stim company asking patients to purchase warranty

[TIVAndy]

my pt just asked me boston asked him if he was willing to purchase 1 yr warranty on his new SCS for $199

this is the first time i've heard about this. do you guys have experience with this? i haven't heard about this before.

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[Agast]

Is that for the remote and charger?

 

[unchockey21]

my pt just asked me boston asked him if he was willing to purchase 1 yr warranty on his new SCS for $199

this is the first time i've heard about this. do you guys have experience with this? i haven't heard about this before.

A casual “Oh, that’s funny. I’ve never heard of [insert name of whatever other stim company] doing that.” to the rep should hopefully stop that. I’d say “the patient asked me if your equipment was really such crap that it cost $199 for just one year and if other companies had more reliable equipment.”

 

[ateria radicularis magna]

my pt just asked me boston asked him if he was willing to purchase 1 yr warranty on his new SCS for $199

this is the first time i've heard about this. do you guys have experience with this? i haven't heard about this before.

Wow

 

[myrandom2003]

Sounds like the rep doing something shady

 

[Dr. Ice]

That’s cause stim is crap and the reps know the hammer is gonna come soon enough..oh did I say that out loud..

Actually let me rephrase..in the right patient its “ok” for awhile…umm just like everything else we do..and then most of these people want it out or they are too old, because they were old when they got it placed, to bother to take it out. And some of them have had them in so long, and it became non functional at year 3-4, but no one wanted to take it out. And then, they show up to your clinic and you can’t get an mri because the stim is not mri compatible, and now you have to get a ct scan..but wait ct scans kinda suck..and so on and so forth

And the new docs will say..”but but, they are all mri safe now…”

 

[jsaul]

The day of reckoning Is coming for stims. They know it. We all know it.
The hammer will fall.

Be prepared

 

[BobBarker]

BSX has tried to sell warranties for years. This is not new.

 

[MitchLevi]

SCS is probably the biggest let down for me in our field. My trial to perm ratio is nearly 100%; it is rare I have a failed trial.

I need to start offering this to more pts according to some people. Ratio should be around 75% or so, but I only want to stim people who are great candidates.

Failed back is 95% of my SCS pts.

Of those FBSS pts, I would guess over 80% are FBSS with persistent radic in one leg or both.

I do NOT like low back pain without radic for SCS, but I do it not infrequently.

...tons of failures post implant.

I talk to the pt and I'm told the device isn't helping. Interestingly, the reps always say otherwise.

Nevro will even send you an email with all these data showing your outcomes over the last yr and it all looks fantastic...Your Nevro rep won't be speaking to your pts BTW, those phone calls go to a person in Delaware or Connecticut or something...

I do Abbott and Nevro.

TBF, I have had some homeruns with stim too...Don't get me wrong, I've changed several lives with SCS.

I've had pts come to me with stimulators placed in a normal spine. In fact, I've removed a number of them.

Without Q it will become much more difficult to get these approved at some point in the future.

BTW, I understand the financial pressure of those doctors fighting to survive in small pain practices. The ones who accept any and all pts referred to them, the guys accepting dumps from ortho and PCPs...Same guys doing cluneal stimulators and monthly in-house urine. These types will put stimulators in anything, and the hyper utilizers of stim will get us all in deep s%&t.

 

[hiyaman]

SCS is probably the biggest let down for me in our field. My trial to perm ratio is nearly 100%; it is rare I have a failed trial.

I need to start offering this to more pts according to some people. Ratio should be around 75% or so, but I only want to stim people who are great candidates.

Failed back is 95% of my SCS pts.

Of those FBSS pts, I would guess over 80% are FBSS with persistent radic in one leg or both.

I do NOT like low back pain without radic for SCS, but I do it not infrequently.

...tons of failures post implant.

I talk to the pt and I'm told the device isn't helping. Interestingly, the reps always say otherwise.

Nevro will even send you an email with all these data showing your outcomes over the last yr and it all looks fantastic...Your Nevro rep won't be speaking to your pts BTW, those phone calls go to a person in Delaware or Connecticut or something...

I do Abbott and Nevro.

TBF, I have had some homeruns with stim too...Don't get me wrong, I've changed several lives with SCS.

I've had pts come to me with stimulators placed in a normal spine. In fact, I've removed a number of them.

