Washington State Now plans to eliminate nerve blocks!

[Ligament]

The Washington state HTA is so incompetent it makes my head spin. They are now planning on eliminating all nerve block injections. Where the hell this came from nobody knows. I encourage you to email them and let them know how utterly out of touch with the practice of medicine they are.

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[lobelsteve]

I could not practice in a state that defines care as: anything but what you do.

I'm sure ASIPP, ISIS, NASS et al will do a joint paper refuting this nonsense. But it would be nice to see a patient go nuts and start shooting at the committee without injuring anyone. Or they could include the appropriate data for review that would support a realistic discussion. 4 studies on MBB? Out of how many excluded?
Flawed methodology by the committee to justify their ends. Any MD on the committee should lose their license for lack of ethics.

 

[PMR2008]

Ligament how does this affect your practice and the other interventional pain physicians in the wonderful state of Washington?

 

[bedrock]

I still refer to my comments about the HTAC last attempt at this.

I think this is all just an extension of the hyperliberalism trend in Washington state. A confidential survey of all the closet granolas on the Washington councils would likely reveal beliefs that any pain can be eliminated with enough Reiki/meditation-
Anything else must be "polluting" the body. I'm sure that the idea to deny payments for cardiac and other well researched drugs is on the mind of at least one panel member in the state.

1- They're all nutjob hippies as I originally theorized.
2- This is Washington's way of balancing the budget. Much as Wisconsin destroyed union pensions.

They'll be disappointed when extra thousands of state employees/insured have spine surgery instead and end up with either
1-more surgery or
2-unemployment/disability!

Let's see what that costs the state government!

 

[SSdoc33]

no "nerve blocks"?

looks like ligament is just gonna have to RF everyone from the get-go

 

[Tenesma]

what about peri-operative nerve blocks?

 

[emd123]

The Washington state HTA is so incompetent it makes my head spin. They are now planning on eliminating all nerve block injections. Where the hell this came from nobody knows. I encourage you to email them and let them know how utterly out of touch with the practice of medicine they are.

Sounds like a really good excuse to move somewhere with a whole lot less rain.

 

[Gauss]

technically RFA is denervation.
would tfesi be denied under the idea it's a snrb?

 

[PinchandBurn]

few questions:

1)What are the names of the docs on the committee that created this?
2)What is their specialty designation?
3) How much experience in pain management do they have?

These people are wrecking people's livelihoods here...

 

[Tenesma]

this is what happens when a few bad apples overdo things....

BCBS recently wanted to refuse to pay for all procedures done on the same day as an E/M... albeit a rare occurence for me, i wanted to find out why?... their answer: a bozo in my state is charging an E/M for every procedure (he does 25 procedures - mostly unwarranted - per day)... I spoke w/ their med director, and thank god, they decided to cancel their contract with him, instead of making things painful for everybody...

that is what the state of washington should have done... make the over-utilizers fill out a 10 page form for auth for each procedure would have fixed their over-utilization quickly and this would be a non-issue...

 

[Aether2000]

It is time for pain physicians to abandon Washington State. The legislators there have abandoned having meaningful input from either patients or physicians that know what they are talking about. The legislators gave complete and absolute authority over any state funded (directly or indirectly) medical care to a quasi-competent panel of physicians and non-physicians, who then contracted with a hired gun consultant (a physical therapist for gods sake) for millions to arrive at their foregone conclusion. Shame on the legislature for abrogating their responsibility and setting up a Kafka-esque state in which physicians practicing pain are completely throttled from having input or a voice. Shame on Washington state for harming millions of citizens through their radical and unsupportable positions adopted by their Nazi propaganda technology committee machine.

 

[emd123]

It is time for pain physicians to abandon Washington State. The legislators there have abandoned having meaningful input from either patients or physicians that know what they are talking about. The legislators gave complete and absolute authority over any state funded (directly or indirectly) medical care to a quasi-competent panel of physicians and non-physicians, who then contracted with a hired gun consultant (a physical therapist for gods sake) for millions to arrive at their foregone conclusion. Shame on the legislature for abrogating their responsibility and setting up a Kafka-esque state in which physicians practicing pain are completely throttled from having input or a voice. Shame on Washington state for harming millions of citizens through their radical and unsupportable positions adopted by their Nazi propaganda technology committee machine.

