What's your plan after the new 10.4% cuts for pain go through?

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Calendar Year (CY) 2023 Medicare Physician Fee Schedule Proposed Rule | CMS

On July 7, 2022, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that announces and solicits public comments on proposed policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, effective on or after January 1, 2023.
www.cms.gov www.cms.gov

Look at what it states. Lots of interesting proposed changes. Including chronic pain mgmt services as "holistic", opioid abuse treatment bundling, single dose refunds for discarded meds. Did not see wRVU cuts.
 
Chronic Pain Management Services

We are proposing new HCPCS codes and valuation for chronic pain management and treatment services (CPM) for CY 2023. We believe the proposed CPM HCPCS codes would, if finalized, facilitate payment for medically necessary services, prompt more practitioners to welcome Medicare beneficiaries with chronic pain into their practices, and encourage practitioners already treating Medicare beneficiaries who have pain to spend the time to help them manage their condition within a trusting, supportive, and ongoing care partnership.

The proposed codes include a bundle of services furnished during a month that we believe to be the starting point for holistic chronic pain care, aligned with similar bundled services in Medicare, such as those furnished to people with suspected dementia or substance use disorders. We are proposing to include the following elements in the CPM code: diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and maintenance of a person-centered care plan that includes strengths, goals, clinical needs and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and coordination between relevant practitioners furnishing care, such as physical and occupational therapy and community-based care, as appropriate.
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What does this even mean? How does this get bundled? Who gets paid? If My PP E/M code is bundled with PT at the hospital...?
 
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this would help my practice:

Chronic Pain Management Services

We are proposing new HCPCS codes and valuation for chronic pain management and treatment services (CPM) for CY 2023. We believe the proposed CPM HCPCS codes would, if finalized, facilitate payment for medically necessary services, prompt more practitioners to welcome Medicare beneficiaries with chronic pain into their practices, and encourage practitioners already treating Medicare beneficiaries who have pain to spend the time to help them manage their condition within a trusting, supportive, and ongoing care partnership.

The proposed codes include a bundle of services furnished during a month that we believe to be the starting point for holistic chronic pain care, aligned with similar bundled services in Medicare, such as those furnished to people with suspected dementia or substance use disorders. We are proposing to include the following elements in the CPM code: diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and maintenance of a person-centered care plan that includes strengths, goals, clinical needs and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and coordination between relevant practitioners furnishing care, such as physical and occupational therapy and community-based care, as appropriate.
 
Ducttape said:
this would help my practice:

Chronic Pain Management Services

We are proposing new HCPCS codes and valuation for chronic pain management and treatment services (CPM) for CY 2023. We believe the proposed CPM HCPCS codes would, if finalized, facilitate payment for medically necessary services, prompt more practitioners to welcome Medicare beneficiaries with chronic pain into their practices, and encourage practitioners already treating Medicare beneficiaries who have pain to spend the time to help them manage their condition within a trusting, supportive, and ongoing care partnership.

The proposed codes include a bundle of services furnished during a month that we believe to be the starting point for holistic chronic pain care, aligned with similar bundled services in Medicare, such as those furnished to people with suspected dementia or substance use disorders. We are proposing to include the following elements in the CPM code: diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and maintenance of a person-centered care plan that includes strengths, goals, clinical needs and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and coordination between relevant practitioners furnishing care, such as physical and occupational therapy and community-based care, as appropriate.
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Then it must be bad for everyone else.
 
Ducttape said:
this would help my practice:

Chronic Pain Management Services

We are proposing new HCPCS codes and valuation for chronic pain management and treatment services (CPM) for CY 2023. We believe the proposed CPM HCPCS codes would, if finalized, facilitate payment for medically necessary services, prompt more practitioners to welcome Medicare beneficiaries with chronic pain into their practices, and encourage practitioners already treating Medicare beneficiaries who have pain to spend the time to help them manage their condition within a trusting, supportive, and ongoing care partnership.

The proposed codes include a bundle of services furnished during a month that we believe to be the starting point for holistic chronic pain care, aligned with similar bundled services in Medicare, such as those furnished to people with suspected dementia or substance use disorders. We are proposing to include the following elements in the CPM code: diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and maintenance of a person-centered care plan that includes strengths, goals, clinical needs and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and coordination between relevant practitioners furnishing care, such as physical and occupational therapy and community-based care, as appropriate.
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We are proposing more paperwork that will not change the delivery of quality care but will include at least 20 minutes of extra paperwork per patient per visit even after auto populated into nonsense extra 5 pages of emr nonsense data per patient


And we are going to cut your pay to pay for it and call it spending the time to help patients manage their own pain….

Also Sounds like Trying to make VAS like A1c
 
Treating chronic pain is not the same as treating substance use disorders. The latter really should go through psych if you want people to actually get better.

Dementia and chronic pain also mix poorly. Especially if you’re not going to allow a demented patient to be sedated for their epidural because Medicare won’t pay for it.
 
