Scope of pain practice

[lmsanscafe]

I see a lot of candidates expressing a lot of interest in highly interventional procedures (SCS, pumps, kypho, vertiflex, etc.) but in real life, what percentage of pain docs would you say actually perform the full spectrum on a consistent basis? Is it more common to just do bread and butter procedures (peripheral and neuraxial joint injections) with just a few of these advanced procedures per month?

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[BobBarker]

Just a few per month would actually be a lot for any of those procedures listed.
3 trials and implants/month is $900,000 in annual revenue for your stimulator rep. So 3/month would be a prized account they would fight over. So I think the question is do more than a few/year really.

 

[PainApp2021]

Just a few per month would actually be a lot for any of those procedures listed.
3 trials and implants/month is $900,000 in annual revenue for your stimulator rep. So 3/month would be a prized account they would fight over. So I think the question is do more than a few/year really.

Is there any situation where it wouldn't be uncommon to do pumps or stims more frequently?

 

[Agast]

Is there any situation where it wouldn't be uncommon to do pumps or stims more frequently?

If you have a large cancer pain population. I don’t think it’s appropriate to routinely implant pumps otherwise and you are doing non-palliative patients a disservice.

 

[BobBarker]

Is there any situation where it wouldn't be uncommon to do pumps or stims more frequently?

Yes, if you are part of a big group and the implant guy or being funneled trials by surgeons. As a stand alone guy, really the most that is feasible is 110 implants or less a year. Most “big implanters” is around 50-60 cases per year. There are many that project that they do more than this but when you look at the objective data it isn’t true.

 

[Ronin1]

Yes, if you are part of a big group and the implant guy or being funneled trials by surgeons. As a stand alone guy, really the most that is feasible is 110 implants or less a year. Most “big implanters” is around 50-60 cases per year. There are many that project that they do more than this but when you look at the objective data it isn’t true.

Damn 110 a year. Stud!

 

[BobBarker]

I haven’t done 110. 2019 was my best year. 40-60/year since entering practice excluding 2019.

you talk to old reps and they will talk about once they got their “whale” over 100 that there was nowhere to go but down. Their doc couldn’t do anymore and they had a huge programming burden in one office that limited their ability to get other doctors going/plus professional jealousy issues between the doctors.

 

[PainApp2021]

Yes, if you are part of a big group and the implant guy or being funneled trials by surgeons. As a stand alone guy, really the most that is feasible is 110 implants or less a year. Most “big implanters” is around 50-60 cases per year. There are many that project that they do more than this but when you look at the objective data it isn’t true.

If you have a large cancer pain population. I don’t think it’s appropriate to routinely implant pumps otherwise and you are doing non-palliative patients a disservice.

Gotcha. Thank you. I love the SCI population and primarily want to do a pain fellowship to take ownership over placing SCS and baclofen pumps. I haven't really considered pumps for cancer patients yet, but that is interesting. Thank you

 

[SommeRiver]

I had an unusual October and did 7 stim cases. That was a huge month in terms of my "monthly numbers."

I avg 2-4 per month. Some months none, some 5 or 6.

BobBarker brings up an interesting point about dudes claiming 100 or whatever. This is another reason I quit going to NANS.

During a lecture, in the opening remarks...Huntoon told the crowd he does "about 100 or so a year."

He probably does that number given who he is and I do not doubt that, but he had no reason to share that with the crowd. We all know who he is if we're at NANS in the 1st place.

Young attendings (me) hear that and start wondering why we're not pulling similar numbers and what we're doing wrong. What's wrong with my referral base?

It is very difficult to do over 50 stim cases a year, trial and implant.

If you are doing 50 cases a year, you better be making serious money bc the required volume in pt load to capture that many stim cases is probably 30-40 clinic pts per day with your hair on fire.

 

[BobBarker]

How are you going to place scs in patients with fixated t spines??

 

[lobelsteve]

How are you going to place scs in patients with fixated t spines??

Send them to you.
Or this idiot...

