Referral Reversal

[TimeToChange]

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Background: Currently a PGY-3 in a great program, chose PMR because it is so multi-dimensional, addresses the often neglected patient's quality of life, and, let's be honest, addresses my quality of life too.

Idea:

As a PGY-3, I am inevitably starting to obsess about what jobs are out there. I happen to enjoy inpatient rehab as well as the so-called outpatient MSK setting. As we all know, a typical next step after residency is to join a multi-specialty group (ortho/neurosurg) and, correct me if I am wrong, be the perennial "bitch" in the group, seeing non-surgical patients and patients who have failed surgical treatment (who inevitably would have a poor outcome). In addition, although compensation is good (but still much less than the surgeons), the possibility of partnership is limited.

I suppose I am optimistic, but here are my thoughts:

In an ideal world (mine), I would be working/contracted with a primary care/geriatrics group and receive all of their MSK referrals. And therefore, I would be the primary referral base for these "surgical groups." In addition, I would be doing some inpatient rehab, acute care consults (to obtain more referrals from other primary care), adding outpatient PT/OT to said PCP/Geri group, among other things.

The benefits that I see are as follows:
1. A more even salary distribution between IM, Geri, PMR (i.e. more level playing field)
2. And therefore a more favorable/symbiotic business environment
3. Although the MSK patients are still the same, PMR would now be at the forefront, instead of just an addendum to a surgical group
4. Probably better patient outcomes (i.e. seeing them earlier along the disease progression)
5. Retention of inpatient knowledge (important to me, as I spent so much time during residency training in that setting)

The problems that I see are as follows:
1. Is it financially favorable to add-on a PMR to PCP/Geri group? I suppose EMG/NCV, basic injections, PT/OT would bring revenue to the group, but is it enough to be "wanted?"
2. Would a PCP/Geri group provide a large enough base of MSK patients?
3. Perhaps the PCP/Geri people just don't know what we can offer...

I'm sure this "setting" is out there, but by just perusing the AAPMR job board, the AAPMR job fair in Boston, probably not common?

So, to those that are out there in the real world, is this all "crazy-talk?" Seems to me like a win-win situation, but I'm sure there are problems with this. Please tell me your thoughts.

 

[topwise]

Someone from my program took a job seeing the MSK patients for a primary care practice. They had never hired someone like that before, but he knew someone in the practice who was persuasive. It was nice for him because he didn't have to take call like the rest of the physicians did.

I think it's a good idea, considering a lot of people go to their PCP for MSK complaints, even though this is a really weak area in the internal medicine training.

 

[axm397]

A lot of jobs are NOT on the AAPM&R job board and at the job fair. It's really a lot of word of mouth and cold calls. My friend partnered up with a PCP solo-practice - shares ownership of office building and gets referrals from PCP. Also plans for having PT gym. (not sure how he gets around Starks).

Another physiatrist I know - in a group practice with 3 other physiatrists - he is medical director of a 12 bed inpatient community rehab and also does outpatient MSK/EMGs. 2 of his partners are trained in interventional procedures - they have 2 office locations and an ASC. They all share ownership of above facilities and share profits. Tons of referrals from local PCPs. - not necessarily in the same "group" as PCPs but still considered first referral for MSK issues by many PCPs.

 

[Disciple]

A couple of things to think about when determining whether this will be feasible or not.

1. You likely will not be able to get your entire patient load from your group.
2. Regarding your statement about evening the salary distribution, if you're doing procedures and EMG, you will likely be generating more than the PCPs in the group. So, the situation you would have with a surgical group is reversed when it comes to yourself and a primary care group. The group will likely be benefiting more than you are. PT/OT may add a little bit of revenue, but it's not going to be a cash cow.
3. Part of this depends on the training/attitudes of your colleagues. Presently, PCPs know 2 things when it comes to musculoskeletal problems (Ortho/Neurosurg and then pain management). This is the way it's still taught in IM/FM residencies. You may be pressured to do opiate management because of this. The group may ask "is it worth having you around if you can't/won't help out with the chronic pain patients"?
4. If you're in an area with a lot of interventional pain doctors who are willing to handle the meds, you may have trouble getting outside referrals and maybe problems within your own group (see #3 above), as it will seem, through the PCPs eyes, that you are offering less instead of more. That's why so many Physiatrists join Ortho/Neurosurg groups. The patients are pre-selected. It's a trade-off for the lower salary.

 

[drusso]

OP,

Your idea about "reversing the food chain" is pretty much the Holy Grail of physiatry. Yes, unequivocally, if physiatrists could see patients earlier (pre-failed back surgery castastrophe) our impact would probably be more palpable. However, until physiatry groups start hiring surgeons and start paying them a salary (instead of the other way around) it is going to be difficult to turn the situation up-side-down. If you're working for surgeons, you can count on doing a fair bit of "Humpty-Dumpty Medicine." Unless...

