Pro's and Con's of accepting Medicaid...

[drusso]

Those of you that accept Medicaid, do you feel that the payment is adequate for the resources that the patients require?

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[Disciple]

Straight Medicaid?

Or managed Medicaid, Medicaid as secondary to Medicare, etc.?

 

[bedrock]

No, which is why I don't accept it.

 

[Aether2000]

Pro- helping humanity, especially the group of disadvantaged that have the highest health care needs
Con- 65% substance abuse/drug addiction/diversion rate, much higher incidence of illicit drug use, much higher incidence of cigarette smoking, very high no-show/no-call rate, much lower compliance rate for treatments proposed even if 100% paid by Medicaid, reimbursement rates that are much lower than Medicare, low income women have nearly a 50% higher obesity rate compared to those of higher incomes complicating treatment, preauthorization required for every X-ray or every aspirin, constantly changing rules that may change daily, legal risk to physicians if attorney generals deem care unnecessary- the physician is charged with criminal fraud.

Accordingly, we do not accept any Medicaid

 

[Ducttape]

On the other hand, accepting medicaid does allow a system to improve the health of a population and may reduce the unnecessary expenditures and risky behaviors (esp excessive opioids)

 

[lobelsteve]

On the other hand, accepting medicaid does allow a system to improve the health of a population and may reduce the unnecessary expenditures and risky behaviors (esp excessive opioids)

I do not think it does at all. It just shuffles care outpatient and away from the ER. But health improvement?

 

[Ducttape]

that's the hope.

reduce reliance on opioids.
reduce availability of opioids in the community.
teach safe use, appropriate use for those patients being prescribed opioids by PCPs.
encourage PCPs who see primarily Medicaid about appropriate use.
teach PCPs about appropriate use, screening, monitoring, especially those who take primarily Medicaid (ie hospital clinics)
reduce reliance on surgery, especially spine fusions.
encourage increased functionality.
encourage better mental health care.
avoid ER, hopefully help with ER crowding, possibly reduce high cost of ER medicine on society (and ER visit is a lot more expensive to the system than, for example, an office visit)

 

[SSdoc33]

crappy medicaid reimbursement justifies the SOS differential. this may be good or bad, depending on who you ask (or where you work)

 

[SSdoc33]

that's the hope.

reduce reliance on opioids.
reduce availability of opioids in the community.
teach safe use, appropriate use for those patients being prescribed opioids by PCPs.
encourage PCPs who see primarily Medicaid about appropriate use.
teach PCPs about appropriate use, screening, monitoring, especially those who take primarily Medicaid (ie hospital clinics)
reduce reliance on surgery, especially spine fusions.
encourage increased functionality.
encourage better mental health care.
avoid ER, hopefully help with ER crowding, possibly reduce high cost of ER medicine on society (and ER visit is a lot more expensive to the system than, for example, an office visit)

this is yeoman's work.

unfortunately, it pays like crap.

 

[Aether2000]

Unfortunately free care results in increasing use of healthcare resources including er departments with no improvement in physical health. http://www.usnews.com/news/blogs/da...-expansion-may-increase-emergency-room-visits

 

[drusso]

Con- 65% substance abuse/drug addiction/diversion rate, much higher incidence of illicit drug use, much higher incidence of cigarette smoking, very high no-show/no-call rate, much lower compliance rate for treatments proposed even if 100% paid by Medicaid, reimbursement rates that are much lower than Medicare, low income women have nearly a 50% higher obesity rate compared to those of higher incomes complicating treatment, preauthorization required for every X-ray or every aspirin, constantly changing rules that may change daily, legal risk to physicians if attorney generals deem care unnecessary- the physician is charged with criminal fraud. Accordingly, we do not accept any Medicaid

So, how do you "manage" the risk on the operational level? No-shows, compliance, limited access to resources? What systems and procedures are in place to not waste physician FTE doing non-reimbursable work on the vulnerable and risky population?

 

[Aether2000]

Outside of going to their house/apartment/under bridge to see them we could not come up with a viable solution.

 

[deleted472101]

Some are good people. Very small percentage and hard to weed out from referrals

 

[Dr. Ice]

So what's gonna happen if Billary tries to mandate docs to take Medicaid?

And this is where all the old timers will say.."I'm so relieved to be done with this ---- soon"

 

[bedrock]

That, and I expect pp docs would become adept at someone having a 6 month wait for a single caid patient.

If the liberals try to turn highly educated physicians into slaves, resistance will be great.

