Clinic volume at the 9th month mark. Need help!

[docodissi]

Hello everyone! I am a relatively inexperienced pain physician that’s a couple years out of fellowship. I joined this hospital-based clinic that is being run by a physician run organization that owns several different hospital-based clinics throughout the state but not hospital employed. I am in Ohio. I am at the nine month mark of this job and totally this clinic has been open for 2 1/2 years. I feel like volumes have dropped but don’t think were very high in general at least for me, I’m not really sure why. I am in a rural setting and there is One other Pain Clinic about half an hour away that is completely private. There are a couple other big health systems that have a tendency to keep referrals within themselves so it’s tough. I’m not really sure what to do about volumes. I have a dedicated marketing team to help and we are doing billboards and I have lunches, give thank you cards, go to health fairs and radio ads etc. On average I have maybe 18 to 22 patients in clinic on a good day. Unfortunately there is a fair bit of medication management because some of the docs back in the day used to prescribe a decent chunk of opioids, on average I’d say my mme is 23-24 and 30-40 percent are on some opioid. However the problem is from a procedure standpoint I’m probably if lucky doing 18 procedures but on average I’m at 16. I know that is horrible. I’m at the clinic 3.5 days a week and 1 full day of procedures which never ends up being a full day because like I said I’m doing about 16 to 18 injections. There is also probably one or two no-shows on those injection days. What do I do? Is this a normal dip in volume at this time in year 2 to 3 of a clinic? Is there any scope for growth? Anything else anyone here can give me insight on? The hospital system my pain clinic is-based with has another competing pain clinic half an hour away that does not prescribe any opioids and that Pain Clinic is academic with a fellowship. It’s in relatively big city. But I also don’t know if patients would necessarily drive half an hour to the small town to come to me rather than go to this academic center. Help!

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[BobBarker]

Just focus 100% on the PCP’s present in the town and affiliated with your hospital/group. They probably are referring everything to surgery first and then they are sending the patients for injection elsewhere.

 

[callmeanesthesia]

Here’s what’s probably happening. The PCPs have their favorite referral for injections, but when a patient is extra-needy, crazy, or just wants meds, they send them to you. Time to start cleaning house on your referrals. BobBarker is right - hit up the PCPs. Advertise your availability and the fact that every patient personally sees the doctor. Give them your cell. Offer to get patients in next day for urgent consults like a disc herniation or compression fracture (if your clinic workflow allows).

If you have the power, reject garbage referrals (“Patient screamed at me and stormed out when I told him I wouldn’t be refilling his fentanyl patches because his UDS was positive for meth and heroin. Refer to pain management.”) Better 5 good referrals than 10 bad ones.

Clean house. Start telling patients you only do opioid management in the context of multimodal treatment. If they’re not willing to try injections, or if they have a surgically treatable problem but are just afraid of surgery, they get tapered. Zero tolerance for benzodiazepines and opioids. Up your frequency of random pill counts and UDSs. You’d be amazed how many of those sweet little old folks are selling their pills or doing a little coke on the weekends. If you want to get rid of the chemical copers, require them to be enrolled in tobacco cessation (bonus: document the time you spent counseling them and bill the cessation counseling code. It ain’t much, but it’s honest work). The more you have a reputation as a hard-ass in the drug-seeker community the better.

 

[docodissi]

Here’s what’s probably happening. The PCPs have their favorite referral for injections, but when a patient is extra-needy, crazy, or just wants meds, they send them to you. Time to start cleaning house on your referrals. BobBarker is right - hit up the PCPs. Advertise your availability and the fact that every patient personally sees the doctor. Give them your cell. Offer to get patients in next day for urgent consults like a disc herniation or compression fracture (if your clinic workflow allows).

If you have the power, reject garbage referrals (“Patient screamed at me and stormed out when I told him I wouldn’t be refilling his fentanyl patches because his UDS was positive for meth and heroin. Refer to pain management.”) Better 5 good referrals than 10 bad ones.

Clean house. Start telling patients you only do opioid management in the context of multimodal treatment. If they’re not willing to try injections, or if they have a surgically treatable problem but are just afraid of surgery, they get tapered. Zero tolerance for benzodiazepines and opioids. Up your frequency of random pill counts and UDSs. You’d be amazed how many of those sweet little old folks are selling their pills or doing a little coke on the weekends. If you want to get rid of the chemical copers, require them to be enrolled in tobacco cessation (bonus: document the time you spent counseling them and bill the cessation counseling code. It ain’t much, but it’s honest work). The more you have a reputation as a hard-ass in the drug-seeker community the better.