I put $10 into our lottery pool. I could probably figure out a way to survive on $50 million.
 
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Agast said:
Treating chronic pain is not the same as treating substance use disorders. The latter really should go through psych if you want people to actually get better.

Dementia and chronic pain also mix poorly. Especially if you’re not going to allow a demented patient to be sedated for their epidural because Medicare won’t pay for it.
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we should probably have a significant portion of chronic pain patients go through psych also.




taken on a macro level - im guessing CMS spends billions on pain treatment. im also guessing that they do not feel they are getting the kind of return for what they are spending on interventional treatments...
 
mid|ine said:
Im going to talk to our group about drafting a letter to our medicare patients letting them know we may be unable to see them if CMS proceeds with these cuts and should instead decrease SOS differential and increase reimbursement commensurate with inflation
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Unless you're a wordsmith your patients will take this as "my greedy a-hole doctor doesn't care about us old people"
 
Ducttape said:
taken on a macro level - im guessing CMS spends billions on pain treatment. im also guessing that they do not feel they are getting the kind of return for what they are spending on interventional treatments...
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By what metric are they eval’ing our outcomes? Genuinely curious since pain is notoriously difficult to categorize, measure, and follow.

I wouldn’t be surprised if the bean counters look at some of the bogus work on “ESI for LBP” which *surprise* shows no benefit.

If CMS really wants to save cash on pain care, perhaps CMS should like at spine surgery outcomes. And, you know, require those patients be cleared by psych…
 
au bon pain said:
By what metric are they eval’ing our outcomes? Genuinely curious since pain is notoriously difficult to categorize, measure, and follow.

I wouldn’t be surprised if the bean counters look at some of the bogus work on “ESI for LBP” which *surprise* shows no benefit.

If CMS really wants to save cash on pain care, perhaps CMS should like at spine surgery outcomes. And, you know, require those patients be cleared by psych…
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Couldn’t agree more. And subject them to far more onerous pre auth criteria. A spine surgeon within the last 2 weeks sent me 2 patients in their 30s for discograms, both WC, both with very unimpressive MRIs. Another patient told me the total hospitalization cost for his spinal fusion was over $400,000.
 
callmeanesthesia said:
Couldn’t agree more. And subject them to far more onerous pre auth criteria. A spine surgeon within the last 2 weeks sent me 2 patients in their 30s for discograms, both WC, both with very unimpressive MRIs. Another patient told me the total hospitalization cost for his spinal fusion was over $400,000.
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Exactly.

All lumbar fusions should much stricter criteria, and psych eval is key.
 
Ducttape said:
we should probably have a significant portion of chronic pain patients go through psych also.




taken on a macro level - im guessing CMS spends billions on pain treatment. im also guessing that they do not feel they are getting the kind of return for what they are spending on interventional treatments...
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you have this strange view of interventional pain management specialty.

why are you even practicing pain management? I don't understand. really don't.

if you feel you're not making a difference in patient's life, why keep doing it?

I sure don't feel the way you feel about CMS wasting money on me treating chronic pain patient. I just feel I'm underpaid by CMS.

let me guess, you work in corporate medicine and really makes no difference if work hard to treat patient or not. Your income is capitated, fixed regardless what you do.

Wait, have I seen this before? VA, Kaiser, or in socialized medicine?
 
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callmeanesthesia said:
I don’t think it would do much - would just result in psychologists rubber stamping inappropriate fusions just like they do for inappropriate stims. How many patients do you see fail their psych eval?
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I agree that could be an issue with surgeons.

Personally I encourage my psych to talk to me. We only deny 1 patient year or so, but I don't want him to rubber stamp anything
 
bedrock said:
I agree that could be an issue with surgeons.

Personally I encourage my psych to talk to me. We only deny 1 patient year or so, but I don't want him to rubber stamp anything
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I have never had psych deny a patient but I’m pretty selective about who I offer it to anyway. Many reasons beyond psych to deny a stim though. The 40 year old “disabled” 20-years-of-back-pain with a normal for age MRI smoking a pack a day and on heavy doses of opiates from their PCP, that some surgeon at some point though a laminotomy might cure? I’ve implanted none of those but explanted several.
 
mid|ine said:
Not to mention with ~10% inflation, a >10% cut, it is really a 20% cut
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it's actually worse. let's say you make $100 and overhead is $50, then you take home $50.
10% inflation increases your overhead to $55 and reimbursement drops to $90. you take home $35. 35/50 = 0.7. therefore it's 30% cut

to put this into perspective, if you normally take home $300k, it'll be near $200k with the new environment
 
callmeanesthesia said:
Couldn’t agree more. And subject them to far more onerous pre auth criteria. A spine surgeon within the last 2 weeks sent me 2 patients in their 30s for discograms, both WC, both with very unimpressive MRIs. Another patient told me the total hospitalization cost for his spinal fusion was over $400,000.
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Are you going to do the discograms? If so, you are complicit. Haven’t done one in over 10 years.
 