 

[Dr. Ice]

Cause we have been so been so successful at resistance thus far..

I anticipate accepting caid will be the law of the land at some point. I guess it's a good thing my group is already taking it..or at least I tell myself that to make me feel better

 

[geauxg8rs]

I love that Medicaid will only pay for cheap crappy drugs that I won't prescribe. Their formula consists of methadone, soma, hydrocodone.

 

[101N]

I pretty much agree with Duct, and I think his heart is in the right
place. But, IMO Medicaid dollars would be better spent by bolstering
behavioral health boots on the ground rather than referrals to a
traditional IPM pain management clinic. This cohort of patients
won't benefit from injections or opioids.

Having seen lots, and lots of Medicaid patients these past
two years has lead me to believe that the attached graph is right.
But with the caveat that, within the CNP medicaid population,
the social and environmental factors and individual behaviors
contributions are much, much larger than depicted, while health
literacy is much lower than in commercial and Medicare insurance.

I think the ACA - I'm in a rural blue state - has created a 'new' cohort of
'patients' heretofore unstudied in the US because they were never
before insured. Treating the social/environmental + individual behaviors
in a traditional medical model is too costly and doesn't address the root cause
of the distress. The big insurer in OR found this out the hard way and
has had to scale back operations due to losses sustained due to an
underestimation of the cost of caring for these newly insured as well as
the Feds risk corridor recalculations.

If you really want to treat this cohort it can't be through the traditional
PA for narcs > IPM doc for injections model. That model makes money
for the IPM doc but it's costly and not beneficial to these patients. The
CCO's know this and the hospital systems are becoming aware. In my
area a hospital system shut this model down, closed the pain clinic, because
the primary care docs and hospital admin realized that pills and shots
wasn't working, the patients never got better and stayed on opioids. Now
the same hospital system is trying to come up with something that
will work, and find someone willing to staff it.

This is pain management as a money saver, not money maker. That's
an entirely different culture than what IPM fellowships inculcate.

 

[Ducttape]

Agree with 101n, however, mental health is in a conundrum itself, with the inability for them to confirm and inform patients that these people do not possess medically treatable disease. Several times, i have recieved referrals from paych stating that they were unsure about treatment and whether patients needed medical treatment for chronic pain

The majority of this work for medicaid population is encouraging exercise, home exercise, and discussion and mental health referrals.... It definitely requires a forward thinking medical system at its core...

 

[drusso]

Every evidence-based pain specialist should send this message to Medicaid policy-makers: You can't make chicken salad out of chicken ****.

Non-evidenced based administrative burdens, inequity in reimbursement for managing high needs populations, lack of payment for wrap around services, and lack of payment for integrated behavioral health in the pain specialists office causes harm and displaces pain care into more expensive and less efficient venues of care.

 

[101N]

Agree with 101n, however, mental health is in a conundrum itself, with the inability for them to confirm and inform patients that these people do not possess medically treatable disease. Several times, i have recieved referrals from paych stating that they were unsure about treatment and whether patients needed medical treatment for chronic pain

The majority of this work for medicaid population is encouraging exercise, home exercise, and discussion and mental health referrals.... It definitely requires a forward thinking medical system at its core...

I think the problem you're identifying here is psychiatry specific. Most psychiatrists are out of their element if it's not depression/anxiety/biopolar disoder and Rx's medications. A lot of what we see and try to treat in a medicaid pain clinic existential suffering, catastrophzing, impaired coping, a lack of resiliency, interpersonal crisis/distress, etc. IMO, psychology or seasoned LCSW's are better suited to serving the needs of this audience: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215913/

 

[lobelsteve]

I think the problem you're identifying here is psychiatry specific. Most psychiatrists are out of their element if it's not depression/anxiety/biopolar disoder and Rx's medications. A lot of what we see and try to treat in a medicaid pain clinic existential suffering, catastrophzing, impaired coping, a lack of resiliency, interpersonal crisis/distress, etc. IMO, psychology or seasoned LCSW's are better suited to serving the needs of this audience: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215913/

That is correct. Problem is the audience is not captive and will seek care elsewhere. The ER, crap clinics, dealers.

 

[101N]

The medicaid audience is more captive. The IPM crowd - some of the most aggressive opioid
prescribers in my state - won't see them because procedures aren't covered. EDs don't really want
to see them and the PDMP will flush out the seekers. Most PCP's would prefer not to see CNP eitherand they are ill equipped to do so. Nothing prevents CCO's from electing to partner with preferred providers including pain management.