Thank you for your insight. I am really focusing on the pcp. This rural town probably has about 10k-20k people. The pcps and I have had lunch multiple times. My concern is that a lot of the country folk here are scared of injections and just want pain meds. I try to help some people that are more reasonable but the pcps come to me and say that sometimes they don’t send the patient because they just want meds and what’s the point. I agree with them when this happens. Also alot of people don’t finish PT and it’s hard to do injections without documented PT. A lot of insurances are sticklers now and are demanding to see the Pt notes and even home PT isn’t enough apparently. How do you guys circumvent this? There are no other Providers these pcps are referring to, I know they are only sending those patients to me. I’m just worried in general about the scope of growth at this clinic being 5 days a week (the previous doc used to only be a here a couple days a week and so volumes looked “better” for them)

 

[BobBarker]

I used to work in a community of 16,000 people. You have to manage medications in these small towns. Lots of these only medication patients are willing to do injections once they are better informed and begin to Ike you.

 

[Pain Applicant1]

I'm not really understanding what you're worried about. If I understand what you're saying you're seeing between 90 to 100 patients per week and doing about 17 procedures per week and you've only been open 10 months. You're doing just fine. Ups and downs in pt volume are normal and should be expected, especially in the early stages of a practice. There is no horrible amount of procedures per week. You can run your practice however you want.

Pain pts don't get better and take a long time to die, sorry. IOW, they stick around and will get continuously cycled throughout your practice as they need to be managed. As time rolls on, you'll gear your practice to the type of pts you want to see. If you want procedures, you'll find pts who depend on them and will keep coming back to you. If you don't want opioid pts, you'll just start telling pts that you don't assume opioids anymore, etc.

Keep in mind that your medical license allows you to do many things. You can take up training in any number of other services that you can offer your pts. - suboxone, cosmetics, etc. The list is endless. Look up weekend courses if you want to pump up your volume.

Cut yourself some slack, you're doing great!

 

[SSdoc33]

so, just to summarize:

you see a lot of opioids. get few referrals for injections. receive most referrals from PCPs. and arent busy enough.

this is not a good job.

you need to get connected with a direct stream of referrals, ideally from a spine or ortho group. you will feed them surgeries, they will feed you shots. this is the only way that it is gonna work. the PCP referrals will invariably be opioids, especially in small town ohio.

#1 refuse referrals from the PCPs that only send you junk
#2 transition away from opioids as much as possible
#3 market to the ortho or spine surgeons. they see more patients and referrals will turn into more shots

 

[drrosenrosen]

It wouldn't be an SDN thread if someone wasn't advising someone to quit their job!!

 

[mid|ine]

I know the group (and am totally jealous of their business model). I would suggest that if you aren't busy enough you need to be more open to med management. Let the PCPs know you are there to help them. Be strict about who you Rx to and set low limits on how much you will manage. If that part of your practice gets to busy you can hire an NP to see refills and screen for injections (that can be a nice profit center for you).

Also, do they have any other hospitals near enough you could help at?

 

[Centurion38]

PCP's will nod their heads and say they understand that you *focus* on procedures but most, in my experience, have an ingrained bias against procedural medicine due to mindset and also prior experience with "bad actors" ie. unscrupulous pain docs or spine surgeons doing injections.

PCP's will kneejerk look at an MRI and if it says "moderate-severe stenosis" they will AUTOMATICALLY refer to neurosurgery or Ortho spine. Like a Labrador retriever, it takes a tremendous amount of patience and repetition to break them of this habit.

In the long run, having PCP's on your side would be excellent, because YOU become the gatekeeper for referrals to spine surgeons. But it could also destroy your practice.

In reality, I would focus on spine surgery and sports med practices, even Chiropractic, and just offer excellent SERVICE. Get their patients in for injections within 2 days. Overbook them. Most of all, do a good job and be nice to them and your reputation will precede you and soon enough all the spine surgeons will be sending you their shots and their mid-levels will do the same.