When did we start seeing meaningful tort reform popping up in a few sensible states? When entire states were left without ob-gyn's and when entire states were left without neurosurgeons who did brain surgery (by selectively dropping their "brain" privileges {high liability to payment ratio} and keeping only their spine privileges {lower liability to payment ratio}).

 

[PinchandBurn]

See...

Unfortunately, I think states realize that physicians with private practices arent going to just 'up and leave'. Especially if they have expensive mortgages on businesses they just started (say in the last few years).

I completely agree though. If you are an employeed pain physician, threaten to leave the state. Or else, get a large stipend from the hospital to subsidize you so that they can maintain a pain physician on staff. Ask for increased pay directly from the hospital admins. If the states arent going to pay, then have the hospitals subsidize you.

 

[Aether2000]

Certainly if I were coming out of fellowship, Washington State would be my last choice to practice at this juncture.

 

[painstop]

It's obscene what's going on here...MBBs are one of the most scientifically valid procedures we do...are they refuting this branch exists or it's possible to block? Bogduk would have a field day with these guys. Our field is really only about 20 years old so, yes, there may be some issues with some of the studies out there but there are many valid studies which this group is excluding...ridiculous!!!

 

[hyperalgesia]

This is messed up. They cite this study:

"For confirmed cervical facet joint pain compared to placebo: no benefit in terms of pain or function at both three and twelve months or on opioid use...", which uses "confirmed" cervical facet joint pain, to justify denying the use of MBBs. How sloppy. Someone needs to go on TV and roast this committee.

 

[Ligament]

I agree. Honestly, algos and emd are right. The only way there will be any meaningful change is when they are faced with no pain physicians available in state.

This will hit them a lot harder considering the legislation they passed that dictates that anyone taking above like 120 mg daily morphine equivalents needs to be seen by a pain specialist. When all these people are mandated by law to see a pain specialist, and there are few-to-none available, then maybe they'll wake up to wtf they did to themselves and their state.

I'd like to comment on the law regarding 120mg MEQ per day and requirement for pain specialist consultation. Again, the state has demonstrated profound and negligent ignorance. Per my last reading of the law, a physician qualifies as a pain management specialist and can give pain management consults if she is:
1. A rheumatologist
2. A neurologist
3. A physiatrist
4. An anesthesiologist (yes, even if their entire career may be pediatric cardiac anesthesia and they have never done one minute outpatient chronic pain as an attending)
5. A board certified and fellowship trained Pain Medicine subspecialist.

Thats right, if you are a primary care doc, you can send your patient to your friendly pediatric anesthesiology subspecialist and get your blessing for your patient on 500mcg of Duragesic. Or your rheumatologist can do that for you, or your neurologist. You know, these guys that are experts in chronic outpatient pain management, they are just as qualified as Pain Medicine subspecialists in the eyes of the state.

It GETS WORSE. If a physician of ANY SPECIALTY (read pill mill PCP docs) has had 1/3 of his practice dedicated to chronic pain for the past 3 years, this physician is exempt from needing a "Pain Management Specialist" consultation. That's right; this law allows pill pusher docs to continue to run pill mills and prescribe with impunity. It literally exempts the very physicians who are the problem.

The state is incompetent. The above is my understanding of the law as I read it a couple months ago. Hopefully it has changed.

 

[SSdoc33]

it is easy for an outsider to say "well, if you are a pain specialist, just leave washington state". its not that easy, especially if you have a house, family, or have built a practice.

what is disturbing is that these changes have taken place where there is such a high concentration of world-class pain and injection specialists.