Without Q it will become much more difficult to get these approved at some point in the future.

BTW, I understand the financial pressure of those doctors fighting to survive in small pain practices. The ones who accept any and all pts referred to them, the guys accepting dumps from ortho and PCPs...Same guys doing cluneal stimulators and monthly in-house urine. These types will put stimulators in anything, and the hyper utilizers of stim will get us all in deep s%&t.

My biggest mistake out of fellowship was joining a small practice where I saw those issues first hand. I had bolt because of disillusionment and constantly worried about doing the right thing for patients.

Smaller private practice vs the academic practice for my fellowship was way different

 

[MitchLevi]

My biggest mistake out of fellowship was joining a small practice where I saw those issues first hand. I had bolt because of disillusionment and constantly worried about doing the right thing for patients.

Smaller private practice vs the academic practice for my fellowship was way different

Freshmen attendings in our field are largely inept, and the ineptitude stems from what I consider to be a failure in fellowship education and of course the subjective nature of our field.

On one hand, I think pain should be a 2 yr fellowship, while on the other hand I know from my own experience the only way to get good at treating pain is by doing it on your own. No one can teach you how to be a pain physician. You legitimately have to figure it out in real time for the first 3 yrs or so out of fellowship.

Where that 2nd yr COULD be beneficial is follow up. Fellows take no ownership over pts. You see someone, schedule a few things and you may see that pt in follow up but what happens over the course of one yr has little bearing on that pt's long term success, especially with SCS.

Fellows need to know stimulators are explanted frequently between 12-24 months post implant.

Taking over a pt's care for 24 months is of immense benefit. RFA worked in Jan, failed in Sept, worked again the following June.

How long do ESI work? Does PT play a role in the short term or long term? Pain psych? Is it actually covered by insurance or not?

Fellows are largely under hypnosis by device reps. Why? They bring nice food for lunch, and every major pain society's annual meeting is funded by industry. I went to NANS for a few yrs and won't return. That is an atrocious meeting.

SIS, on the other hand looks honest and I can't wait to start going to that one. The online education is fantastic, and the video case discussions are on point.

You go into pain for two main reasons - Procedures and schedule. No nights. Use a Bovie. Tie knots.

All you're concerned about in fellowship is learning technical skills, and the reps pump your ego.

I did my fellowship on the West Coast, I practice in Georgia now. I had a rep here tell me he'd heard of me by reputation from one of the reps IN CALIFORNIA!!!

"Dr Lxxx, I know your name from so and so in California. I've heard about you, and from what I hear you're legit. Can't wait to see you work."

Dude...GTFO...

My pain fellowship has long been known as one that isn't extremely procedure heavy. Back then I was sort of pissed bc we spent so much time discussing pain psych and conservative care and treating crazy ppl. I have a different perspective now.

 

[Ligament]

BTW, I understand the financial pressure of those doctors fighting to survive in small pain practices. The ones who accept any and all pts referred to them, the guys accepting dumps from ortho and PCPs...Same guys doing cluneal stimulators and monthly in-house urine. These types will put stimulators in anything, and the hyper utilizers of stim will get us all in deep s%&t.

I agree with what you said, except WE won't get in deep ****. The doctors you describe will make huge money, and keep that money, after SCS dies. Then they will rinse and repeat with the next medical device whose reps take selfies with you to post on instagram. And the same thing will happen. They will keep the money they make on these factories they run.

 

[ateria radicularis magna]

What are the factories? Are they a few large groups or is there a factory every where ? Who are the most despicable players ?

 

[MitchLevi]

I agree with what you said, except WE won't get in deep ****. The doctors you describe will make huge money, and keep that money, after SCS dies. Then they will rinse and repeat with the next medical device whose reps take selfies with you to post on instagram. And the same thing will happen. They will keep the money they make on these factories they run.

You most certainly will feel it my friend.

You'll feel it at 1230 on a Tuesday when you've got a CRPS pt you want to trial and potentially implant and now you're on the phone with a semi retired internist from Aetna who is stealing your lunch from you in a P2P you know you can't win.

Same internist who denied your RFA bc the pt only got 75% relief from an MBB.

You'll feel it when stim reimburses like an RFA and ultimately becomes cost prohibitive. Those pts you would have treated with SCS continue to follow up with you asking, "What's the next step doctor?"

