Slashed Reimbursements

[MSKmonky]

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http://online.wsj.com/article/SB124646885862181139.html#articleTabs=article

just wanted to share. Any word on how this effects Pain?

 

[knoxdoc]

Wow, that sucks. I can see Obama's rationalization though - we need more primary care docs for the huge patient influx he is anticipating. Apparently he doesn't think that any of these new patients will need any specialized care. So they can get in to see a PCP, but the treatment will end there.

So who the hell is going to do a 7 year, get-your-ass-handed-to-you Neurosurgery residency if you get paid what a PCP gets? Who will bother with a 3 year fellowship in cards, pulm, etc? Nobody. Goal accomplished -we'll have a crappy Canadian system. Nice plan Obama. Thats the change we all wanted.

I fear that some of our esteemed politicians could have an MI one day but we wouldn't have the resources to get them cathed.

 

[drusso]

I'd like to tell you about an exciting new way to own your business---it's called Anway and it's making a difference in my life. Maybe yours too!

 

[knoxdoc]

I'd like to tell you about an exciting new way to own your business---it's called Anway and it's making a difference in my life. Maybe yours too!

Tell me more DR - cuz this medicine thing is looking grim.

 

[drusso]

I think pain management is going to always be a busy endeavor, there's no shortage of patients in pain out there.

I also have a feeling that all those freshly minted family practice docs, NP's, and PA's are going to rapidly discover what a hassle it is to have pain patients roaching around one's primary care "medical home" requesting refills on their Vicosomaxanax every 30 days. The DEA is also going to become stricter about Schedule II prescribing so the referrals will keep pouring in to specially certified pain management clinics...soon we'll have "orthopedic homes," "pain management homes," "complex metabolic disease homes," etc. We'll just all have to settle for making about 1/3 of what we make now.

It's called disease management. Patients with complex chronic diseases and clinical conditions have improved outcomes when managed by specialists...it's been shown for inpatient hospital care, cardiology, pulmonology, etc.

 

[Tenesma]

actually, while i am somewhat worried about the near term changes which will have significant changes in my income --- i am a bit more hopeful that this will actually create a scenario where i can go to an all cash practice...

if none of the PCPs can or want to rx narcotics - i can change my practice to nothing but narcotic management and charge huge bucks for it to be done in a safe/well-controlled environment. not that i want to .... but that is clearly an option in the future.

 

[SSdoc33]

actually, while i am somewhat worried about the near term changes which will have significant changes in my income --- i am a bit more hopeful that this will actually create a scenario where i can go to an all cash practice...

if none of the PCPs can or want to rx narcotics - i can change my practice to nothing but narcotic management and charge huge bucks for it to be done in a safe/well-controlled environment. not that i want to .... but that is clearly an option in the future.

this sounds dangerously close to what some may call a drug dealer.

i actually think that the cash-only business model would work well for the interventional side of things. yeah, i suppose you absolutely dont NEED an epidural, but i think a lot of people would pay a lot of money even for the chance of being in less pain.

 

[Tenesma]

a drug dealer is selling narcotics in an illegal fashion - prescribing narcotics for legitimate medical reasons is not necessarily all that evil - just something i'd rather not be involved in.

cash-only business model for interventions will unfortunately ONLY work in super-un-saturated markets (of which there are few if any left) OR in large metropolitan areas with very snobby wealthy people.... i mean most patients would rather take meds every day then cough up 1k for an ESI

 

[Jcm800]

a drug dealer is selling narcotics in an illegal fashion - prescribing narcotics for legitimate medical reasons is not necessarily all that evil - just something i'd rather not be involved in.

cash-only business model for interventions will unfortunately ONLY work in super-un-saturated markets (of which there are few if any left) OR in large metropolitan areas with very snobby wealthy people.... i mean most patients would rather take meds every day then cough up 1k for an ESI

not to metion price shopping and discount seeking patients, similar to what the plastic guys are all experinecing right now...

"we will meet or beat the price on an ESI in the area. If you pay in full for 2 epidurals, we will give you the third one free! Thats right, Free! And if you act now or within in 30 days of this comercial we are offering an additional level or the other side for half off. thats over a 500 dollar value for free. all you have to do is call now"

they just have to remember the promotion code number.

