Will pain fellowship become competitive again?

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klumpke

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We all know that pain used to be a pretty competitive fellowship to get a spot. Now with that $$$ general anesthesiology money, spots are going unfilled so it’s more or less an easy match.

These things usually swing on a pendulum it seems. Do you think that pain will become competitive again in the future? Why or why not?

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We all know that pain used to be a pretty competitive fellowship to get a spot. Now with that $$$ general anesthesiology money, spots are going unfilled so it’s more or less an easy match.

These things usually swing on a pendulum it seems. Do you think that pain will become competitive again in the future? Why or why not?
Pain will not get competitive again with Anesthesiology because there are so many lower paying specialties that can do pain fellowships. Why pay an Anesthesiologist when you can get a PMR/Pain for significantly less money? I happened to luck out because I retired just after the time PMR/Pain became a viable specialty. And honestly, some of them do a great job. It's interesting how Anesthesiologists created ICU intensivists, and Pain Medicine then lost both of them. Do you see any evidence of Anesthesia intensivists coming back? Hmmm?
 
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Programs wont pare back the fellowship spots now that the field is saturated, midlevels won’t stop doing shots, unaccredited fellowships will continue to proliferate.
 
There is definitely a trend towards reimbursement favoring OVs vs procedures. A 99214 pays over two times more than a hip injection under fluoro and about the same as a CESI. Procedures are being pushed out slowly to where they are not worth the trouble. When you make more doing office visits than procedures who will go into interventional pain? Thre are only a few outlying procedures left and I’m pretty sure CMS is looking at them for some tasty cuts as well. Under the current system you will make the hospital a ton of money off your work, education, and medical risk exposure though. I’m sure the best and brightest will be chomping at the bit for IPM soon..
 
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We all know that pain used to be a pretty competitive fellowship to get a spot. Now with that $$$ general anesthesiology money, spots are going unfilled so it’s more or less an easy match.

These things usually swing on a pendulum it seems. Do you think that pain will become competitive again in the future? Why or why not?

Pain was the dream of the 1990's. Obamacare more or less ruined the specialty.
 
Pain will not get competitive again with Anesthesiology because there are so many lower paying specialties that can do pain fellowships. Why pay an Anesthesiologist when you can get a PMR/Pain for significantly less money? I happened to luck out because I retired just after the time PMR/Pain became a viable specialty. And honestly, some of them do a great job. It's interesting how Anesthesiologists created ICU intensivists, and Pain Medicine then lost both of them. Do you see any evidence of Anesthesia intensivists coming back? Hmmm?
I wouldn’t say this is why the specialty is dying. i’m PMR and am paid more than my anesthesia colleagues.

It’s dying because CMS is cutting procedural reimbursement all the time and bc of mid-level creep. In 5 to 10 years nurse anesthetists will be doing everything we do and we’ll be obsolete. That’s when I get into medical legal work to be an expert witness against these posers.
 
I wouldn’t say this is why the specialty is dying. i’m PMR and am paid more than my anesthesia colleagues.

It’s dying because CMS is cutting procedural reimbursement all the time and bc of mid-level creep. In 5 to 10 years nurse anesthetists will be doing everything we do and we’ll be obsolete. That’s when I get into medical legal work to be an expert witness against these posers.
At least in the Northeast, there is not much of a push for nurse anesthetists to do pain procedures. The market is so hot for locums doing easy cases, "independence" with cases, and setting your own schedule with chill hours that it would be a huge cut in the lifestyle a lot of them want to do pain. Besides, I don't think they get much training (or any) in interpreting imaging as I have yet to meet one that can accurately tell me what I am looking at on an ultrasound or an x-ray.
 
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What does juice the vig (vyigorish) mean?
I am also making more every year but I started 2 years ago
“Juicing the Vig on the SOS” is an Obamacare (un-Affordable Care Act) enabled scheme between hospitals and employed physicians that became popular in the early 2000’s to defraud patients and Medicare.