You're working in some managed care/group practice environments where the surgeons are salaried and, quite frankly, are lazy or don't like to operate. This is why physiatry THRIVES in the VA system. There are some other large group practices with this model: Kaiser, GroupHealth Co-op, etc. Some of these places have Spine Centers and others don't. I think marketing yourself as someone interested in developing a Spine Center of Excellence in oneof those places would be the way to go. The PCPs would refer patients to the Spine Center for comprehensive, coordinated, conservative treatment and *YOU* would determine if they were a surgical candidate.

 

[lobelsteve]

This model is starting to happen more and more.

I believe it will be the future of pain medicine.

Point of service. No outside referral needed.
Maintain PT, MRI, EMG, etc. No reason to send them away.
THey can see their PCP for medical issues, walk down the hall and see the pain specialist, walk a little further to the MRI, a little further PT, a little further is the LNR ASC/office fluoro suite (depends on state reqs).

It goes deeper and I have been working on preparing this model in a different incarnation for some time.

 

[drusso]

This model is starting to happen more and more.

I believe it will be the future of pain medicine.

Point of service. No outside referral needed.
Maintain PT, MRI, EMG, etc. No reason to send them away.
THey can see their PCP for medical issues, walk down the hall and see the pain specialist, walk a little further to the MRI, a little further PT, a little further is the LNR ASC/office fluoro suite (depends on state reqs).

It goes deeper and I have been working on preparing this model in a different incarnation for some time.

Why point of service and not referral only? Just wondering...it seems like you're going to clog the pipes with a lot of low yield medical E&M service.

 

[PMR 4 MSK]

As we all know, a typical next step after residency is to join a multi-specialty group (ortho/neurosurg) and, correct me if I am wrong, be the perennial "bitch" in the group, seeing non-surgical patients and patients who have failed surgical treatment (who inevitably would have a poor outcome). In addition, although compensation is good (but still much less than the surgeons), the possibility of partnership is limited.

OP,

If you're working for surgeons, you can count on doing a fair bit of "Humpty-Dumpty Medicine." Unless...

You're working in some managed care/group practice environments where the surgeons are salaried and, quite frankly, are lazy or don't like to operate.

Have all PM&Rs been burned by surgeons, or did we just learn it from our attendings? You only have to be the "bitch" if you sell yourself short. Sure, I investigated groups where I was pretty sure I'd be the universal dumping ground. I don't know why anyone would take those jobs.

Surgeons want someone who is a strong team player and an asset to their group, financially and professionally. If they respect you, they won't dump on you. We bring skills to a group that can help an ortho group more efficiently manage their patients, add to the bottom line, and increase marketability.

I agree in the principles you put forward as far as reversing the food chain. We're too often seen as the "bottom feeders."

Depending on the locale you end up in, being aligned with one PCP group might not be good for you. If there is a lot of territorialism and/or competition for patients, you won't get enough from a smaller PCP group to survive, and their competitors aren't likely to send their patients your way if they see you as aligned with them. Being in a seperate group you can develope a lot more referral patterns from many groups in town.

I don't think we'll ever become the front line for MSK, as there are certainly plenty of PCPs who are comfortable treating simple sprains and strains, some even more complex ones. While FP/IM traditionally don't have a lot of MSK training, many have become quite good at it. Others, of course, want nothing to do with it.

I think we need to be seen as a secondary referral service, rather than tertiary. Work on getting the referrals before they go to the ortho's, neuro's, etc.

Also, you can get self-referrals. About 20% of my patients are, most of them well-insured. Many of them are word-of-mouth, the best marketing you can get.

 

[lobelsteve]

Why point of service and not referral only? Just wondering...it seems like you're going to clog the pipes with a lot of low yield medical E&M service.

Working in house for a large IM/FP group has the benefit of a zero overhead sum excluding salary/benefits/additional staffing. It is a referral only based practice, but the referrals are done at their PCP's office (your office).

The question would become: How many PCP/providers does it take to keep a single pain doc busy enough to not need to do a lot of marketing?

Answer: Who cares. If I get too busy, I hire on additional staff. I will court the NS/OSS, GS, Ob/Gyn, other FP groups, Urology, GI, etc. My process, if successful, will allow for me to bring on my first fellow within 18 months. No PA or NP can perform at the level I'd require to provide the care for my patients. The cost of the fellow would be mine to bear, so they would need to perform at a level where they cover their own salary/benefits in seeing patients. That is pretty easy to do in PM at $50k per year.

There is a lot more than what I am touching on currently, but I cannot afford to give away all my info (intellectual property rights) until I have things established from a consultative point of view.