Bottom line- if you market to PCP's you are going to have to do a ton of opioid management for them. Those patients are extremely exhausting, litigious. I don't like "hey doc" conversations in the parking lot at 5 pm. Maybe you do?

 

[GoBeers]

Hello everyone! I am a relatively inexperienced pain physician that’s a couple years out of fellowship. I joined this hospital-based clinic that is being run by a physician run organization that owns several different hospital-based clinics throughout the state but not hospital employed. I am in Ohio. I am at the nine month mark of this job and totally this clinic has been open for 2 1/2 years. I feel like volumes have dropped but don’t think were very high in general at least for me, I’m not really sure why. I am in a rural setting and there is One other Pain Clinic about half an hour away that is completely private. There are a couple other big health systems that have a tendency to keep referrals within themselves so it’s tough. I’m not really sure what to do about volumes. I have a dedicated marketing team to help and we are doing billboards and I have lunches, give thank you cards, go to health fairs and radio ads etc. On average I have maybe 18 to 22 patients in clinic on a good day. Unfortunately there is a fair bit of medication management because some of the docs back in the day used to prescribe a decent chunk of opioids, on average I’d say my mme is 23-24 and 30-40 percent are on some opioid. However the problem is from a procedure standpoint I’m probably if lucky doing 18 procedures but on average I’m at 16. I know that is horrible. I’m at the clinic 3.5 days a week and 1 full day of procedures which never ends up being a full day because like I said I’m doing about 16 to 18 injections. There is also probably one or two no-shows on those injection days. What do I do? Is this a normal dip in volume at this time in year 2 to 3 of a clinic? Is there any scope for growth? Anything else anyone here can give me insight on? The hospital system my pain clinic is-based with has another competing pain clinic half an hour away that does not prescribe any opioids and that Pain Clinic is academic with a fellowship. It’s in relatively big city. But I also don’t know if patients would necessarily drive half an hour to the small town to come to me rather than go to this academic center. Help!

what was the volume before you came in? i feel like your volume is fine for the 9 months. doesn't it usually take 2 years for one to be fully operational? do good work, get good reputation, your schedule will fill up the way you want it to be.

 

[Pain Applicant1]

@SSdoc33 doc brings up good points but don't listen to him, jk.

Sorry, i read fast and fudged your numbers but I still stick to my original post. You're doing just fine for 9 months out and your pt volume. Just be kind to your pts and get them better and you'll be busier than you want. You'll get pts through word of mouth and once the pts say good things about you to the referring docs you'll break current referral patterns. Once you're more established you can start shredding off the pts or payers you don't want to deal with and direct the evolution of your practice.

FWIW, I looked for a catchment area of about 1:25,000 so 1 pain doc to 25k population when I first started. At that ratio, you can have the pick of the litter with your pts.

 

[SSdoc33]

@SSdoc33 doc brings up good points but don't listen to him, jk.

Sorry, i read fast and fudged your numbers but I still stick to my original post. You're doing just fine for 9 months out and your pt volume. Just be kind to your pts and get them better and you'll be busier than you want. You'll get pts through word of mouth and once the pts say good things about you to the referring docs you'll break current referral patterns. Once you're more established you can start shredding off the pts or payers you don't want to deal with and direct the evolution of your practice.

FWIW, I looked for a catchment area of about 1:25,000 so 1 pain doc to 25k population when I first started. At that ratio, you can have the pick of the litter with your pts.

thats fair.

i made my recs based on the practice that i would like to have. that is: higher injection volume, fewer opioids. painapplicant sees suboxone pts and a good deal of opioids, if im not mistaken.

definitely reach out of the nearest surgeons. they will have a built-in referral base from the PCPs and huge volumes. id start with ortho. they tend to see more patients and dont have the sort of hang-ups with inejcitons that many neurosurgeons tend to have. NSG often way overthink things and want specialized injections that are ridiculous. not always, but that is what i see.

also, it doesnt have to be just spine surgeons. i have learned that general ortho, sports, joint, shoulder guys -- they are all good referral sources. these docs will invariably see a lot of spine work, but have no interest in actually treating spine. that is where you come in. the hip and shoulder guys often cant tell if its a spine or joint problem. enter docodissi. a quick hip or shoulder injection is a good way to fill injection slots and it comes with an easy 99204.