 

[PMR 4 MSK]

Obama and most Americans believe doctors, especially specialists, are greedy, overpaid money-******. 12 years of extra education means nothing. Most people want healthcare to be free, and don't care whether we get paid.

Most of what this will do is cause specialists to limit or stop taking Medicare. Then when a Senator's mom can't get in to a specialist, maybe things will change again.

 

[Tenesma]

to underline your point you should have watched CNN's special several weeks ago "Are doctors paid too much?"... unbelievable, clearly they are trying to paint us as the source of all evil in this messed up system - and what they forget is that without doctors there ain't no healthcare --- if you find the transcript please post it, i can't find it anywhere ?

 

[lobelsteve]

There are two docs competing in my area to be the first one's out of the gate for Obamacare.





This is a real pic I took from a crappy cellphone. These docs are putting up these signs all over the place.

 

[Disciple]

a drug dealer is selling narcotics in an illegal fashion - prescribing narcotics for legitimate medical reasons is not necessarily all that evil - just something i'd rather not be involved in.

Any cash practice needs to focus on customer service/satisfaction. With a narcotics clinic, the question is, how to do this without giving in to drug seekers.

Pain docs will feel pressured to be lax with their prescribing habits. Prescription drug abuse goes up.

 

[Aether2000]

The battles between specialists and primary care physicians will be bloody and the overall impact on healthcare is not yet decided. The idea that simply promoting good health and adopting a healthy lifestyle has been proven to fail over and over in the US since we are the land of the free to do whatever we want to our bodies. Also, preventative care always has a cost/benefit ratio that tends to favor doing nothing preventative in a system with many constraints on access to care as is being proposed by congress. The wildcard in the health care debate is the now fillibuster proof majority....and the half baked Obamanation that will come out of a ridiculously emergent time table will simply steam roll through congress and over the American public.
The boutique care model works best in situations where insurance copays and deductables have reached astronomical levels (yes, we are there), where there is an already established clientele, or there exists a service that is not available anywhere else. We have for many years had unadvertised $50 rate self-pay when our patients lose their insurance, and only through use of the same controls placed on the opiate use of these patients as those with insurance, can one find that balance between ethical and unethical practices. One can never be afraid to stop prescribing opiates when they are no long medically indicated (substance abuse, diversion), no matter what the circumstances.

 

[Jcm800]

are doctors being paid too much? Never mind what the CEOs are getting paid, pro-atheletes, hell, even the president. He makes more than most of us...

Eventually we will have to band together and say No! We cannot be bullied anymore. We eventually have to agree not to feel guilty about being rewarded for our 12-13 years of hard work, and our skill set that most do not possess. When we opt out of medicare, and we opt out of the other insurance plans and we do everything out of network, then what will the cost of healthcare be?

To penalize specialists, and to compare our training (length and miserableness) and our RISKs to those of a primary care physician is short-sighted. Many PCPs were given rewards already for going into p-care, such as at my medical school, where the 4th year was free. Not too mention, 2-3 years of extra-earning potential out of training.

you cannot change the rules of the game in the 5th inning and expect people to keep playing. I hope when push comes to shove (if it does and i hope it doesnt) that I can step up with my teamates and say, im taking my ball and im going home. Cure your own cancer, hernia, and back pain.

 

[SSdoc33]

are doctors being paid too much? Never mind what the CEOs are getting paid, pro-atheletes, hell, even the president. He makes more than most of us...

Eventually we will have to band together and say No! We cannot be bullied anymore. We eventually have to agree not to feel guilty about being rewarded for our 12-13 years of hard work, and our skill set that most do not possess. When we opt out of medicare, and we opt out of the other insurance plans and we do everything out of network, then what will the cost of healthcare be?

To penalize specialists, and to compare our training (length and miserableness) and our RISKs to those of a primary care physician is short-sighted. Many PCPs were given rewards already for going into p-care, such as at my medical school, where the 4th year was free. Not too mention, 2-3 years of extra-earning potential out of training.

you cannot change the rules of the game in the 5th inning and expect people to keep playing. I hope when push comes to shove (if it does and i hope it doesnt) that I can step up with my teamates and say, im taking my ball and im going home. Cure your own cancer, hernia, and back pain.

i agree with most of this. changing the rules in the middle of the "game" really isnt fair. but who says life is fair?

fact remains, however, that there are too many specialists and not enough PCPs, from a public health stand point. the reason for this is not because everyone wants to do colonoscopies, it is because PCPs get paid way, way less. in an ideal world, we would be able to make going into primary care more attractive, with increased incentives and more pay without taking a slice out of the specialist's pie. however, when there is only X number of dollars to spend, that doesnt really seem all that likely.

on another note, docshark, do you really think you should be making more money than obama? honestly? most powerful man in the world? 400K seems more than reasonable to me.

