Slashed Reimbursements

[Doctodd]

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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.

i think this is what ur looking for 😛uke:....guess not

i dont think i could stand fibro patients all day every day

 

[Jcm800]

i think this is what ur looking for 😛uke:....guess not

i dont think i could stand fibro patients all day every day

i cant even see one a month...

my NP sees them, uggh. Thank god she is a team player.

 

[lobelsteve]

Why is everyone so down on Fibro?

Easiest thing to see and do.

Meds to choose from, pick one or two. We will titrate to effect or side effect. If they don't help, we pick the next one down on the list.
The mainstay is exercise. start 5 min walks and if you cannot tolerate that, then here is a Rx for aquatic therapy. You need to exercise everyday to the point where you just break a sweat.

Meds include:

Ultram, Lyrica, Cymbalta, Pamelor, Elavil, Flexeril, Parafon forte, Savella, Effexor, Zanaflex, Robaxin, Amrix. TENS at low settings.

No narcotics, no Soma, no BZD's.
No procedures.
No phone calls unless true allergy with hives and swelling of your throat, then don't call me call 911.
I'll see you in 1 month, because that is how long it takes the medications and exercise to take effect.

I hand them the article of exogenous opioid lack of effect in FMS.

The true fibro's who want to get better will get some better on this plan. The rest of the folks never come back, but they had exemplary treatment.

 

[ampaphb]

The problem with Steve's approach, in my experience, is the 15 minute arguement that ensues with the 90% of "fibro" patients who don't want to abide by a reasonable regimen

 

[lobelsteve]

Never an argument. I always end with, "what just told you is based on the best medical data and that is what I have to offer.

If they are looking for narcotics, they can go to yahoo's with the pain md yard signs all over north Georgia

 

[SSdoc33]

The problem with Steve's approach, in my experience, is the 15 minute arguement that ensues with the 90% of "fibro" patients who don't want to abide by a reasonable regimen

thats exactly the problem. i find you have to sit there and just explain, explain, explain, but they dont want to hear or appreciate anything you have to say. i also find it frustrating.

 

[nvrsumr]

Why is everyone so down on Fibro?



I hand them the article of exogenous opioid lack of effect in FMS.

.

Steve, Any chance you could post this article? Id like to have something to show my patients.

 

[Jcm800]

The problem with Steve's approach, in my experience, is the 15 minute arguement that ensues with the 90% of "fibro" patients who don't want to abide by a reasonable regimen

i used to go through this huge explanation, and the whole bit. they would listen, nod their heads, and agree. I say no opiates, And say yea that makes sense, yeah thats a good idea. Id wrap it up and say, ok, thats what i got, and thats what i can offer you. "ok, just one question, what about my vicodin and soma ive been taking, my doctor said you are going to refill them from now on..."

i say nope. and the next line is always one of two a) well what am i suppose to do, im in pain...

b) well that was a big waste of time.


and i agree, it was.

 

[Doctodd]

2nd on that article........might need to send Steve some $$$ for passive income by not wasting time bargaining with the patients.....ill tell them they can bargain with the article at home

 

[knoxdoc]

"I hand them the article of exogenous opioid lack of effect in FMS."


Totally agree, but why stop with fibro? I also hand patients Martell's study on opioids for CLBP and explain that they don't work for that either. When you closely scrutinize the main articles evaluated by Martell (Hale et al, Jamison et al) you can clearly see that opioids are a worthless treatment for CLBP. In fact, they are quite detrimental when you consider the side effects and abuse potential.

 

[Jcm800]

"I hand them the article of exogenous opioid lack of effect in FMS."


Totally agree, but why stop with fibro? I also hand patients Martell's study on opioids for CLBP and explain that they don't work for that either. When you closely scrutinize the main articles evaluated by Martell (Hale et al, Jamison et al) you can clearly see that opioids are a worthless treatment for CLBP. In fact, they are quite detrimental when you consider the side effects and abuse potential.

i have said " i typically do not recommend chronic opiates in cases of non-malignant chronic pain" so many times now. it has lost its appeal. My NP says it for me now...

 

[lobelsteve]

"I hand them the article of exogenous opioid lack of effect in FMS."


Totally agree, but why stop with fibro? I also hand patients Martell's study on opioids for CLBP and explain that they don't work for that either. When you closely scrutinize the main articles evaluated by Martell (Hale et al, Jamison et al) you can clearly see that opioids are a worthless treatment for CLBP. In fact, they are quite detrimental when you consider the side effects and abuse potential.

It's a good opening salvo in the argument for using opioids for one process and not another. I'll go nuclear.

CLBP is a peripheral process that leads to peripheral and central sensitization.
FMS is a central process that may lead to central and peripheral sensitization. Opioids have traditionally been thought of and studied as ineffective for central pain states. (I believe FMS is a central pain state, and the literature bears this out).