"Nothing. You gotta hurt."

 

[nvrsumr]

The factories are every practice where there is a np prescribing narcs while the pain surgeon is busy implanting devices until there aren’t any places left to put them, the patient goes on caid or finally just wants meds and won’t pay for the in-house uds

 

[ateria radicularis magna]

The factories are every practice where there is a np prescribing narcs while the pain surgeon is busy implanting devices until there aren’t any places left to put them, the patient goes on caid or finally just wants meds and won’t pay for the in-house uds

Is this common? Any of these large equity groups involved in this or is it smaller under the radar groups?

 

[drusso]

My biggest mistake out of fellowship was joining a small practice where I saw those issues first hand. I had bolt because of disillusionment and constantly worried about doing the right thing for patients.

Smaller private practice vs the academic practice for my fellowship was way different

Can you elaborate? Most people think that the future of innovation in our specialty occurs in the private practice sector, not academics.

 

[NJPAIN]

SCS is probably the biggest let down for me in our field. My trial to perm ratio is nearly 100%; it is rare I have a failed trial.

I need to start offering this to more pts according to some people. Ratio should be around 75% or so, but I only want to stim people who are great candidates.

Failed back is 95% of my SCS pts.

Of those FBSS pts, I would guess over 80% are FBSS with persistent radic in one leg or both.

I do NOT like low back pain without radic for SCS, but I do it not infrequently.

...tons of failures post implant.

I talk to the pt and I'm told the device isn't helping. Interestingly, the reps always say otherwise.

Nevro will even send you an email with all these data showing your outcomes over the last yr and it all looks fantastic...Your Nevro rep won't be speaking to your pts BTW, those phone calls go to a person in Delaware or Connecticut or something...

I do Abbott and Nevro.

TBF, I have had some homeruns with stim too...Don't get me wrong, I've changed several lives with SCS.

I've had pts come to me with stimulators placed in a normal spine. In fact, I've removed a number of them.

Without Q it will become much more difficult to get these approved at some point in the future.

BTW, I understand the financial pressure of those doctors fighting to survive in small pain practices. The ones who accept any and all pts referred to them, the guys accepting dumps from ortho and PCPs...Same guys doing cluneal stimulators and monthly in-house urine. These types will put stimulators in anything, and the hyper utilizers of stim will get us all in deep s%&t.

I’ve been told the same thing “ if nearly 100% of your trials go to implant then you’re not doing enough trial”. Perhaps true BUT who likes to fail? Also, I see so many do well short term but meh long term I can only imagine what I would deal with if I trialed people I don’t think are great candidates.

 

[NJPAIN]

You most certainly will feel it my friend.

You'll feel it at 1230 on a Tuesday when you've got a CRPS pt you want to trial and potentially implant and now you're on the phone with a semi retired internist from Aetna who is stealing your lunch from you in a P2P you know you can't win.

Same internist who denied your RFA bc the pt only got 75% relief from an MBB.

You'll feel it when stim reimburses like an RFA and ultimately becomes cost prohibitive. Those pts you would have treated with SCS continue to follow up with you asking, "What's the next step doctor?"

"Nothing. You gotta hurt."

I’m afraid….you are absolutely correct.

 

[Taus]

I’ve been told the sane thing “ if nearly 100% of your trials go to implant then you’re not doing enough trial”. Perhaps true BUT who likes to fail? Also, I see so many do well short term but meh long term I can only imagine what I would deal with if I trialed people I don’t think are great candidates.

This has been my experience as well. I have zero financial incentive to do stim. Some home runs. More meh long term

 

[geauxg8rs]

You most certainly will feel it my friend.

You'll feel it at 1230 on a Tuesday when you've got a CRPS pt you want to trial and potentially implant and now you're on the phone with a semi retired internist from Aetna who is stealing your lunch from you in a P2P you know you can't win.

Same internist who denied your RFA bc the pt only got 75% relief from an MBB.

You'll feel it when stim reimburses like an RFA and ultimately becomes cost prohibitive. Those pts you would have treated with SCS continue to follow up with you asking, "What's the next step doctor?"

"Nothing. You gotta hurt."