The scheme was designed to promote consolidation in healthcare in order to direct and control patient care. It depends upon physicians giving up autonomy in order to work for hospitals who direct them to do procedures in high reimbursement sites of service, order imaging, tests from hospital owned imaging centers, order u-tox from hospital owned labs, etc in exchange for more salary than the physician would otherwise receive if they were independent.

The hospitals can afford doing this because of a site of service differential and greedy or lazy physicians are more than happy to be complicit in the scheme. The scheme is inherently inflationary and also creates an unlevel market place for independent physicians.

I started raising awareness about this trend circa 2005 when patients would show me their EOB’s for yhe same service done at a hospitall, ASC, or HOPD. It is eye-popping. HOPD physicians, here and other places, resent having the conversation claiming that they’ve never been told about SOS or that they’re being paid to work for the hospital that uses large facility fees to subsidize their salary. Most deny that the scheme exists but it is actually Frderal policy, supported mostly by Left-leaning politicians who want “free healthcatw” for their constituents.

Some brave MD/DO’s have started to step forward and talk about their experiences of being directed and controlled into trading SOS for salary. Now, even some D’s in Congress are concerned (Wyden and Warren) about the scheme’s “unintended” consequences—skyrocketing costs and consolidation—but for the last 20 years the HOPD-employed MD’s have been laughing all the way to the bank.

In the 2010’s I completed a health policy fellowship and studied the issue. The policy and scheme have all but wrecked the American health care system.

Thanks, Obama.
 
“Juicing the Vig on the SOS” is an Obamacare (un-Affordable Care Act) enabled scheme between hospitals and employed physicians that became popular in the early 2000’s to defraud patients and Medicare.

The scheme was designed to promote consolidation in healthcare in order to direct and control patient care. It depends upon physicians giving up autonomy in order to work for hospitals who direct them to do procedures in high reimbursement sites of service, order imaging, tests from hospital owned imaging centers, order u-tox from hospital owned labs, etc in exchange for more salary than the physician would otherwise receive if they were independent.

The hospitals can afford doing this because of a site of service differential and greedy or lazy physicians are more than happy to be complicit in the scheme. The scheme is inherently inflationary and also creates an unlevel market place for independent physicians.

I started raising awareness about this trend circa 2005 when patients would show me their EOB’s for yhe same service done at a hospitall, ASC, or HOPD. It is eye-popping. HOPD physicians, here and other places, resent having the conversation claiming that they’ve never been told about SOS or that they’re being paid to work for the hospital that uses large facility fees to subsidize their salary. Most deny that the scheme exists but it is actually Frderal policy, supported mostly by Left-leaning politicians who want “free healthcatw” for their constituents.

Some brave MD/DO’s have started to step forward and talk about their experiences of being directed and controlled into trading SOS for salary. Now, even some D’s in Congress are concerned (Wyden and Warren) about the scheme’s “unintended” consequences—skyrocketing costs and consolidation—but for the last 20 years the HOPD-employed MD’s have been laughing all the way to the bank.

In the 2010’s I completed a health policy fellowship and studied the issue. The policy and scheme have all but wrecked the American health care system.

Thanks, Obama.
in fact, isnt there a Lund report article about this?
 
in fact, isnt there a Lund report article about this?

It’s part of why I remind every medical student and resident who works with me that “elections have consequences.” When you spend your whole life building a business and a politician comes along and says, “you did not build that,” what might otherwise be considered farcical rhetoric is actually prelude to nothing short of government confiscation of your livelihood.
 
obama did not come in to office until 2008. he became a US senator as of Jan 3, 2005 and assumed office of president as of Jan 20, 2009.

so i would highly doubt that your comment stands ground: to wit your statement “Juicing the Vig on the SOS” is an Obamacare (un-Affordable Care Act) enabled scheme between hospitals and employed physicians that became popular in the early 2000’s to defraud patients and Medicare. is not possible.

in plain words - it started during the Republican Bush's term prior to ACA (which, in addition, was not active until March 23, 2010)
 
It’s part of why I remind every medical student and resident who works with me that “elections have consequences.” When you spend your whole life building a business and a politician comes along and says, “you did not build that,” what might otherwise be considered farcical rhetoric is actually prelude to nothing short of government confiscation of your livelihood.
You mean that exact politician that you were praising a few posts above? or barry-o?