Rules:
1. Patient care comes first
2. this space for rent😎

 

[ampaphb]

Working in house for a large IM/FP group has the benefit of a zero overhead sum excluding salary/benefits/additional staffing. It is a referral only based practice, but the referrals are done at their PCP's office (your office).

The question would become: How many PCP/providers does it take to keep a single pain doc busy enough to not need to do a lot of marketing?

Answer: Who cares. If I get too busy, I hire on additional staff. I will court the NS/OSS, GS, Ob/Gyn, other FP groups, Urology, GI, etc. My process, if successful, will allow for me to bring on my first fellow within 18 months. No PA or NP can perform at the level I'd require to provide the care for my patients. The cost of the fellow would be mine to bear, so they would need to perform at a level where they cover their own salary/benefits in seeing patients. That is pretty easy to do in PM at $50k per year.

There is a lot more than what I am touching on currently, but I cannot afford to give away all my info (intellectual property rights) until I have things established from a consultative point of view.

Rules:
1. Patient care comes first
2. this space for rent😎

The problem with the model, as generally implemented in large multi specialty groups, is that the fees generated from ancillaries (facility fees, MRIs, PT, etc), do not enrich the pain doc, but rather are generally used to pay down the overhead of the group as a whole. While this sounds good in theory, what it means is that the pain doc is basically supplementing the salaries of all the PCPs. On the whole, the model of PCPs feeding pain docs works great on a referral basis, but in a large multi-specialty setting, the pain doc does almost as badly as when he works as an employee of a hospital.

 

[lobelsteve]

The problem with the model, as generally implemented in large multi specialty groups, is that the fees generated from ancillaries (facility fees, MRIs, PT, etc), do not enrich the pain doc, but rather are generally used to pay down the overhead of the group as a whole. While this sounds good in theory, what it means is that the pain doc is basically supplementing the salaries of all the PCPs. On the whole, the model of PCPs feeding pain docs works great on a referral basis, but in a large multi-specialty setting, the pain doc does almost as badly as when he works as an employee of a hospital.

Unless of course, well you know... Shh!

Not ready to divulge my package at this time.

 

[olafa]

Unless of course, well you know... Shh!

Not ready to divulge my package at this time.

the intergrative medicine/ medical co-op model has unlimited potential..... and bring the idea to the forfront tat specialities should be interacting, talking rather than faxing thier notes back and forth. I think its a much more collegial environment granted everyone is thinking on the dame principle- the patient's benefit not their greed.

 

[drusso]

The problem with the model, as generally implemented in large multi specialty groups, is that the fees generated from ancillaries (facility fees, MRIs, PT, etc), do not enrich the pain doc, but rather are generally used to pay down the overhead of the group as a whole. While this sounds good in theory, what it means is that the pain doc is basically supplementing the salaries of all the PCPs. On the whole, the model of PCPs feeding pain docs works great on a referral basis, but in a large multi-specialty setting, the pain doc does almost as badly as when he works as an employee of a hospital.

lobelsteve,

I eagerly wait to hear the results of your venture. As much as it pains me, , I tend to agree with ampa's analysis above...not bad if you're a socialist!

 

[medicineman1]

drusso- what model do you envision as optimal for the pain physician?

 

[drusso]

drusso- what model do you envision as optimal for the pain physician?

referral ---> consult with recs ---> procedure vs med titration vs optomize other treatments---> retrurn to PCP!

I think that this is the most efficient use of a specialist's time and resources and prevents patients from developing too much of a "sick role" mentality. You ever spend any time in hanging out in pain clinic waiting rooms??? I think that the most powerful message you can give a patient is, "You've gotten better, you don't need a specialist anymore."

PCPs can manage HTN, DM, CRF, MS, High Cholesterol, etc. They can also manage chronic pain. It is a *CHRONIC* condition, afterall...

I applaud the one-stop shop approach, but if you're not careful, I see the potential to accumulate patients in the practice who would be best managed (with guidance and recs) by their PCP. Am I really to believe that a competent internist who can calculate a daily insulin requirement, a FENA, a Cr clearance, etc can't read an equianalgesic opioid conversion table?!?!

Hmmmm...

 

[Disciple]

The question is,

Will PCPs ever accept this type of arrangement?

One recent example,

I saw a patient the other day who was seen by a senior associate of mine 1 year ago. At the time the recommendation was made for continued opiate management by the PCP as the current regimen was effective. Problem was, the PCP didn't want recommendations, just someone else to write the scripts. So the patient gets sent for another eval 1 year later (no change in status or medication regimen). Not being a partner in the practice, I don't want to piss off the referral source and reluctantly agree to write the scripts.

Or this, I recently got a call from a PCP (repeat referral source) who told me he agreed with my treatment plan (opiate taper) but that he wanted me to write for all the opiates (which I did not initiate) and that if he wanted "an opinion" he would have sent the patient to the local academic center. Again, not wanting to lose the referral source, I reluctantly agreed.