How do you let the patients say they got 75 percent relief. I don’t play the game anymore. Patients need to know it’s 80 percent relief or no rf. So just to recap what percentage relief did you get? Always then 80-100%. It’s dumb but I didn’t make the rules

 

[MitchLevi]

How do you let the patients say they got 75 percent relief. I don’t play the game anymore. Patients need to know it’s 80 percent relief or no rf. So just to recap what percentage relief did you get? Always then 80-100%. It’s dumb but I didn’t make the rules

They call in the next day and read off their pain scores from their pain diary. Goes straight into the chart.

 

[bedrock]

They call in the next day and read off their pain scores from their pain diary. Goes straight into the chart.

Good way to have a lot of RFA denied for only 70% relief. Unless I’m missing something.

 

[Dr. Ice]

The whole thing is stupid. Not sure how this went from stim to Rf but anyway..the entire conversation with patients about rfa is extremely challenging. I have worked tirelessly to get them to understand the concept of rfa. I have information with images I give them, I will google image search medial branch nerves and show them on the computer, I will show them on the X-ray/mri and still at the end of the day, so many blank faces and question marks. Not to mention after that blocks, they say it didn’t help only to see the pain diary with zeros after the initial pre procedure score.

Honestly makes me really question how people 1)hold down jobs 2) care for other people including children 3) feed themselves and dress themselves 4) manage to live however long they have without dying

 

[geauxg8rs]

The whole thing is stupid. Not sure how this went from stim to Rf but anyway..the entire conversation with patients about rfa is extremely challenging. I have worked tirelessly to get them to understand the concept of rfa. I have information with images I give them, I will google image search medial branch nerves and show them on the computer, I will show them on the X-ray/mri and still at the end of the day, so many blank faces and question marks. Not to mention after that blocks, they say it didn’t help only to see the pain diary with zeros after the initial pre procedure score.

Honestly makes me really question how people 1)hold down jobs 2) care for other people including children 3) feed themselves and dress themselves 4) manage to live however long they have without dying

And serve in jury duty as a jury of your peers

 

[Agast]

The whole thing is stupid. Not sure how this went from stim to Rf but anyway..the entire conversation with patients about rfa is extremely challenging. I have worked tirelessly to get them to understand the concept of rfa. I have information with images I give them, I will google image search medial branch nerves and show them on the computer, I will show them on the X-ray/mri and still at the end of the day, so many blank faces and question marks. Not to mention after that blocks, they say it didn’t help only to see the pain diary with zeros after the initial pre procedure score.

Honestly makes me really question how people 1)hold down jobs 2) care for other people including children 3) feed themselves and dress themselves 4) manage to live however long they have without dying

Also, everyone who gets an epidural for their sciatica will ask you when you’re going to burn their nerves like their friend did since it helped them so much.

 

[MitchLevi]

Good way to have a lot of RFA denied for only 70% relief. Unless I’m missing something.

Other option is to what...lie or see them face to face after MBB?

I can't do either.

 

[bedrock]

Other option is to what...lie or see them face to face after MBB?

I can't do either.

I have a PA 3 days a month. They see new patients without MRI/PT and order both before patient sees me so I don’t waste time. Also have PA do in person visits after 2nd MBB.

If you don’t have that, then I would give them a sheet to record their post MBB pain relief.

I used to have a MBB sheet with 4 options.
1-0 % relief
2- 30% relief
3- 80% relief
4- 100% relief

Clearly only 3, 4 go onto RFA. And 1-2 shouldn’t have RFA.

Patients who clearly got more than 30% relief but less than 80% relief would often ask about another % option between 30-80. Those come in for F/U and I would explain how the world works and again give them the option of staying 30 or 80% relief. The vast majority choose wisely.

 

[MitchLevi]

I have a PA 3 days a month. They see new patients without MRI/PT and order both before patient sees me so I don’t waste time. Also have PA do in person visits after 2nd MBB.

If you don’t have that, then I would give them a sheet to record their post MBB pain relief.

I used to have a MBB sheet with 4 options.
1-0 % relief
2- 30% relief
3- 80% relief
4- 100% relief

Clearly only 3, 4 go onto RFA. And 1-2 shouldn’t have RFA.

Patients who clearly got more than 30% relief but less than 80% relief would often ask about another % option between 30-80. Those come in for F/U and I would explain how the world works and again give them the option of staying 30 or 80% relief. The vast majority choose wisely.