There is room for a level of specialty care like Duct talks about. One with pain management and
behavioral health bundled together. It might look something like this.

 

[Aether2000]

But......is there really any EBM to support the use of psychiatric intervention or behavioral intervention specifically in the Medicaid population, that has a very different view and response to the medical system compared to other patient groups? Aren't we really repeating with psychiatry what has been done with opioids- throwing interventions at a diagnosis of chronic pain without sufficient evidence? And are there no down sides to psychiatric care? Certainly I have seen them in my practice with patients returning on an anticonvulsant, an antipsychotic, and two antidepressants in addition to klonopin......patients became zombies. On the other hand, perhaps taking a whining-non-working-opioid seeking-prescription drug abusing-illegal drug using-drug diverting-histrionic-personality disordered-depressed-thieving patient into a zombie may not be such a bad idea..... But of course most psychiatrists and psychologists and LSW will not see Medicaid in my state, largely for the same reasons we won't.

 

[Disciple]

Having seen lots, and lots of Medicaid patients these past
two years has lead me to believe that the attached graph is right.
But with the caveat that, within the CNP medicaid population,
the social and environmental factors and individual behaviors
contributions are much, much larger than depicted, while health
literacy is much lower than in commercial and Medicare insurance.

This is pain management as a money saver, not money maker. That's
an entirely different culture than what IPM fellowships inculcate.

I'm in an area with a lot of ethnic diversity/sizeable ethnic populations, who are also participants in the managed Medicaid expansion.

I've found that certain groups, who may not be far removed from their country of origin, rarely ask for or take opioid pain meds, or opt for elective surgeries/procedures(Medicaid enrolled).

I suppose it's un-PC to put a strong emphasis on social and environmental factors.

As for establishing a savings based model, why not replicate the Kaiser model? They seem to be the leaders when it comes to system savings.

 

[lobelsteve]

The Kaiser program is a bunch of crap. I just reviewed a thousand pages on a single patient who is seen three times a week from numerous providers in the Kaiser program. He went to PT / 50 visits for this year he had 5 epidurals he was not on narcotics thank goodness but he got no better and he wanted to be disabled interviews to work this pain started in the ribs was in the abdomen groin penis and went down the left leg the MRI did not show anything concordance. They kept trying and trying to make him better when it was clear he had no organic pathology

 

[Disciple]

Sounds like his treating doctors' poor judgment for the overtreatment.

But, I believe Kaiser has a chronic pain program as well, cognitive-behavioral focused. Group therapy, but maybe that's how the savings are realized.

Can any Kaiser doctors here comment?

 

[lobelsteve]

Sounds like his treating doctors' poor judgment for the overtreatment.

But, I believe Kaiser has a chronic pain program as well, cognitive-behavioral focused. Group therapy, but maybe that's how the savings are realized.

Can any Kaiser doctors here comment?

Yup, he was in that, and seeing PT, NP, Neuro, spine surgery, and PMR. All for same complaint. Also saw uro or GS for groin pain. 3 MRI in 1 year, us scrotum, ct abd/pelvis. ER visits. All for ill defined pain.

 

[hyperalgesia]

Let me guess, he was 35y/o, healthy male? These guys come in, absolutely convinced they are sick and determined to get medical attention. Not completely excusing the medical system but you sometimes can't stop a patient who wants to go on a wild goose chase. In the old days, he would simply run out of money. Now that we have infinite money for healthcare, he'll just keep on truckin'.

 

[101N]

Sounds like his treating doctors' poor judgment for the overtreatment.

But, I believe Kaiser has a chronic pain program as well, cognitive-behavioral focused. Group therapy, but maybe that's how the savings are realized.

Can any Kaiser doctors here comment?

Kaiser has a lot of VERY smart docs. Over time they tend to become
administrators. Over all their system is one the best, if not the best,
for urban medicine in the US.

"I suppose it's un-PC to put a strong emphasis on social and environmental factors."
Yes, but if you're paying for care - and we are - it's reality based medicine. Some on this thread pretend to be advocates for pain patients - & thereby enabling their dysfunctional pain behavior - strictly to increase their market share.

 

[Aether2000]

So does Kaiser have any demonstrably better outcomes for the medicaid chronic pain population compared to any other system? In my area psychologists charge cash $150 per hour and up. Forget about seeing a psychiatrist. We have no addictionologists that see medicaid. None of the pain docs in the area see medicaid...i get 10 calls a day for the past 5 years asking if we take medicaid.... The only pain docs that employ psych on their staff are scamming patients with out of network surgery center charges and mandatory genetic testing on every patient.