I see this all too often. Ortho or Neurosurg for diagnosis and treatment, pain doc for the narcs. It's much harder to say no when you've got competition across the street.

 

[lobelsteve]

referral ---> consult with recs ---> procedure vs med titration vs optomize other treatments---> retrurn to PCP!

I think that this is the most efficient use of a specialist's time and resources and prevents patients from developing too much of a "sick role" mentality. You ever spend any time in hanging out in pain clinic waiting rooms??? I think that the most powerful message you can give a patient is, "You've gotten better, you don't need a specialist anymore."

PCPs can manage HTN, DM, CRF, MS, High Cholesterol, etc. They can also manage chronic pain. It is a *CHRONIC* condition, afterall...

I applaud the one-stop shop approach, but if you're not careful, I see the potential to accumulate patients in the practice who would be best managed (with guidance and recs) by their PCP. Am I really to believe that a competent internist who can calculate a daily insulin requirement, a FENA, a Cr clearance, etc can't read an equianalgesic opioid conversion table?!?!

Hmmmm...

These are the issues that are discussed prior to signing on board. There is actually a great deal of training the group as to what services/style/patient management the pain doc will provide, what the PCP's responsibility will be.

Worst case scenario: PCP's dump all of their methadone and darvocet patients on you and expect you to run with your Rx pad to cleanup their messes. No discussion as to how to improve patient care ensues, no changes are made except you change their drugs to a more appropraite regimen and the patient wlaks down the hall to complain about you to the PCP. The group asks you to leave in 6 months.

Best case scenario: The group turns into a pseudo-fellowship program with a lecture series on Pain Medicine. The docs are eager to learn, more eager for your help. Interventional lectures are not hands on, but given so that the docs know what their patients will be going through. The current lecture series is at 10 1.5 hr lectures.

There is a lot more in the planning than just signing up with a group and hoping it works out. Though cliche, the use of the term paradigm shift is appropriate in this situation. Hey, if I can't change PM to become it's own residency program, I can change the face of pain treatment.🙂

 

[TimeToChange]

Thanks for all the responses thus far. Seems like most of us agree on the "holy grail" of physiatry (i.e. reversing the feeding chain).

However, before we dive even deeper into the intricacies of how such a practice would work, wouldn't the process be much easier if the PCP's, Ob's, other referring fields were "courted" much earlier during their training?

It is essentially a "marketing" or "branding" problem. At least in my institution, PMR is known only to a fraction of the other services (ortho, stroke neuro, IM). Unfortunately, the IM residents (future colleagues) know PMR as merely a place to transfer a complex patient (dumping ground), and not much more. Just going through my log book, and out of over 400 consults, there was only 2 MSK-like consults (piriformis, PIN entraptment) from IM.

Do other PMR programs suffer the same problem?

So, am I to expect open arms from these PCP's when invited to have a drink from the "holy grail?" I applaud those out there attempting/preparing to "spread the good word." I am optimistic that PMR training programs would assume a leadership role in preparing our future referral base by being more vocal at their institutions.

What are your experiences in "the real world" in establishing a new referral base? What is the prevailing attitude towards PMR? Is there a need to explain/describe what we do? I almost feel as if I have to become a "PMR rep" and persuade a referral via fancy dinners and golf outings.

 

[PMR 4 MSK]

So, am I to expect open arms from these PCP's when invited to have a drink from the "holy grail?" I applaud those out there attempting/preparing to "spread the good word." I am optimistic that PMR training programs would assume a leadership role in preparing our future referral base by being more vocal at their institutions.

What are your experiences in "the real world" in establishing a new referral base? What is the prevailing attitude towards PMR? Is there a need to explain/describe what we do? I almost feel as if I have to become a "PMR rep" and persuade a referral via fancy dinners and golf outings.

I started over with a new practice a few years ago, in a new location as the practice's 1st PM&R. The other 4-5 PM&Rs in the town mostly do inpt and EMGs, 1 does some pain, partly CAM. I've had to go office-to-office, bringing lunch, a laptop and a projector to give a talk on what I do. Some knew a little about PM&R, others nothing, very few knew a lot. Some started sending me pts right away, some did not remember meeting me a few months later.

Most PCPs are very welcoming about PM&R when they learn how much we can help them. They're not looking for anything in return other than good patient care and a specialist to refer to. You don't need to wine and dine them. I brought lunch in order to be able to sit down with them for 20 minutes. I brought lunch for their staff whenever possible too (might help if their nurse remembers me and can make suggestions later). This is where you tailor your practice to how you want it - let them know what you're good at and what you're not. After that, it's all about what the patient says when they return to their PCP after seeing you.