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Since I know everyone here loves SI joint fusions, here’s someone I saw for a new consult today. At least, I assume that was supposed to be an SI joint fusion. Either that or she got “grazed” like the guy above. Shockingly, her SI joint still hurts... Axial and coronal CT (again sorry for the...

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[buddababa]

Just a few per month would actually be a lot for any of those procedures listed.
3 trials and implants/month is $900,000 in annual revenue for your stimulator rep. So 3/month would be a prized account they would fight over. So I think the question is do more than a few/year really.

Wait. Explain that 900k in revenue? How much cut does a rep get off of that?

 

[Espn123]

Just a few per month would actually be a lot for any of those procedures listed.
3 trials and implants/month is $900,000 in annual revenue for your stimulator rep. So 3/month would be a prized account they would fight over. So I think the question is do more than a few/year really.

How long have you been out in practice?

 

[BobBarker]

How long have you been out in practice?

5 years

 

[BobBarker]

Wait. Explain that 900k in revenue? How much cut does a rep get off of that?

The hospital or ASC pays around that much for product for 36 trials and implants. An IPG costs around $16.5k minimum plus leads and extras. Rep compensation is tied to meeting a base quota. Usually this is around $1.5M for the rep with one clinical specialist on the team. The more clinical specialists tells you how successful the rep is. MDT has more CS though due to dealing with the pumps. The bonus structure can be aggressive. The least successful stim rep makes around $150k. The most successful in the country $1M if not more. Most very successful reps which there are in any market make over $500k. The CS’s make $120k max.

long story short your rep makes at least twice (really 3-4x is more likely) as much as your physician fees on every implant you do.

 

[buddababa]

The hospital or ASC pays around that much for product for 36 trials and implants. An IPG costs around $16.5k minimum plus leads and extras. Rep compensation is tied to meeting a base quota. Usually this is around $1.5M for the rep with one clinical specialist on the team. The more clinical specialists tells you how successful the rep is. MDT has more CS though due to dealing with the pumps. The bonus structure can be aggressive. The least successful stim rep makes around $150k. The most successful in the country $1M if not more. Most very successful reps which there are in any market make over $500k. The CS’s make $120k max.

long story short your rep makes at least twice (really 3-4x is more likely) as much as your physician fees on every implant you do.

I knew about the pricing, but i didn't realize the payout for the reps/cs etc. That's interesting. Makes sense why they're so persistent.

 

[Ducttape]

I had an unusual October and did 7 stim cases. That was a huge month in terms of my "monthly numbers."

I avg 2-4 per month. Some months none, some 5 or 6.

BobBarker brings up an interesting point about dudes claiming 100 or whatever. This is another reason I quit going to NANS.

During a lecture, in the opening remarks...Huntoon told the crowd he does "about 100 or so a year."

He probably does that number given who he is and I do not doubt that, but he had no reason to share that with the crowd. We all know who he is if we're at NANS in the 1st place.

Young attendings (me) hear that and start wondering why we're not pulling similar numbers and what we're doing wrong. What's wrong with my referral base?

It is very difficult to do over 50 stim cases a year, trial and implant.

If you are doing 50 cases a year, you better be making serious money bc the required volume in pt load to capture that many stim cases is probably 30-40 clinic pts per day with your hair on fire.

how you can do it without working your butt off is if you work in a group of several pain docs and NPs and you schnooker the rest of the group to give you to do the "big" procedures ie stim, implant, and pumps. essentially the interventionalist for the group...

 

[gdub25]

I have a fair amount of experience in the private world and do a lot of stimulation/advanced procedures and have to say I agree with everything Bob has said. He’s pretty much spot on with all of this in my experience as well.

 

[BobBarker]

If you have a large cancer pain population. I don’t think it’s appropriate to routinely implant pumps otherwise and you are doing non-palliative patients a disservice.

I have an oncologist that shares office space with me. They opened a FQHC next door and she is getting a lot of patients from there and I have seen a few of them. One pump, but the rest were too far along with just a month or two left or terrible infection risks.