 

[lobelsteve]

So is the answer taking away the ability to earn a living via enterprise in medicine?

Maybe all specialists will be salaried at 50% MGMA with a 3% COLA.
Here is a way to see fewer patients, do less procedures, and take care of enough of the folks who hurt. It would end the abuses in interventional pain, force the PCP's to stop billing blind facets and SIJ, and kill neuromodulation.

Pain docs get about $400k per year, work M-F, no call, 4 weeks vacation, etc.

Must see 20 patients per day, can get paid extra to see a max of 30 patients per day. (Includes new, f/u, and procedures)

Opioid prescribing would be done by NP's, who know less, have less training, and get paid less.

Office staffs get cut back, because to see 20 patients in a day only takes 1 nurse and 1 MA per doc. Most of us could work 8-1, play golf every afternoon (or get another job outside of medicine).

 

[Doctodd]

i was reminded of the life of a resident/intern last night.....100 hr workweeks with sleepless call nights and some programs being pyramidal(mostly surgical) so you have no guarantee of making it to the next year while slugging thru the year being backstabbed and screwed every night by competing residents/interns. I can see the luster of this field for the joy of being a physician. Who cant see/remember the joy? Ask a resident/intern to remind you. All the while racking up 6 figures of debt. The only appeasement Obama has offered is paying your loans.

My fiancee is a nurse and im telling her to be a CRNA or NP.

 

[Ligament]

I disagree with the drug dealer statement; tenesma said in a safe and well controlled environment meaning proper prescription and proper monitoring; I see nothing wrong with that.

this sounds dangerously close to what some may call a drug dealer.

i actually think that the cash-only business model would work well for the interventional side of things. yeah, i suppose you absolutely dont NEED an epidural, but i think a lot of people would pay a lot of money even for the chance of being in less pain.

 

[Ligament]

Algos will you please go to DC for us and kick some ass?

 

[ampaphb]

I disagree with the drug dealer statement; tenesma said in a safe and well controlled environment meaning proper prescription and proper monitoring; I see nothing wrong with that.

There is nothing wrong with what Tenesma proposes, but the suggestion of cash for narcotic practice puts a target on your back for the State Medical Board. I, for one, would prefer for them to barely know I exist.

 

[lobelsteve]

There is nothing wrong with what Tenesma proposes, but the suggestion of cash for narcotic practice puts a target on your back for the State Medical Board. I, for one, would prefer for them to barely know I exist.

We all feel the same way, that we barely knew you existed.


He shoots he scores.... Had to take it. Sorry AMP.

 

[SSdoc33]

the reason is said it is because there is a clear conflict of interests. there is an incentive to keep seeing the pts and keep prescribing narcs even if it may not be appropriate because of the financial incentive. good medicine would go straight out the window when the cash is right there in front of you, no matter how ethical you think you'd want to be. maybe you'd give em a pass with marijuana on the tox screen. extra visit--extra fee. maybe you believe them that they lost their prescription. extra vosot -- extra fee. the fact is that the patients will not generally keep paying out of pocket if narcs arent precribed, so it is a direct relationship; patient pays money and gets narcotics. seems like a bad idea to me.

 

[Tenesma]

1st of all some of you guys gotta give Ampa a break - his opinion is always valued...

Obama makes a TON of money as POTUS -- sure he has a 400k salary, but he also gets a 19k entertainment stipend (not taxable), he gets a 100k travel allowance (not taxable), he gets to live in a nice house with TONS of staff (not considered taxable income), he gets to eat for free (not considered taxable), he gets to travel by police escort and in Marine One/Airforce One (not considered taxable), plus when he finishes his term(s) he is guaranteed multi-million dollar per year income from book royalties and speeches.... so I wouldn't use his salary as a standard by any means

the key is to diversify ----

 

[ampaphb]

1st of all some of you guys gotta give Ampa a break - his opinion is always valued...