 

[GoBeers]

thats fair.

i made my recs based on the practice that i would like to have. that is: higher injection volume, fewer opioids. painapplicant sees suboxone pts and a good deal of opioids, if im not mistaken.

definitely reach out of the nearest surgeons. they will have a built-in referral base from the PCPs and huge volumes. id start with ortho. they tend to see more patients and dont have the sort of hang-ups with inejcitons that many neurosurgeons tend to have. NSG often way overthink things and want specialized injections that are ridiculous. not always, but that is what i see.

also, it doesnt have to be just spine surgeons. i have learned that general ortho, sports, joint, shoulder guys -- they are all good referral sources. these docs will invariably see a lot of spine work, but have no interest in actually treating spine. that is where you come in. the hip and shoulder guys often cant tell if its a spine or joint problem. enter docodissi. a quick hip or shoulder injection is a good way to fill injection slots and it comes with an easy 99204.

that's why i appreciate neurosurgeons though, they actually spend a tiny amount of time examining and even creating possible differentials.
what i see with ortho is if it's not a clear cut joint replacement case, then refer to pain management without any further discussion, workup, prognosis, expectation set up.

one of the more recent egregious case was ortho surgeon referred me a "sciatica" patient when in fact she had acetabular and pubic rami fractures. 🤦‍♂️

 

[SSdoc33]

that's why i appreciate neurosurgeons though, they actually spend a tiny amount of time examining and even creating possible differentials.
what i see with ortho is if it's not a clear cut joint replacement case, then refer to pain management without any further discussion, workup, prognosis, expectation set up.

one of the more recent egregious case was ortho surgeon referred me a "sciatica" patient when in fact she had acetabular and pubic rami fractures. 🤦‍♂️

NSG may give better referrals

ortho will give MORE referrals

 

[cowboydoc]

Half my referrals come from NSG/Ortho. The NSG is great for ruling out surgical indications and most are appropriate for interventional procedures. (hit rate is phenomenal). Ortho sends a lot of patients, almost always for non-operative "hip pain" or "spinal stenosis" for all issues they think are coming from the spine.

After a year, you should start getting a lot of repeat customers for another RFA, etc. Patients will talk positively about you over coffee and there friends will come in.

In the meantime, enjoy working less than full time and fill the extra time with something productive. Don't be a gas, filling all available space. i.e. don't fill your whole day with the 8 visits. Get in, get done and spend your time wisely. That way you won't have to break bad habits when you become busier.

 

[Pain Applicant1]

When I first started I was very procedure-oriented and I prescribed very few controlled substances. I probably lost half of my pts back then which was fine. I was busy enough that it didn't matter.

Now, I dread doing procedures and enjoy speaking more with my pts. I now manage mostly suboxone and lower-dose low-risk opioid pts and am happy where I am with practice. My first preference for pts would be my suboxone pts.

With all of that said, I find my practice boring but I think that would occur no matter what I did in medicine at this point. I think it's listening to pt's complaints and being responsible for taking care of them that bores me. That makes me sound like a creep, ugh!

I still think medicine is a great field, is lucrative, and at the end of the day, it's still very rewarding to help people out. The pros >>>>>cons!!

 

[cowboydoc]

When I first started I was very procedure-oriented and I prescribed very few controlled substances. I probably lost half of my pts back then which was fine. I was busy enough that it didn't matter.

Now, I dread doing procedures and enjoy speaking more with my pts. I now manage mostly suboxone and lower-dose low-risk opioid pts and am happy where I am with practice. My first preference for pts would be my suboxone pts.

With all of that said, I find my practice boring but I think that would occur no matter what I did in medicine at this point. I think it's listening to pt's complaints and being responsible for taking care of them that bores me. That makes me sound like a creep, ugh!

I still think medicine is a great field, is lucrative, and at the end of the day, it's still very rewarding to help people out. The pros >>>>>cons!!

You're so positive. You sound like one of those "health and wealth" preachers on TV.

 

[Pain Applicant1]

You're so positive. You sound like one of those "health and wealth" preachers on TV.

LOL! I just don't want to sound discouraging to anyone, especially younger docs. It's just the way my practice is set up but honestly, it's better to have boredom in a practice. It equals stability. It's not good to have "exciting" things going down in the office.