The Journal of Neuroscience, September 12, 2007, 27(37):10000-10006;
JNEUROSCI.2849-07.2007 Neurobiology of Disease
Decreased Central µ-Opioid
Receptor Availability in Fibromyalgia
Richard E. Harris,1 Daniel J. Clauw,1 David J. Scott,2
Samuel A. McLean,3 Richard H. Gracely,1
and Jon-Kar Zubieta2,4


Most of what we know about FMS comes from Clauw's work.

The abstract:

The underlying neurophysiology of acute pain is fairly well characterized, whereas the central mechanisms operative in chronic pain states are less well understood. Fibromyalgia (FM), a common chronic pain condition characterized by widespread pain, is thought to originate largely from altered central neurotransmission. We compare a sample of 17 FM patients and 17 age- and sex-matched healthy controls, using µ-opioid receptor (MOR) positron emission tomography. We demonstrate that FM patients display reduced MOR binding potential (BP) within several regions known to play a role in pain modulation, including the nucleus accumbens, the amygdala, and the dorsal cingulate. MOR BP in the accumbens of FM patients was negatively correlated with affective pain ratings. Moreover, MOR BP throughout the cingulate and the striatum was also negatively correlated with the relative amount of affective pain (McGill, affective score/sensory score) within these patients. These findings indicate altered endogenous opioid analgesic activity in FM and suggest a possible reason for why exogenous opiates appear to have reduced efficacy in this population.

 

[Disciple]

In context of the original post, if healthcare reform decreases the average income of an Interventional Pain Specialist to the primary care range, and cash pay narcotic management becomes the predominant, albeit higher risk, method of maintaining previous income levels, how many will quit the specialty?

My guess is 70-80%

 

[Jcm800]

In context of the original post, if healthcare reform decreases the average income of an Interventional Pain Specialist to the primary care range, and cash pay narcotic management becomes the predominant, albeit higher risk, method of maintaining previous income levels, how many will quit the specialty?

My guess is 70-80%

I will. Ill do 80% ansthesia and 10% pain, and 10% looking for something else to do...

 

[Tenesma]

maybe that is something that should be negotiated into contracts with hospitals - that if pain reimbursement drops below a certain amount then the hospital HAS to offer an anesthesia job?

 

[nvrsumr]

"I hand them the article of exogenous opioid lack of effect in FMS."


Totally agree, but why stop with fibro? I also hand patients Martell's study on opioids for CLBP and explain that they don't work for that either.

Steve thanks for posting the pdf. Knoxdoc any chance you could share the martell study with us?

Best.

 

[PMR 4 MSK]

I hate it when I go away for the weekend and miss so much. 😛

The problem with Steve's approach, in my experience, is the 15 minute arguement that ensues with the 90% of "fibro" patients who don't want to abide by a reasonable regimen

Only 15 minutes? Wow, IME, if you let them and engage them in it, they'll argue with you for an hour or more.

thats exactly the problem. i find you have to sit there and just explain, explain, explain, but they dont want to hear or appreciate anything you have to say. i also find it frustrating.

I stopped explaining. Steve has the most time saving and sensible approach. I'm sure he learned it over time like I did.

Essentially I offer them a buffet, not a menu. "These are the things you can pick from, 1 or 2 at a time. Vicodin and Soma are not on this buffet. If that's what you are looking for, there's guy down the street..."

"I hand them the article of exogenous opioid lack of effect in FMS."


Totally agree, but why stop with fibro? I also hand patients Martell's study on opioids for CLBP and explain that they don't work for that either. When you closely scrutinize the main articles evaluated by Martell (Hale et al, Jamison et al) you can clearly see that opioids are a worthless treatment for CLBP. In fact, they are quite detrimental when you consider the side effects and abuse potential.

Almost there....

i have said " i typically do not recommend chronic opiates in cases of non-malignant chronic pain" so many times now. it has lost its appeal. My NP says it for me now...

There it is. Agree 100%.

In context of the original post, if healthcare reform decreases the average income of an Interventional Pain Specialist to the primary care range, and cash pay narcotic management becomes the predominant, albeit higher risk, method of maintaining previous income levels, how many will quit the specialty?

My guess is 70-80%

I'll start looking into side businesses. Maybe start taking my camera out more and become a freelancer.

I'd definately cut my hours back if they take away my incentive to be productive.

 

[Tenesma]

i have had quite a few patients who have figured out what is on my Buffet menu... so they gladly go down all those roads and within a few months they are in my exam room with a smile: "so you have done X, Y, and Z - i don't want surgery, I know that percocet works for me - can I have some now?"...

 

[Mister Mxyzptlk]

Most of the FMS referrals I've seen were not FMS. They were people with lazy doctors who didn't want to deal with multiple pain complaints. Once you tag the patient with FMS all subsequent complaints can be shut down with "It's your fibro. There's nothing I can do." End of discussion.

The vast majority of "FMS" that I have seen turned out to have multiple pain sites (most of them have polyarthralgia due to plain old OA) or to a much lesser extent a systemic problem like PMR or SLE. One was a Chiari malformation.