No offense taken - when it is Mikey and Steve volleying the salvos, you just have to keep in mind it is a battle of wits with the intellectually unarmed. 😀

 

[Disciple]

the key is to diversify ----

So, from what I've seen (pain physician wise) that means:

1. Dispensing meds
2. Owning your own surgery center/specialty hosptial
3. medicolegal work
4. Owning your office building (realestate)


and if 1-3 are taken away?



What I see happening (this is a cynical viewpoint so take it with a grain of salt) is:


High volume cash pay practices:

The hiring of desperate new grad PCPs at cut rate wages to do quick newpt evals on chronic pain patients (with some crash course training)

4:1 physician to midlevel ratios (like anesthesia team care models) for narcotic refills

2:1 to 3:1 physician to EMG tech ratio

midlevels doing fluoro guided procedures (unless more widespread legislation is enacted) under "supervision".


Please, somebody give my some reassurance that this is just a nightmare

 

[Jcm800]

i agree with most of this. changing the rules in the middle of the "game" really isnt fair. but who says life is fair?

fact remains, however, that there are too many specialists and not enough PCPs, from a public health stand point. the reason for this is not because everyone wants to do colonoscopies, it is because PCPs get paid way, way less. in an ideal world, we would be able to make going into primary care more attractive, with increased incentives and more pay without taking a slice out of the specialist's pie. however, when there is only X number of dollars to spend, that doesnt really seem all that likely.

on another note, docshark, do you really think you should be making more money than obama? honestly? most powerful man in the world? 400K seems more than reasonable to me.

i was waiting to see what people would say about the Obama salary thing...but beyond his salary is his potential to make millions and millions from the position...that being said. he is quite an important person, and i am not. this i know. But i think it is rare that someone becomes president, or spends his career trying to be president, and doesnt make many millions for the remainder of their years, each year. Look what clinton made last year.

so my crack about obamas true actual salary was actually tongue in cheek, but he does make quite a bit of money from that position. I would like to see what he would say if we all of sudden said, "you know what, the president can no longer make any money aside from the 400k and 50k spending bonus, a year, for the rest of their lives." they would freak, because they know, they become president, allegedly serve their country, and their will be rewarded, not just with power, but financially.

you could argue that was money they made writing books, giving, speaches etc. but it is related to politicking... the same way some of us make money on imaging or PT (not me) and that also is getting slashed...

alas, a rant without much thought.

 

[Ligament]

the reason is said it is because there is a clear conflict of interests. there is an incentive to keep seeing the pts and keep prescribing narcs even if it may not be appropriate because of the financial incentive. good medicine would go straight out the window when the cash is right there in front of you, no matter how ethical you think you'd want to be. /QUOTE]

Dude there is NO confilict of interest. There is a hell of a lot more conflict of interest dealing with insurance companies and third parties in the physician patient relationship!!!

How does you above statement NOT apply equally as well to insurance covered patients?

 

[PMR 4 MSK]

So, from what I've seen (pain physician wise) that means:

1. Dispensing meds
2. Owning your own surgery center/specialty hosptial
3. medicolegal work
4. Owning your office building (realestate)


and if 1-3 are taken away?



What I see happening (this is a cynical viewpoint so take it with a grain of salt) is:


High volume cash pay practices:

The hiring of desperate new grad PCPs at cut rate wages to do quick newpt evals on chronic pain patients (with some crash course training)

4:1 physician to midlevel ratios (like anesthesia team care models) for narcotic refills

2:1 to 3:1 physician to EMG tech ratio

midlevels doing fluoro guided procedures (unless more widespread legislation is enacted) under "supervision".


Please, somebody give my some reassurance that this is just a nightmare

Medicolegal will always be there - lawyers will make sure of that. Might just be our last refuge.

You'll always be able to dispense pills, just Not Oxycontin or Kadian. Everyone will only get non-tylenol-containing hydrocodone, oxycodone or codeine.

I see surgery centers getting blown away by signficantly reduced payment, in favor of hospitals (and I see hospital CEOs stroking themselves madly at the thgouth...).

You'll always be able to afford your own office, but you'll likely make more money renting it to either lawyers or making it goverment-subsidized housing (people who own those buildings get their government checks like clock-work).

Mid-levels are going to move in as physicians abdicate their positions and practices. As are the chiros, naturopaths and similar doctor-wannabees. How much you want to bet the chiros successfully lobby to get their care covered under Obamacare?