lizzy:

There is nobody in this country who got rich on their own. Nobody. You built a factory out there - good for you. But I want to be clear. You moved your goods to market on roads the rest of us paid for. You hired workers the rest of us paid to educate. You were safe in your factory because of police forces and fire forces that the rest of us paid for. You didn't have to worry that marauding bands would come and seize everything at your factory... Now look. You built a factory and it turned into something terrific or a great idea - God bless! Keep a hunk of it. But part of the underlying social contract is you take a hunk of that and pay forward for the next kid who comes along.​


obama
"Somebody helped to create this unbelievable American system that we have that allowed you to thrive. Somebody invested in roads and bridges. If you've got a business, you didn't build that."
 
obama did not come in to office until 2008. he became a US senator as of Jan 3, 2005 and assumed office of president as of Jan 20, 2009.

so i would highly doubt that your comment stands ground: to wit your statement “Juicing the Vig on the SOS” is an Obamacare (un-Affordable Care Act) enabled scheme between hospitals and employed physicians that became popular in the early 2000’s to defraud patients and Medicare. is not possible.

in plain words - it started during the Republican Bush's term prior to ACA (which, in addition, was not active until March 23, 2010)
Obamacare made site of service arbitrage the law of the land.
 
obama did not come in to office until 2008. he became a US senator as of Jan 3, 2005 and assumed office of president as of Jan 20, 2009.

so i would highly doubt that your comment stands ground: to wit your statement “Juicing the Vig on the SOS” is an Obamacare (un-Affordable Care Act) enabled scheme between hospitals and employed physicians that became popular in the early 2000’s to defraud patients and Medicare. is not possible.

in plain words - it started during the Republican Bush's term prior to ACA (which, in addition, was not active until March 23, 2010)

Don't confuse your Internet search with my health policy thesis.
 
Pain will not get competitive again with Anesthesiology because there are so many lower paying specialties that can do pain fellowships. Why pay an Anesthesiologist when you can get a PMR/Pain for significantly less money? I happened to luck out because I retired just after the time PMR/Pain became a viable specialty. And honestly, some of them do a great job. It's interesting how Anesthesiologists created ICU intensivists, and Pain Medicine then lost both of them. Do you see any evidence of Anesthesia intensivists coming back? Hmmm?
ABA blowing it for our specialty/subspecialty is pretty much commonality.

You’re worried about PMR???

How about the CRNAs?
 
Duct and ssdoc came out to speak up right on cue. It’s too easy.
because one of you lie right on cue.


stop lying and we wont have to post to tell the truth.

and to tell you the truth, this is easier than shooting fish in a barrel. its more like having a manservant throw a hand grenade in that barrel.
 
There is definitely a trend towards reimbursement favoring OVs vs procedures. A 99214 pays over two times more than a hip injection under fluoro and about the same as a CESI. Procedures are being pushed out slowly to where they are not worth the trouble. When you make more doing office visits than procedures who will go into interventional pain? Thre are only a few outlying procedures left and I’m pretty sure CMS is looking at them for some tasty cuts as well. Under the current system you will make the hospital a ton of money off your work, education, and medical risk exposure though. I’m sure the best and brightest will be chomping at the bit for IPM soon..
Agree. This rewards opioid heavy clinics. If you write relatively responsibly, pack your clinic full, you can make a killing one office visit at a time.
 
Agree. This rewards opioid heavy clinics. If you write relatively responsibly, pack your clinic full, you can make a killing one office visit at a time.

With your DEA handler laughing in the background...only a matter of time before they swoop in and clean house.
 
With your DEA handler laughing in the background...only a matter of time before they swoop in and clean house.
I hope they do, maybe my frustration didn’t come across correctly. My point is the government says they are combating the opioid crisis and yet with every decision they make it is easier to write opioids than do anything else.

