Why Decline in Fellows?!

Discussion in 'Pain Medicine' started by Jeff05, Dec 17, 2008.

  1. Jeff05

    Jeff05 Senior Member
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    NUmber of Fellows in ABA accredited Pain Management Programs

    2006 - 250
    2007 - 268
    2008 - 188

    that's a 30% one year drop!

    why are fewer people going into pain?!
     
  2. August_Bier

    August_Bier Member
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    With the restructuring of the ACGME accredited pain fellowships to one interdisciplinary fellowship per institution and expanded requirements of participating departments some fellowship programs had to merge and reduce slots, others had to close (UF comes to mind).

    So I think it is a matter of less spots, not less interest.
     
  3. panetrain

    panetrain ASA Member
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    I just interviewed at 10 pain fellowships and each stated that this year was the MOST competitive in regards too the quantity and quality of applicants. The interest in pain is stronger than ever!


     
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    #3 panetrain, Dec 17, 2008
    Last edited: Dec 17, 2008
  4. brori

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    I just interviewed at 10 pain fellowships and each stated that this year was the most competitive in regards too the quantity and quality of applicants. The interest in pain is stronger than ever![/quote]

    Pain medicine is certainly fascinating and emotionally gratifying, but is less and less financially rewarding (see proposed 2009 Medicare fee schedule).

    In America, economics plays a huge role in residency and fellowship trends. A 30% drop in fellows is significant. Sure there are program mergers and discontinuations, but I feel that less reimbursement and the fear of non-physician (CRNA, etc) procedure trends are factors here.
     
  5. Ligament

    Ligament Interventional Pain Management
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    How does this compare to the gold standard dermatology?
     
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    #5 Ligament, Dec 17, 2008
    Last edited: Dec 17, 2008
  6. drusso

    Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    Economics and I think that the field has been becoming more successful in educating folks that pain medicine requires a breadth of skills---chronic disease management, diagnosis, manual dextrity/procedural knowledge, people skills, etc. Residents do rotations in pain and realize, its not a "treat'em and street'em" specialty.
     
  7. ampaphb

    ampaphb Interventional Spine
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    Medicine has always been an economic shell game - Medicare makes pumps profitable, and they are done to excess. Reimbursement drops precipitously, and low and behold, far fewer pumps are appropriate!

    Intradiscal firbrin glue, chondrocytes, or gene vectors, percutaneous x-stops, biaccuplasty, etc are all coming down the pike or have recently emerged. Stim indications are expanding exponentially. I have heard physicians gripe about reductions in reimbursement for 25 years. Pain, like every other aspect in medicine, will modify practice patters in accord with changes in fee schedules.

    So please don't cry me a river of tears for the poor starving pain practitioner - the only people whose incomes will suffer are those who aren't able to adapt.
     
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    #7 ampaphb, Dec 17, 2008
    Last edited: Dec 18, 2008
  8. brori

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    Intradiscal firbrin glue, chondrocytes, or gene vectors, percutaneous x-stops, biaccuplasty, etc are all coming down te pike or have recently emerged.......

    So please don't cry me a river of tears for the poor starving pain practitioner - the only people whose incomes will suffer are those who aren't able to adapt.[/quote]

    Nobody is crying here. Please name fellowships that are currently teaching intradiscal glue, biaccuplasty, x-stops, etc.

    What you are suggesting is that in order to "adapt", you do procedures that weren't part of your original training. Sure, this is how medicine works, but it is a slippery slope.
     
  9. Tenesma

    Tenesma Senior Member
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    not to mention that medicare becomes cash-flow negative in 2010... i wonder what will happen then

    1) increase medicare tax
    2) "real" cuts in medicare

    and not to mention that private insurances are raising premiums at an accelerated rate as more and more businesses are laying-off more and more employees, thus really constricting the cash-flow of private payers... so the private payers will start cutting rates as well.

    for those doctors who think they are going to slide through the recession - i suspect that we will see a significant drop in income...

    i have already seen a steady decline of private payers in my practice --- i have also seen a LOT of patients who basically say:
    1) i can't afford the co-pays for physical therpay
    2) i can't afford co-pays, co-insurances, deductibles for procedures
    3) just give me some norco until i get new insurance...

    great!
     
  10. panetrain

    panetrain ASA Member
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    Does anyone know if biacuplasty is currently being reimbursed by medicare? Or, is it included in the TIPs (thermal intradiscal procedures), which are not currently being reimbursed in most states by medicare?




     
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  11. Jeff05

    Jeff05 Senior Member
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    but, even if pain reimbursement decreases by 20%, it will still be one of the highest paid specialities in medicine. during this time, every specialty will also take a hit, so the relative decrease will hurt even less.

    as far as learning new skills...the vascular surgeons that trained 20 years ago did not learn any catheter based techniques. now a major part of their practice is catheter based techniques.

    i think in order to SURVIVE people must do things that were not a part of their original training. in a field as rapidly advancing as medicine, it would be malpractice is practitioners only used techniques they learned during original training.

    so what some of you are saying is that pain medicine is more dependent on the economy? i mean do you see anesthesiology salaries taking as big of a hit as pain?
     
  12. Tenesma

    Tenesma Senior Member
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    i am already seeing it ---- the surgeons have seen a huge decline in the number of elective surgeries, either because their companies have changed over to HIGH deductible plans or because they are in fear of lay-off if they take time off or because they or their spouse has been laid off...

    in my hospital the surgeons have seen a 15% decrease in elective cases in November and december is looking worse (and USUALLY december is the busiest because everybody tries to get things done before deductibles reset).

    so by default the anesthesiologist are going to see a similar drop.

    and this is even before reimbursements drop...

    i am seeing this in my practice as well...
     