I think we should rename this LSDS - lazy stupid doctor syndrome.

And how do we even know that it's one disease? It's like lumping Rocky Mountain Spotted fever, measles, and thrombocytopenia together as "red spotted skin syndrome". Try making any progress with that approach to red spots on the skin.

FMS would not be the first. Giants of medicine such as Paracelsus, Pare' and Sydenham all believed that that gonorrhea and syphilis were the same disease, and let's not forget the unfortunate experiment that John Hunter performed on himself (http://www.marshall.edu/library/speccoll/virtual_museum/hoffman/hunter_john.asp)

The next designer disease is going to be "mitochondrial dysfunction".

 

[Tenesma]

i still don't really understand fibromyalgia.... my patients get to educate me all the time - and if i still look confused they will usually hand me internet print-outs with all of their symptoms circled...

 

[pmrmd]

Most of the FMS referrals I've seen were not FMS. They were people with lazy doctors who didn't want to deal with multiple pain complaints. Once you tag the patient with FMS all subsequent complaints can be shut down with "It's your fibro. There's nothing I can do." End of discussion.

The vast majority of "FMS" that I have seen turned out to have multiple pain sites (most of them have polyarthralgia due to plain old OA) or to a much lesser extent a systemic problem like PMR or SLE. One was a Chiari malformation.

I think we should rename this LSDS - lazy stupid doctor syndrome.

And how do we even know that it's one disease? It's like lumping Rocky Mountain Spotted fever, measles, and thrombocytopenia together as "red spotted skin syndrome". Try making any progress with that approach to red spots on the skin.

FMS would not be the first. Giants of medicine such as Paracelsus, Pare' and Sydenham all believed that that gonorrhea and syphilis were the same disease, and let's not forget the unfortunate experiment that John Hunter performed on himself (http://www.marshall.edu/library/speccoll/virtual_museum/hoffman/hunter_john.asp)

The next designer disease is going to be "mitochondrial dysfunction".

thank you. finally found another out there that sees it the same way. treat "fibro" all the time. imho just a way for the pcp to not have to get deeply involved with the pain complaint when there is only 10-15 minutes per visit.

 

[knoxdoc]

Nevrsumr-will be happy to post the articles, but I am clueless as to how to pull it off on the forum. Can anyone help me out? Lobelsteve - how did you post that FMS article? Magic dust?

 

[PMR 4 MSK]

thank you. finally found another out there that sees it the same way. treat "fibro" all the time. imho just a way for the pcp to not have to get deeply involved with the pain complaint when there is only 10-15 minutes per visit.

Or a way for rheumatologists to have a CPT code to use to bill for patients who are negative for everything on their lab panels.

I was covering for our rheumatologists this weekend for phone calls. It was a light weekend, but I did get one lady calling asking if I could call her in her "something for break-through pain." (I wish that phrase had never been invented.) I asked her what she was taking - cymbalta 60mg/d and neurontin @ 400mg/d. I suggested she try increasing the neurontin to 500mg that day and 600 the next, then calling the rheum on Monday. Sort of a squib kick rather than a punt. 😀

Did I ever mention a patient years ago who insisted huffingly she did not have fibromyalgia and bristled at it? She insisted she had "fibro-myo-sitis," with accent on the first syllable of each section. She was apparently told by a specialist at UCLA ("The chairman of the hospital" she would tell me with great pride...) that fibromyalgia and fibromyositis were two completely different, unlrelated disorders and that her doctors should never confuse the two as they were treated very differently. When she came to me it was treated with 80 mg Oxycontin + muscle relaxors and benzos, and this was in a 70-ish year-old lady. Her husband wanted her on higher doses. I thought he just wanted her sedated so she would finally STFU.

 

[lobelsteve]

Most of the FMS referrals I've seen were not FMS. They were people with lazy doctors who didn't want to deal with multiple pain complaints. Once you tag the patient with FMS all subsequent complaints can be shut down with "It's your fibro. There's nothing I can do." End of discussion.

The vast majority of "FMS" that I have seen turned out to have multiple pain sites (most of them have polyarthralgia due to plain old OA) or to a much lesser extent a systemic problem like PMR or SLE. One was a Chiari malformation.

I think we should rename this LSDS - lazy stupid doctor syndrome.

And how do we even know that it's one disease? It's like lumping Rocky Mountain Spotted fever, measles, and thrombocytopenia together as "red spotted skin syndrome". Try making any progress with that approach to red spots on the skin.

FMS would not be the first. Giants of medicine such as Paracelsus, Pare' and Sydenham all believed that that gonorrhea and syphilis were the same disease, and let's not forget the unfortunate experiment that John Hunter performed on himself (http://www.marshall.edu/library/speccoll/virtual_museum/hoffman/hunter_john.asp)

The next designer disease is going to be "mitochondrial dysfunction".

My sister is a mito specialist at UPMC. Peds Neurologist. She has asked me to lecture to families at the next big Mito meeting. SO we are already there.
Wait til I get them approved for SCS....😎