PT: denied
Injection: denied
Hell even abuse deterrent opioids: denied
 
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I hope they do, maybe my frustration didn’t come across correctly. My point is the government says they are combating the opioid crisis and yet with every decision they make it is easier to write opioids than do anything else.

PT: denied
Injection: denied
Hell even abuse deterrent opioids: denied

All that stuff costs money and has questions to the long term efficacy. Large scale opioid prescribing costs pennies per script. Insurers and government love the savings but aren't gonna parade the point to the public given the current opioid epidemic.
 
Few bucks for opioids vs thousands.. they can pay for years for just one procedure. But hey.. don’t overprescribe lol
 
If you are “diligent” prescribing meds, follow the “rules” work a few hours on Saturdays, you can kill it without doing any procedures. Trust me, guy in my group does it. Ortho practice, he is the second highest earner in the group, highest earner is doing all sorts of call and works like an animal

It’s actually great in an ortho group..cause wow what a shocker orthopedic surgery doesn’t really work..and no it’s not my group, I worked in a very “reputable” 🤦🏽‍♂️ group before and failed surgeries were “because it’s coming from the back.”

It’s no wonder the guy still has a job and they haven’t fired him yet. He sees all the preops just before they get surgeries and all
the post ops to continue the “functional pain managment”
 
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If you are “diligent” prescribing meds, follow the “rules” work a few hours on Saturdays, you can kill it without doing any procedures. Trust me, guy in my group does it. Ortho practice, he is the second highest earner in the group, highest earner is doing all sorts of call and works like an animal

It’s actually great in an ortho group..cause wow what a shocker orthopedic surgery doesn’t really work..and no it’s not my group, I worked in a very “reputable” 🤦🏽‍♂️ group before and failed surgeries were “because it’s coming from the back.”

It’s no wonder the guy still has a job and they haven’t fired him yet. He sees all the preops just before they get surgeries and all
the post ops to continue the “functional pain managment”
Sounds like hell to me
 
We all know that pain used to be a pretty competitive fellowship to get a spot. Now with that $$$ general anesthesiology money, spots are going unfilled so it’s more or less an easy match.

These things usually swing on a pendulum it seems. Do you think that pain will become competitive again in the future? Why or why not?


The time has come for the Pain Medicine community to execute a pathway forward. This is an exciting juncture. Our recommendation is to first support the fellowships by:

1) using ambassadors at institutions to engage trainees in Pain Medicine experiences to improve early exposure to the specialty,
2) emphasize the core values of a multimodal care plan through societal annual meeting offerings,
3) develop academic curricula and requirements for advanced pain procedures,
4) partner with academic spine surgeons to define scopes of practice and develop mutually beneficial relationships,
5) embolden academic practices to design and execute randomized controlled trials of the novel procedures to build evidence,
6) utilize enhanced high-fidelity simulation training and
7) encourage collaboration and advocacy across the different pain societies at regional and national levels.

These solutions will not only improve the caliber of Pain Medicine education but also answer the concerns raised by surgeons regarding training and supply insurance companies with the needed data to shift novel procedures from “investigational" to “standard of care." The time to act is now.
 
If you are “diligent” prescribing meds, follow the “rules” work a few hours on Saturdays, you can kill it without doing any procedures. Trust me, guy in my group does it. Ortho practice, he is the second highest earner in the group, highest earner is doing all sorts of call and works like an animal

It’s actually great in an ortho group..cause wow what a shocker orthopedic surgery doesn’t really work..and no it’s not my group, I worked in a very “reputable” 🤦🏽‍♂️ group before and failed surgeries were “because it’s coming from the back.”

It’s no wonder the guy still has a job and they haven’t fired him yet. He sees all the preops just before they get surgeries and all
the post ops to continue the “functional pain managment”
How much do they make? Seems like it would be hard to compete with joint and spine ortho doing just clinic visits
 
45 patients per day x 1.9 rvus x multiplier x days worked.. can be a lot plus new patient visits
 
Easy to do clinic all day and make 50 rvus per day x 4.5 days per week x 48 weeks x whatever $/rvu you want.

$60/wrvu = $650k

Or $70/wrvu = $750k
 
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