 

[Ducttape]

i may agree with psychiatrists putting patients on multiple medications, but it is usually not in the scope of practice for psychologists.

a counterargument (hopefully not one of drusso's Strawman arguments) is that risk mitigation, decreased opioid supply in for the patient and reduced prescription opioids in the community, and reduced use of expensive interventional procedures is preferable to what more commonly occurs. steve, no offense, but i could equally see that patient getting into a pure IPM, being put on COT, having multiple TF injections, then spinal cord stim trial, followed by implant, then a short while later getting explanted, then having a ITPump placed...

yes, i know that the argument can also be made that reducing prescription opioid availability has lead to increased heroin use...

 

[Disciple]

Kaiser has a lot of VERY smart docs. Over time they tend to become
administrators. Over all their system is one the best, if not the best,
for urban medicine in the US.

"I suppose it's un-PC to put a strong emphasis on social and environmental factors."
Yes, but if you're paying for care - and we are - it's reality based medicine.

Yes, but who's running things (Medicare, etc.) right now?

How about in your state, or previous state of employment?

They will never honestly tell the masses, "This is reality, and this is what you're going to get".

Which is why I could get behind the idea of Pain trained psychiatrists being the front line for chronic pain management.

Let them (in tandem with psychologists) do what they need to do, without "offending" anyone.

The physical component can be outsourced, or addressed first, by other departments (Ortho Spine, Neurosurg, Anesthesia, PMR, Neurology, etc.).

Isn't that what Kaiser does?

 

[Disciple]

So does Kaiser have any demonstrably better outcomes for the medicaid chronic pain population compared to any other system? In my area psychologists charge cash $150 per hour and up. Forget about seeing a psychiatrist. We have no addictionologists that see medicaid. None of the pain docs in the area see medicaid...i get 10 calls a day for the past 5 years asking if we take medicaid.... The only pain docs that employ psych on their staff are scamming patients with out of network surgery center charges and mandatory genetic testing on every patient.

When I see patients go through functional restoration programs. The functional gains, decreased reliance on pain meds, etc. are realized when the patient is willing to/able to change their mindset, with the help of the psychologist.

Similar to Addiction Medicine, if the patient is not ready to accept help, the treatment efforts are doomed to failure.

If we are talking about public health, for a certain percentage of chronic pain patients, we may have to accept that the best we can do is try to keep the costs down, and minimize the damage.

 

[Aether2000]

When I see patients go through functional restoration programs. The functional gains, decreased reliance on pain meds, etc. are realized when the patient is willing to/able to change their mindset, with the help of the psychologist.

Similar to Addiction Medicine, if the patient is not ready to accept help, the treatment efforts are doomed to failure.

If we are talking about public health, for a certain percentage of chronic pain patients, we may have to accept that the best we can do is try to keep the costs down, and minimize the damage.

 

[Aether2000]

The question remains does psych or behavioral medicine work for the medicaid population. I cannot find evidence for this in a pubmed search. It would be disingenuous if not potentially damaging to embrace and recommend expensive untested therapies for a large segment of the chronic pain population simply because we do not know what else to do.

 

[Aether2000]

I have not seen medicaid patients willing to engage in functional restoration programs with any significant positive outcome and since psych is unavailable to the medicaid population it is speculative as to improved outcomes.

 

[drusso]

A counterargument (hopefully not one of drusso's Strawman arguments) is that risk mitigation, decreased opioid supply in for the patient and reduced prescription opioids in the community, and reduced use of expensive interventional procedures is preferable to what more commonly occurs.

Strawman?? Medicaid doesn't recognize through payment quality pain care...ample evidence abounds...

 

[101N]

Business as usual just isn't going to pencil out in caring for this cohort. If you take the 45y/o -54y/o
CNP cohort - probably the highest risk of bad outcome - an OR CCO is given about $7-8K/yr to manage
all of their care. Even before being diagnosed with CNP the cost of managing the patients described below
was $20K. It's hard not to predict that specialty care and pharmacy costs are going to be a big target.

Pain Pract. 2015 Oct 7. doi: 10.1111/papr.12357. [Epub ahead of print]
Cost Burden of Chronic Pain Patients in a Large Integrated Delivery System in the United States.
Park PW1, Dryer RD2, Hegeman-Dingle R1, Mardekian J1, Zlateva G1, Wolff GG3, Lamerato LE3.
Author information

Abstract
OBJECTIVES:
To estimate all-cause healthcare resource utilization and costs among chronic pain patients within an integrated healthcare delivery system in the United States.