 

[SSdoc33]

the reason is said it is because there is a clear conflict of interests. there is an incentive to keep seeing the pts and keep prescribing narcs even if it may not be appropriate because of the financial incentive. good medicine would go straight out the window when the cash is right there in front of you, no matter how ethical you think you'd want to be. /QUOTE]

Dude there is NO confilict of interest. There is a hell of a lot more conflict of interest dealing with insurance companies and third parties in the physician patient relationship!!!

How does you above statement NOT apply equally as well to insurance covered patients?

you cant say there is no conflict of interest and also say that the above statement also applies to insurance covered patients. in reality, there is a conflict of interest in BOTH cases. however, when a patient has insurance, they are not "losing" anything by trying alternative therapies like PT or injections. if they are paying out of pocket, they will generally only come for drugs.

 

[Ligament]

if they are paying out of pocket, they will generally only come for drugs.

This is very untrue in my experience when I was in a cash practice (for a short time period); the patients specifically did not want drugs, especially opioids, but rather non drug treatment.

 

[Tenesma]

i can tell you that most patients who pay cash to see me just want to get my opinion and have my recs sent to their PCP who is much more affordable... so i usually only see cash patients once and then that is it...

 

[lobelsteve]

i can tell you that most patients who pay cash to see me just want to get my opinion and have my recs sent to their PCP who is much more affordable... so i usually only see cash patients once and then that is it...

Me too. I see it as an independent risk factor for misuse of meds.
I have a handful of self pay patients. THey scrape by for an SIJ or ESI.
I feel terrible because of the cost of the procedures when I know how much it takes away from their personal lives. I refuse procedures if it takes food off their table.

Big softy.

 

[Jcm800]

Me too. I see it as an independent risk factor for misuse of meds.
I have a handful of self pay patients. THey scrape by for an SIJ or ESI.
I feel terrible because of the cost of the procedures when I know how much it takes away from their personal lives. I refuse procedures if it takes food off their table.

Big softy.

I agree with Tenesma that you can be in cash practice and write narcotics without a confilct of interest. Im not saying I want to do this, and neither is he... But as it stands with insurance patietns, W/C, whatever, there is still an incentive to do more and keep them coming back. Im not sure that cash pay makes a difference. Regardless of who is paying,ie the patient, the insurance carrier, our medical system financially rewards doing more...

So, dont see the conflct, just stigma of prescriptions for cash. But right now if i write a prescription, i still eventually get paid (usually)...

 

[sweetalkr]

just curious. How hard would it be to make a nice op-ed article to submit to the wall street journal or ny times?
A lot of you guys have a lot of interesting points, so maybe if we were to gather the best points and present what could happen if physician reimbursement dropped (less people go through medicine, less ambitious people, less innovation in health care, America yet again falling behind other countries in another field now health care) and what the real problems are (malpractice, insurance companies, doing an aortic valve replacement on a bed-ridden 98y/o that lives in a nursing home), maybe we could get published and get nationwide recognition.
anyone here a journalism major or know anyone/married to someone that is? it would be nice to at least give it a shot. make one draft,and everyone on this website submit it to their local paper. if even 5 of us got it published, it would make news.
just being proactive. sort of.

 

[Disciple]

I guess we all have different practices.

I've had several patients lose their insurance over the past year and have continued treating them, cash pay. Without insurance, they generally choose to forego imaging, procedures, and newer brand name narcotics. It's generally Norco, 1Q6 hours, f/u every 30-60 days.

Every now and then, I'll get a patient who will pay cash for an ESI. They're usually people who've had good results with previous epidurals, and happen to be in away from their home state and in my zipcode when their back and leg pain really starts to flare-up.

Of course there are those who will pay cash for acupuncture, chiropractic, massage, biofeedback...but these generally aren't the ones who are going to seek out a "pain" specialist.

I've found that those who are willing to pay me cash for a newpt consult are often desparate to find someone willing to continue their current narcotic regimen. If their expectations aren't met, alot of times they start crying and yelling, sometimes they threaten me.

With a cash narcotics practice, imagine seeing 8 new patients per day, and 5-6 of them are like this.

When you know the referrals are going to keep coming (HMO, etc.) it's easier to let these types of situations just roll off your back.