 

[stim4u]

it is easy for an outsider to say "well, if you are a pain specialist, just leave washington state". its not that easy, especially if you have a house, family, or have built a practice.

what is disturbing is that these changes have taken place where there is such a high concentration of world-class pain and injection specialists.

what are the commercial insurances doing in this state? are they following suit?

Sound like WC, governmental plans, are done.... I would lock in my commercial insurance contracts and market cash based procedures heavily. may not be so terrible, especially if you are looking to wind down your practice over 5 years.

 

[docnyc]

It GETS WORSE. If a physician of ANY SPECIALTY (read pill mill PCP docs) has had 1/3 of his practice dedicated to chronic pain for the past 3 years, this physician is exempt from needing a "Pain Management Specialist" consultation. That's right; this law allows pill pusher docs to continue to run pill mills and prescribe with impunity. It literally exempts the very physicians who are the problem.


Ligament,

This is just terrible. Washington is on its to becoming the next Florida. I dont think you have to worry about the pediatric cardiac anesthesiologists giving approval on a ridiculous opioid regimen, its more the pill mill docs who have been grandfathered through.

Any word from the IPM physicians at the academic centers? These policies will probably topple the ivory towers of academic medicine in Washington state also.

 

[powermd]

it is easy for an outsider to say "well, if you are a pain specialist, just leave washington state". its not that easy, especially if you have a house, family, or have built a practice.

what is disturbing is that these changes have taken place where there is such a high concentration of world-class pain and injection specialists.

In a way that might be a mixed blessing, as these are the very folks most qualified to bump back.

 

[painstop]

Ultimately if the private payors follow suit then, yes, this will impact the academic setting. When you have exceptional pain faculty being forced to beg their anesthesiology chair to perform MBB/RFA for academic purposes (I'm sure in the guise of charity care) to teach the pain fellows appropriately then we are dealing with a sad state of affairs.

 

[Mister Mxyzptlk]

Did I read this correctly? They shot down MBBs because they didn't provide relief? I guess there shouldn't be any MRIs because they don't provide any relief either.

Is this just WC? If so, fine. If the commercial carriers follow suit you might not have any choice but to pull up stakes or just live on Medicare.

And when you get those referrals for being over 120 mg of MSO4 just shrug your shoulder and tell them you can't do anything because it's not covered and the prescription writing service is closed.

 

[drusso]

Did I read this correctly? They shot down MBBs because they didn't provide relief? I guess there shouldn't be any MRIs because they don't provide any relief either.

Is this just WC? If so, fine. If the commercial carriers follow suit you might not have any choice but to pull up stakes or just live on Medicare.

And when you get those referrals for being over 120 mg of MSO4 just shrug your shoulder and tell them you can't do anything because it's not covered and the prescription writing service is closed.

Welcome to my world...1/3 of my industrial medicine patients are WA L&I.

 

[Mister Mxyzptlk]

Welcome to my world...1/3 of my industrial medicine patients are WA L&I.

Edit: 1/3 WERE your patients. As soon as you run up against one of these new regs you just explain that you're very sorry but the treatment they need is not available in WA and no, you aren't writing a prescription.

Then let public outrage do the rest. This is what happened in TX. TWCC cut fees and the injured workers couldn't find a doctor so the fees went back up.

 

[Ligament]

Here are some links to update you guys on what is going on in Washington.

http://www.hta.hca.wa.gov/documents/meeting_materials_part_one_061711.pdf

http://www.hta.hca.wa.gov/documents/meeting_materials_part_two_061711.pdf

Read and learn now so that when YOUR state tries to destroy your practice and cause tens of thousands of state workers needless suffering you can fight.

 

[epidural man]

It's obscene what's going on here...MBBs are one of the most scientifically valid procedures we do...are they refuting this branch exists or it's possible to block? Bogduk would have a field day with these guys. Our field is really only about 20 years old so, yes, there may be some issues with some of the studies out there but there are many valid studies which this group is excluding...ridiculous!!!

This may be true, but the real problem is that MBB billing has increase something like 700% over the last few years. Facetogenic pain hasn't increased, and given the prevelance of facet mediated pain is rather small compared to discogenic pain or other causes, it is a concerning statistic.

