etc. Previously the technical factor in the codes have been more highly valued. There is also "drift." Usually, newer procedures get artificially higher RVU's in the beginning and then there is sort of downward drift as more physicians become expert and experienced with a given procedure, complications are better understood, efficacy is established, etc.

It also depends upon who is actually sitting on the committee and what their individual biases and knowledge are about the procedures. You'll note that the AOA sends one representative to the RUC. That representative needs to advocate for *all* procedures that DO's perform not just OMT. Thus, it may be a higher priority to advocate for higher physician reimbursement for skin biopsies or pap smears than OMT.

wait what happened to OMT being our distinction?

 

[catwhisperer]

I don't think that you understand how the process works. The Feds don't change reimbursement for specific procedures.

Physicians bill their services using codes developed by a seventeen member committee known as the CPT Editorial Panel. The AMA nominates eleven of the members while the remaining seats are nominated by the Blue Cross Blue Shield Association, the Health Insurance Association of America, CMS, and the American Hospital Association. The CPT Committee issues new codes twice each year.

A separate committee, the Relative Value Update Committee (the RUC), determines the Resource Based Relative Value for each new code and revalues all existing codes at least once every five years. The RUC has 29 members, 23 of whom are appointed by major national medical societies. The six remaining seats are held by the Chair (an AMA appointee), an AMA represenative, a represenative from the CPT Editorial Panel, a representative from the American Osteopathic Association, a representative from the Health Care Professions Advisory Committee and a representative from the Practice Expense Review Committee.

The RBRVS for each CPT code is determined using three separate factors: physician work, practice expense, and malpractice expense. The RUC examines each new code to determine a relative value unit (RVU) by comparing the physician work of the new code to the physician work involved in existing codes.

The practice expense, determined by the Practice Expense review Committee, consists of the direct expenses related to supplies and non-physician labor used in providing the service, and the pro rata cost of the equipment used. In addition, there is an amount included for the indirect expenses.

In the development of the RBRVS, the physician work (including the physician's time, mental effort, technical skill, judgement, stress and an amortization of the physician's education), the practice expense and the malpractice expense are factored into the result. The calculation of the fee includes a geographic adjustment. The RBRVS does not include adjustments for outcomes, quality of service, severity, or demand.

Every year Congress approves an equation that is used to generate a conversion factor. The conversion factor multiplied by the RVU assigned to every CPT code generates a dollar amount that is paid to the physician. If the conversion factor is lowered it effects all physicians. The codes and their resulting RVU's are in constant flux based upon which stake holders are on the RUC

I fully understand how the RVU system works.
I recall that this system was used to reduce reimbursement for EMG services in the early 1990s, with the approval of "stakeholders"
I also recall that the 75% rule was put forward by PM&R "stakeholders" ....
I guess I don't have as much faith in the system as you do.

 

[drusso]

I fully understand how the RVU system works.
I recall that this system was used to reduce reimbursement for EMG services in the early 1990s, with the approval of "stakeholders"
I also recall that the 75% rule was put forward by PM&R "stakeholders" ....
I guess I don't have as much faith in the system as you do.

And what procedures went up? Interventional rads, ENT, rad onc, etc. Wrong stakeholders, wrong outcome.

 

[paz5559]

I also recall that the 75% rule was put forward by PM&R "stakeholders" ....

75% rule was put up by CMS over the fierce opposition of PM&R powers that be. They based their categories on a 25 year old document, and the same people who had written it in the 80's strenuously objected when the rule was proposed.