While I think, you can have a cash narcotics practice without a conflict of interest, the pressures to ignore your better judgement are going to be that much higher.

 

[PMR 4 MSK]

In my former life, I saw too many patients for opioid management. The highest risk ones were often the self-pay pts. They preyed upon my sense of duty pushed up against my awareness of their lack of insurance. They'd come in with little or no money, promising to pay later in the day or the next day (read, after I sell these pills you're gonna give me). Then they would show up at the next visit having paid nothing, trying to do it again. Then they could scrape up enough for last visit but not this one. Or they'd try and do the "pay half this time, the rest next time" rinse and repeat. I discounted them off my regular prices to match Medicare approximately, even had them fill out a "hardship" waiver to avoid Medicare getting pissy.

Most were on hydrococone 7.5 - 10 mg QID to Q4H. Most wanted Soma and Xanax of course ("But my muscles get so tight, and I'm so jittery all the time!") and, of course, could not afford SSRI's, health club memberships (YMCA had sliding scale - anyone could be a member) or anything resembling x-rays, injections counseling or PT.

The thing they had in common was a near-universal inability to adhere to an opioid agreement. Many were doctor shopping drug dealers or addicts. Many more were habitually running out early, losing them, knocking them down the drain, etc. It was rare for a self-pay pt to be able to stay on opioids with me longer than 6 months.

I finally stopped accepting new self-pay pts when I realized they could not afford what I would prescribe, and would only accept what I did not want to do - only prescribe pills. About the same time, I stopped accepting Medicaid for the same general reasons - they stopped paying for counseling, already paid very poorly for PT (less than what I paid the PT) would not pay for in-office injections, and paid crappy for anything else. I had a lot of very unhappy patients in a short period of time.

Now, in my new life, I do accept self-pay/uninsured pts, but they are told up front that they need to pay $300 prior to seeing me, and that my treatment tends to be very expensive - MRI, EMG, PT, ESI, etc. Very few accept that, and like Disciple, most are just desperately looking for someone willing to continue prescribing the 500 mg MS/d that their doc in Idaho was prescribing.

For me, lack of insurance and pain management are not compatible. It may work for many of you, but not for me. I could handle the not getting paid and considering it charity, it's the unwillingness to use anything other thanopioids in high-risk pts. I believe lack of insurance to be an independent risk factor for opioid abuse. Couple that with most uninsured being younger, and you start out with two strikes at the beginning of the game.

 

[Tenesma]

i would agree w/ PMR --- however, i would also say that about 1 out of every 10 patients i have is a legit pain patient who is self-employed and in this economy can't afford health insurance, but are willing to pay from their savings to further diagnose or manage their pain... they also have realistic expectations unlike the other 9 out of 10.

 

[jsaul]

I guess we all have different practices.

I've had several patients lose their insurance over the past year and have continued treating them, cash pay. Without insurance, they generally choose to forego imaging, procedures, and newer brand name narcotics. It's generally Norco, 1Q6 hours, f/u every 30-60 days.

Every now and then, I'll get a patient who will pay cash for an ESI. They're usually people who've had good results with previous epidurals, and happen to be in away from their home state and in my zipcode when their back and leg pain really starts to flare-up.

Of course there are those who will pay cash for acupuncture, chiropractic, massage, biofeedback...but these generally aren't the ones who are going to seek out a "pain" specialist.

I've found that those who are willing to pay me cash for a newpt consult are often desparate to find someone willing to continue their current narcotic regimen. If their expectations aren't met, alot of times they start crying and yelling, sometimes they threaten me.

With a cash narcotics practice, imagine seeing 8 new patients per day, and 5-6 of them are like this.

When you know the referrals are going to keep coming (HMO, etc.) it's easier to let these types of situations just roll off your back.

While I think, you can have a cash narcotics practice without a conflict of interest, the pressures to ignore your better judgement are going to be that much higher.

I have had the exact same experiences. How many cash paying patients would go to a spine surgeon? There is a spine surgeon in our group and there has been only 1 time in the past 4 years that happened.

In that same time, there has numerous cash patients wanting to come in to be continued on pain meds.

 

[Jcm800]

I have had the exact same experiences. How many cash paying patients would go to a spine surgeon? There is a spine surgeon in our group and there has been only 1 time in the past 4 years that happened.