TIVAndy said:
it's actually worse. let's say you make $100 and overhead is $50, then you take home $50.
10% inflation increases your overhead to $55 and reimbursement drops to $90. you take home $35. 35/50 = 0.7. therefore it's 30% cut

to put this into perspective, if you normally take home $300k, it'll be near $200k with the new environment
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But if youre HOPD employed on a base + RVU model, no effect?
 
Do you guys anticipate that pain medicine will be lucrative going forward, say 5-10 years? I see these cuts being discussed almost every year... I know reimbursement cuts happen for lots of fields but I tend to see it discussed more on this forum specifically
 
bdoc13 said:
Do you guys anticipate that pain medicine will be lucrative going forward, say 5-10 years? I see these cuts being discussed almost every year... I know reimbursement cuts happen for lots of fields but I tend to see it discussed more on this forum
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GandalfTheWhite said:
how much money do you think is left on the table going HOPD vs PP?
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Apples to oranges.

No overhead. No HR. No lights to keep on. Just grind for 30-50 hrs per week and take home a paycheck. No baller status. No risk. No reward.
 
clubdeac said:
Not true, hospitals are cutting pay every few years, or at least they’re trying to
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Cant you just not renew and take your patients with you?

drusso said:
The site of service arbitrage (shifting SOS revenue from facility to MD salary) both squeezes PP and creates co-dependency between hospital Admin and HOPD-MDs.

Freedom is not free.
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But isnt it most practical financially for $/hr worked to be HOPD-MD? it seems that you do less paperwork and admin work in exchange for less overall income from ownership.
 
bdoc13 said:
Do you guys anticipate that pain medicine will be lucrative going forward, say 5-10 years? I see these cuts being discussed almost every year... I know reimbursement cuts happen for lots of fields but I tend to see it discussed more on this forum specifically
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Yes, probably. If you search this forum over the years, you'll see similar conversations have always come up. It's a recurring theme. You'll have to figure out how to make do. Chronic pain is such a complicated animal with no easy answer. No treatment will be entirely successful due to its nature, and someone needs to manage it. They can try this and that but the outcomes, for the most part, will always be the same.

To be fair, most of the time, every industry has the same worries. Costs increase, sales decrease, more competition drives prices down, etc. The lean companies survive and others don't.
 
GandalfTheWhite said:
Cant you just not renew and take your patients with you?
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Not that easy with noncompetes and nonsolicitation clauses requiring one to move. Plus in my city PMR/Pain/Spine is controlled by a few major groups. Going out on one’s own here would be challenging to say the least
 
au bon pain said:
By what metric are they eval’ing our outcomes? Genuinely curious since pain is notoriously difficult to categorize, measure, and follow.

I wouldn’t be surprised if the bean counters look at some of the bogus work on “ESI for LBP” which *surprise* shows no benefit.

If CMS really wants to save cash on pain care, perhaps CMS should like at spine surgery outcomes. And, you know, require those patients be cleared by psych…
Click to expand...
thats part of the problem. the metrics we use are entirely subjective, unlike spine surgery where they can point to "improved canal capaciousness" (the exact words taken from a spine surgeon's notes on a patient with persistent pain after 3 level fusion) to show that their surgery "worked".

in addition, pain scores may be altered based on a patient's expectations or desires. how many times do we do an injection that not-so-surprisingly prompts the response "well, the shot didnt work. can i get percs now?"

we need a marker to use that is objective. CRP? catecholamine levels? CNTN1?

or these: An exploratory identification of biological markers of chronic musculoskeletal pain in the low back, neck, and shoulders - PubMed

drpainfree said:
you have this strange view of interventional pain management specialty.

why are you even practicing pain management? I don't understand. really don't.

if you feel you're not making a difference in patient's life, why keep doing it?

I sure don't feel the way you feel about CMS wasting money on me treating chronic pain patient. I just feel I'm underpaid by CMS.

let me guess, you work in corporate medicine and really makes no difference if work hard to treat patient or not. Your income is capitated, fixed regardless what you do.

Wait, have I seen this before? VA, Kaiser, or in socialized medicine?
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common misconception, one that is derived from how we practice pain medicine.

it is about doing what is right for the patient. for a significant portion of the population, our focus on injections is not the right modality. neither are pills. lifestyle changes, changes in perception of pain, changes in expectations on pain control, improvement in functional capacity are much more important in the long run than an injection or a pill, particularly if it is an opioid.

unfortunately, we get blinded by $$$ to decide what treatments to "offer". in fact, im willing to bet a sizeable proportion of docs here will discharge a patient if they refuse shots - the modus operandi in the local community.


if i didnt feel i was making a difference, i would have just become a grouchy old guy that doesnt bother posting to encourage introspection on pain management, just does his 9-4 job, checks out mentally during the day, browses WSJ or tik tok etc., and spend the day musing on his golf swing and where to get good barbeque.
 
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