My sheet is a pain diary and you write down your scores before injxn and hourly after the injxn.

There's no way I'd give a sheet with % on it when 90% of pts HAVE NO FREAKING CLUE what it is we're doing despite the fact I explained it to them in the clinic and DURING THE PROCEDURE!

Hahaha.

I don't trust they know what % means TBH.

 

[Taus]

I have been considering just taking the numbers/math out of this. It just confuses things on many levels, as noted above.

No better, slightly better, a lot better, all gone.

 

[cowboydoc]

I have been considering just taking the numbers/math out of this. It just confuses things on many levels, as noted above.

No better, slightly better, a lot better, all gone.

Schneider presented his research at SIS showing a disconnect between % improvement and VAS (0-10) pain reduction. It was half funny and half sad how unreliable these measures are. It was an impressive statistical analysis demonstrating most people don't seem understand basic math.

 

[hiyaman]

Can you elaborate? Most people think that the future of innovation in our specialty occurs in the private practice sector, not academics.

I was talking about some practices essentially offering scs or peripheral stim to anyone whether or not they were actually a good candidate. The place I was at was sort of like that but it felt more like "if nothing works then do this shiny new procedure". Of course it's difficult to have good studies to study intervention efficacy in pain which is one of the pitfalls and I thought I was okay with that as well but turns out I wasn't.

 

[MitchLevi]

I was talking about some practices essentially offering scs or peripheral stim to anyone whether or not they were actually a good candidate. The place I was at was sort of like that but it felt more like "if nothing works then do this shiny new procedure". Of course it's difficult to have good studies to study intervention efficacy in pain which is one of the pitfalls and I thought I was okay with that as well but turns out I wasn't.

Well, when a pain doctor doesn't know much about stim, and especially when the young pain doctor is trying to become profitable, he or she will start throwing stimulators in ppl "as a last resort," and they back it up by saying, "Everything else failed."

The problem is there's no ICD 10 for "Everything else failed."

There are specific diagnoses for stim.

"Everything else failed" is a trashcan Dx that inevitably leads to nasty pay cuts and the eventual addition of 6 more hoops we have to jump through to get it approved.

...it's still gonna be mediocre in its efficacy as a treatment, even on those pts who on paper are slam dunk candidates. Some great cases too, don't get me wrong.

People who stim like crazy must take a ton of these things out. Good Lord.

Good on you for leaving. You'll look back on that decision one day and realize it was the right one.

 

[Ducttape]

they dont take them out. that would be a failure.

after implant, they may take the victim back to the OR to "adjust placement" of the leads due to "unexpected patient initiated migration" of leads.

after this, miraculously, they are cured of their pain with 100% reduction of symptoms, and are discharged as a success. if patient calls to schedule followup, they cant get past secretary gatekeeper.


eventually, the patients migrate to steve, who takes them out.

 

[MitchLevi]

they dont take them out. that would be a failure.

after implant, they may take the victim back to the OR to "adjust placement" of the leads due to "unexpected patient initiated migration" of leads.

after this, miraculously, they are cured of their pain with 100% reduction of symptoms, and are discharged as a success. if patient calls to schedule followup, they cant get past secretary gatekeeper.


eventually, the patients migrate to steve, who takes them out.

Have you seen that happen?

 

[ateria radicularis magna]

they dont take them out. that would be a failure.

after implant, they may take the victim back to the OR to "adjust placement" of the leads due to "unexpected patient initiated migration" of leads.

after this, miraculously, they are cured of their pain with 100% reduction of symptoms, and are discharged as a success. if patient calls to schedule followup, they cant get past secretary gatekeeper.


eventually, the patients migrate to steve, who takes them out.

Lol migrates to Steve !

 

[lobelsteve]

Lol migrates to Steve !

Thank you all for explants. Drawer is almost full.

 

[mid|ine]

...
1 no relief
2 good relief (>80%)

I fixed your pain diary for you

 

[nynydoc]

I've heard it a few times on the interview trail what the "future" looks like for pain and certain programs specifically look for (and throw out applications if not) candidates who have a strong desire to use neuromodulation. I've had a program director at one of these newer programs specifically say that the private practice set up is the future in which pain will expand into neuromodulation and that it will not be in academic medicine; this program was primarily PP with an association to a hospital. It's tough to believe this when the director is the face of major societies as well and has industry in their back pocket.