In that same time, there has numerous cash patients wanting to come in to be continued on pain meds.

im not saying it would be FULFILLING practice, or anything i would want to do, in fact i would go back to anesthesia before i would do a cash narcotic business, but what i am saying is it is not a conflict of interest. it is most definitly a sucky way to practice...

 

[Tenesma]

i don't know why you guys are bashing a narcotic practice ---.... i think you guys are just adverse to dealing w/ druggies and personality disorders.... these are VERY easy to screen out of a narcotic practice...

1) initial visit: you have the prescription monitoring reports from your state and adjoining states, criminal records, records from previous treating physicians as well as a psychological evaluation.... any red flags get a partial refund and get booted from the practice....

 

[Jcm800]

as much as i dislike anesthesia, i would rather do anesthesia then do medical management all day long.

 

[Disciple]

i don't know why you guys are bashing a narcotic practice ---.... i think you guys are just adverse to dealing w/ druggies and personality disorders.... these are VERY easy to screen out of a narcotic practice...

1) initial visit: you have the prescription monitoring reports from your state and adjoining states, criminal records, records from previous treating physicians as well as a psychological evaluation.... any red flags get a partial refund and get booted from the practice....

While that would make for an ideal patient base, it would screen out 70% of my current patients.

Cash pay, I would have 5 patients per day, before word got around about the screening and then it would decrease to 2 per day.

I don't know that it would work unless you were overloaded with referrals and there was no competition around. Then, you could base down your patient base like a PCP converting to a concierge practice.


Then again, you've been able develop a practice alot of us here would like to have (high volume, independent, little narcotic management), so maybe there's hope.

 

[Tenesma]

i believe in self-fulfilling prophecies.... if you establish yourself as an outpatient hemorrhoid king, initially (the first few months - years) things will be very slow --- but over time, all you are going to get are hemorrhoid consults...

i'd rather see 2 patients per day than 35 if the money ends up about the same?

what would be the logistics of a concierge pain clinic?

 

[jsaul]

i believe in self-fulfilling prophecies.... if you establish yourself as an outpatient hemorrhoid king, initially (the first few months - years) things will be very slow --- but over time, all you are going to get are hemorrhoid consults...

i'd rather see 2 patients per day than 35 if the money ends up about the same?

what would be the logistics of a concierge pain clinic?

A fibromyalgic told me she had a pain doctor who would follow her to the hospital or er for any problem such as SOB, fever, bleeding from rectum, etc and would tell the doctors what pain meds to put her on. Because she required a special concoction and regimen due to her fibro. She would call the doc on his cell phone and he would meet her in the er or hospital room.

 

[Tenesma]

if the price is right i'd also put in a foley and rectal bag if asked

 

[PMR 4 MSK]

A fibromyalgic told me she had a pain doctor who would follow her to the hospital or er for any problem such as SOB, fever, bleeding from rectum, etc and would tell the doctors what pain meds to put her on. Because she required a special concoction and regimen due to her fibro. She would call the doc on his cell phone and he would meet her in the er or hospital room.

I can't think of anything I'd like less than to have a fibro pt, or worse more than 1, calling me day and night and following her to the hospital. I think you'd lose all credibility. I can't think of more of a co-dependent relationship.

 

[ampaphb]

Why sure Michael, I'll meet you in the ER - or even better, I'll just drive to your house, and inject the Diprivan there ...

 

[Disciple]

i believe in self-fulfilling prophecies.... if you establish yourself as an outpatient hemorrhoid king, initially (the first few months - years) things will be very slow --- but over time, all you are going to get are hemorrhoid consults...

i'd rather see 2 patients per day than 35 if the money ends up about the same?

what would be the logistics of a concierge pain clinic?

I assume, what's been discussed above, plus, an annual membership fee for better availability, or 24/7 access.

Does not sound appealing at all.

 

[Finally M3]

A fibromyalgic told me she had a pain doctor who would follow her to the hospital or er for any problem such as SOB, fever, bleeding from rectum, etc and would tell the doctors what pain meds to put her on. Because she required a special concoction and regimen due to her fibro. She would call the doc on his cell phone and he would meet her in the er or hospital room.

Vomit smiley, vomit smiley. Don't we have a vomit smiley?

A practice of fibro patients hopped up on narcs with your cell phone number; I can't think of a more hellish practice.