I'm not on the side of WA by the way - I think they proved themselves ******ed when they decided that L&I wasn't going to pay for SCS because of the study they did where they used 50 patients in each arm, and on the 50 that got trialed, many of them had an unsuccesful trail - yet these were included in the data as a failure of SCS. Seriously, how dumb does one have to be to think that is a good study?

 

[Mister Mxyzptlk]

Facetogenic pain hasn't increased, and given the prevelance of facet mediated pain is rather small compared to discogenic pain or other causes . . .

I couldn't disagree more. I remember the first time I heard the "statistic" that 40% of back pain is discogenic. I thought maybe they mistakenly added a zero.

My approach to axial back pain almost always starts with the posterior elements and the SI joints. With aggressive attention to those areas I end up resorting to very few discograms and I believe I am rendering both the patient and the public a great service.

 

[Ligament]

Yes, I agree there is no way discogenic pain accounts for 40% of axial back pain. Facets and/or SIJs take care of the issue 90% of the time.

 

[bedrock]

Yes, I agree there is no way discogenic pain accounts for 40% of axial back pain. Facets and/or SIJs take care of the issue 90% of the time.

Maybe for AARP members-

For patients under 50, I would definitely argue that axial back pain secondary to a discogenic source is greater than 10%.

 

[epidural man]

I couldn't disagree more. I remember the first time I heard the "statistic" that 40% of back pain is discogenic. I thought maybe they mistakenly added a zero.

My approach to axial back pain almost always starts with the posterior elements and the SI joints. With aggressive attention to those areas I end up resorting to very few discograms and I believe I am rendering both the patient and the public a great service.

I guess any discussion about prevelance needs an age qualifier.

 

[Ligament]

I guess any discussion about prevelance needs an age qualifier.

You are absolutely correct. My population is older than most. I agree discogenic pain is higher in younger folks, but still way less than 40%.

 

[epidural man]

You are absolutely correct. My population is older than most. I agree discogenic pain is higher in younger folks, but still way less than 40%.

Well I have no idea what the actually prevalence is - so I have to go on published data. In a population that closely mimics mine, Cohen found a prevalence of 65% (article attached).

In my young population, we do so much Dx MBB's and so many are negative, and many of them have HIZ's on MRI - and just axial back pain.

 

[lobelsteve]

Can we separate acute from chronic here?

Acute LBP is going to be a lot easier to sort out than chronic as MOI should help determine what was hurt. Fall onto buttock with pain localizing at or below LS junction to one side = SIJ>disk>facet.

Whiplash with left sided neck pain to shoulder=facet

Lifting a couch to vacuum under it and a band of pain about the LS junction shows up the next day = disk.

Now let those patients have poor coping skills, let 1 year go by while they do chiro, eat McDonalds, continue smoking, watch more Springer, lose their job, smoke some weed, get a few tattoos, put on 20 pounds- and bring them back to clinic. Now they have chronic pain and I have no way of knowing where to begin except to get the complete H&P and yada yada yada. I think this is when Nik takes a puff on a cigarette and says, " Only the needle knows."

 

[epidural man]

Can we separate acute from chronic here?

Acute LBP is going to be a lot easier to sort out than chronic as MOI should help determine what was hurt. Fall onto buttock with pain localizing at or below LS junction to one side = SIJ>disk>facet.

Whiplash with left sided neck pain to shoulder=facet

Lifting a couch to vacuum under it and a band of pain about the LS junction shows up the next day = disk.

Now let those patients have poor coping skills, let 1 year go by while they do chiro, eat McDonalds, continue smoking, watch more Springer, lose their job, smoke some weed, get a few tattoos, put on 20 pounds- and bring them back to clinic. Now they have chronic pain and I have no way of knowing where to begin except to get the complete H&P and yada yada yada. I think this is when Nik takes a puff on a cigarette and says, " Only the needle knows."

 

[Doctodd]

Did anyone try calling the press?