Neuromodulation has it's place for sure but out of these same programs, fellows barely know how to do a proper neuro exam. It is unfortunate as industry continues to push into the field but the clinicians, at the infancy of their training, are inundated with the fancy toys that they can't learn the basics of identifying a proper diagnosis.

 

[Dawkter]

I have not really been out of training long enough to see the number of explants that are discussed in the posts above. It is really interesting to read about others' experience and this group offers a wealth of information that would take years to acquire in clinical practice.

How many years of effective pain reduction are most of you seeing prior to the patient no longer using the SCS device or requesting explant? I am typically trialing for failed back, radicular pain, or CRPS and almost never for axial low back pain.

Are you noticing a difference in explant rate or efficacy between different companies?

 

[Ducttape]

Have you seen that happen?

all the time.

I have not really been out of training long enough to see the number of explants that are discussed in the posts above. It is really interesting to read about others' experience and this group offers a wealth of information that would take years to acquire in clinical practice.

How many years of effective pain reduction are most of you seeing prior to the patient no longer using the SCS device or requesting explant? I am typically trialing for failed back, radicular pain, or CRPS and almost never for axial low back pain.

Are you noticing a difference in explant rate or efficacy between different companies?

on average? most of these people say they used the device for about 2 years. no real difference between the companies.

 

[drrosenrosen]

all the time.


on average? most of these people say they used the device for about 2 years. no real difference between the companies.

Are these ones that you did, or that someone else did? I have seen patients from a lot of unscrupulous docs (including my own grandfather, sadly) who were implanted after failed trials, with the promise that it would get better once the perm was in.

 

[Spine MD]

The day of reckoning Is coming for stims. They know it. We all know it.
The hammer will fall.

Be prepared

The atrocious safety record for SCS is known, but incredibly most of those implanting SCS aren't aware (so patient's aren't being told either). It's the #3 for adverse events *bad enough that they get reported to the FDA* out of ALL medical devices in American medicine. Estimates are around 50 people die a year from it in the US. For a SQ TENS unit. We learned this back in 2018. Now the Australians are publishing their data and it mirrors ours.

 

[BobBarker]

I am explanting 3 of my own next week.

 

[MitchLevi]

The atrocious safety record for SCS is known, but incredibly most of those implanting SCS aren't aware (so patient's aren't being told either). It's the #3 for adverse events *bad enough that they get reported to the FDA* out of ALL medical devices in American medicine. Estimates are around 50 people die a year from it in the US. For a SQ TENS unit. We learned this back in 2018. Now the Australians are publishing their data and it mirrors ours.

I'm very critical of SCS but to say "SQ TENS" is a little dramatic right?

 

[Taus]

Odd situation recently…. Not sure if it’s just coincidence,… I do about 5-10 scs trials a year. I sometimes go months with zero. Only 4 in past couple years since Covid started. I’ve done 3 in the last month, all same company and all of a sudden reps from 2 other companies have contacted me about setting up a lunch. I hadn’t heard from them in a year or 2. I have no problem meeting with them, but just seems odd with the timing….. does my name pop up in a database when I do a trial? Reps talking? Or just pure coincidence?

 

[RoloTomassi]

Odd situation recently…. Not sure if it’s just coincidence,… I do about 5-10 scs trials a year. I sometimes go months with zero. Only 4 in past couple years since Covid started. I’ve done 3 in the last month, all same company and all of a sudden reps from 2 other companies have contacted me about setting up a lunch. I hadn’t heard from them in a year or 2. I have no problem meeting with them, but just seems odd with the timing….. does my name pop up in a database when I do a trial? Reps talking? Or just pure coincidence?

I've heard stim has been slow lately, so probably just a heavier marketing push. But if there is a database I'd like to know.

 

[Taus]

I've heard stim has been slow lately, so probably just a heavier marketing push. But if there is a database I'd like to know.

Too many shiny new toys to play with beyond stim now?

 

[RoloTomassi]

Too many shiny new toys to play with beyond stim now?

It's the long con. Put in the time now to do tons of ISS/PILD/SI fusion, then there will be a surge in "FBSS" in 6 mo.

 

[MitchLevi]

A rep from one company knew exactly how many cases I'd done with another company.