  13. algosdoc

    algosdoc algosdoc
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    Panetrain, biaculoplasty, IDET, Distrode, Accutherm, PRFT, Annuloplasty are all included on the non-coverage list by Medicare when used to treat back pain. Also included is Plasma Disc Decompression (Coblation nucleoplasty). The entities not included in TIPS are laser disc decompression and disc decompressor. It is not clear if these would be covered for low back pain treatment or were just not addressed.
     
  14. Disciple

    Disciple Senior Member
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    Ressurgence of Work Comp?:laugh:
     
  15. panetrain

    panetrain ASA Member
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    Have most private insurance companies followed suit, meaning are they not covering these procedures either? Are any of these procedures still viable? If not, then why are they still being marketed by medical device companies with high dollar training courses?:eek:


     
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  16. PMR 4 MSK

    PMR 4 MSK Large Member
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    I've been seeing a lot more no-shows and last-minute cancellations lately. More people are being turned over to collections, too.
     
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  17. brori

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    In some states, maybe, but not Texas. I see resurgence in LOP/PIP.
     
  18. Tenesma

    Tenesma Senior Member
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    i am seeing a lot more work-comp as well...
     
  19. chauffeur

    chauffeur Member
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    what's LOP/PIP?
     
  20. brori

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    Ha! It is a weird entity that you don't get any exposure to as a resident. LOP/PIP is letter of protection or personal injury protection. Let's say person A gets in motor vehicle collision and claims injuries. Person A calls an attorney to maximize any financial judgement. The attorney generates an LOP or PIP that is basically a contract agreement that medical and other expenses will be reimbursed once case is settled.

    Person A may seek medical care through their own personal insurance (if they have it) or through the LOP/PIP. They can also do a combination (needs a separate discussion topic). LOP/PIP are a total pain. You treat patients with certain secondary gain and the final payments are made only once final decision has been made (may take a while) and attorney often requests a reduction (it's their nature)

    I forecast/predict a rise in LOP/PIP due to massive layoffs and people not being able to afford traditional insurance. LOP/PIP does come with a world of headaches, but on average is about 140% of medicare. WC (another weird entity with little exposure as a resident) in some states (Texas for example) is terrible 130% of medicare before loopholes, etc. In some states, WC is highly sought after.
     
  21. ampaphb

    ampaphb Interventional Spine
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    In Louisiana, medico-legal cases generally pay 100% of charges. Some third party payers will guarantee payment in 60 days if you are willing to accept 65-80% of charges.
     
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  22. Disciple

    Disciple Senior Member
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    With a simultaneous rise in Plasma Disc Decompressions/Nucleoplasties billed as 63056?
     
  23. Tenesma

    Tenesma Senior Member
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    I no longer do LOP....

    the average time between services rendered, and payments made is about 16-22 months.

    and the lawyers in my neck of the woods are crooks.

    they get a judgement of let's say 80k...

    out of that 80k, they will either "forget" to pay you... OR they will tell you that the settlement was only 60k and that they only have 2k for medical...

    a lot of the dr.s in my community have taken the lawyers to court (which is tough because they all protect themselves), have had them brought before the bar's disciplinary committees --- all to little avail...

    so therefore, I don't know ANY doctors locally who do LOP anymore --- once you have been burned a few times then you get sick of it.


    re: PIP... Med-pay is a tricky business... and the PIPs aren't always honest with you.... I have seen many patients who supposedly still had Med-Pay benefits - treat them for 3-6 visits, only to find out that the Med-Pay benefits were all consumed by the first treating chiropractor. Of course, the patient then tries to get a LOP (see above) or has no money and ends up as collection...

    LOP/PIP basically sucks... and isn't worth the time/aggravation/phone calls/faxes and the patients who ALL have secondary gain and hardly ever get better...
     
  24. PMR 4 MSK

    PMR 4 MSK Large Member
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    There are other parts of the forest where they are not?

    Where?!? :D
     
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  25. ampaphb

    ampaphb Interventional Spine
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    Everybody hates lawyers ... until they need one.
     
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  26. PMR 4 MSK

    PMR 4 MSK Large Member
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    No, then we still hate them, we just hope our lawyer is better than their lawyer.

    Lawyers are kind of like pit bulls. Most people would agree that they should all be destroyed and society would likely be much better without them. But when you are in trouble, you want the biggest, baddest, meanest pit bull you can find fighting on your side.

    Then, just like pit bulls, we put the lawyers in a central arena and watch them fight, and the losing owner pays the victor.
     
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  27. Tenesma

    Tenesma Senior Member
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    perfect analogy... i have a friend who is a pitbull attorney --- i wouldn't wish him on my worst enemy, he can totally eviscerate ANYBODY within a few minutes... i am going to hire him on my team if i ever need a team - just for the sake of having an attorney frothing at the mouth to chew up the opposing attorney...
     
  28. ampaphb

    ampaphb Interventional Spine
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    Just as there are phenomenally talented surgeons who have the bedside manner of a box of rocks. You don't hire these folks to be your friends - they are brought on the do a job, and their personalities clearly suit their ability to complete the task at hand.

    The converse is also true - I know some incredibly nice PCPs who are complete morons - personality and competence have little to do with one another.
     
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