METHODS:
Electronic medical records and health claims data from the Henry Ford Health System were used to determine healthcare resource utilization and costs for patients with 24 chronic pain conditions. Patients were identified by ≥ 2 ICD-9-CM codes ≥ 30 days apart from January to December, 2010; the first ICD-9 code was the index event. Continuous coverage for 12 months pre- and postindex was required. All-cause direct medical costs were determined from billing data.

RESULTS:
A total of 12,165 patients were identified for the analysis. After pharmacy, the most used resource was outpatient visits, with a mean of 18.8 (SD 13.2) visits per patient for the postindex period; specialty visits accounted for 59.0% of outpatient visits. Imaging was utilized with a mean of 5.2 (SD 5.5) discrete tests per patient, and opioids were the most commonly prescribed medication (38.7%). Annual direct total costs for all conditions were $386 million ($31,692 per patient; a 40% increase from the pre-index). Pharmacy costs comprised 14.3% of total costs, and outpatient visits were the primary cost driver.

CONCLUSIONS:
Chronic pain conditions impose a substantial burden on the healthcare system, with musculoskeletal conditions associated with the highest overall costs. Costs appeared to be primarily related to use of outpatient services. This type of research supports integrated delivery systems as a source for assessing opportunities to improve patient outcomes and lower the costs for chronic pain patients.

 

[nvrsumr]

I have alot of medicaid patients who work 40 hour/wk and have dependents. They do great with shots. Overall alot of unmet musculoskeletal needs. On the other hand i dont write for narcs so have selected the population that gets better. My choice to enjoy my work and help needy patients. Win:win except for my wallet.

 

[drusso]

Business as usual just isn't going to pencil out in caring for this cohort. If you take the 45y/o -54y/o
CNP cohort - probably the highest risk of bad outcome - an OR CCO is given about $7-8K/yr to manage
all of their care. Even before being diagnosed with CNP the cost of managing the patients described below
was $20K. It's hard not to predict that specialty care and pharmacy costs are going to be a big target.

Pain Pract. 2015 Oct 7. doi: 10.1111/papr.12357. [Epub ahead of print]
Cost Burden of Chronic Pain Patients in a Large Integrated Delivery System in the United States.
Park PW1, Dryer RD2, Hegeman-Dingle R1, Mardekian J1, Zlateva G1, Wolff GG3, Lamerato LE3.
Author information

Abstract
OBJECTIVES:
To estimate all-cause healthcare resource utilization and costs among chronic pain patients within an integrated healthcare delivery system in the United States.

METHODS:
Electronic medical records and health claims data from the Henry Ford Health System were used to determine healthcare resource utilization and costs for patients with 24 chronic pain conditions. Patients were identified by ≥ 2 ICD-9-CM codes ≥ 30 days apart from January to December, 2010; the first ICD-9 code was the index event. Continuous coverage for 12 months pre- and postindex was required. All-cause direct medical costs were determined from billing data.

RESULTS:
A total of 12,165 patients were identified for the analysis. After pharmacy, the most used resource was outpatient visits, with a mean of 18.8 (SD 13.2) visits per patient for the postindex period; specialty visits accounted for 59.0% of outpatient visits. Imaging was utilized with a mean of 5.2 (SD 5.5) discrete tests per patient, and opioids were the most commonly prescribed medication (38.7%). Annual direct total costs for all conditions were $386 million ($31,692 per patient; a 40% increase from the pre-index). Pharmacy costs comprised 14.3% of total costs, and outpatient visits were the primary cost driver.

CONCLUSIONS:
Chronic pain conditions impose a substantial burden on the healthcare system, with musculoskeletal conditions associated with the highest overall costs. Costs appeared to be primarily related to use of outpatient services. This type of research supports integrated delivery systems as a source for assessing opportunities to improve patient outcomes and lower the costs for chronic pain patients.

...Our CCO is spending $15,000 per dose of drug to treat hepatitis C...and wants to build public housing projects for low income people...

Maybe if taxpayer-paid Medicaid bureaucrats got out of the business of subsidizing private insurance companies and CCO's were re-organized with public meeting laws and local control and accountability then there were would be more money to pay for chronic pain care..

 

[bedrock]

I have alot of medicaid patients who work 40 hour/wk and have dependents. They do great with shots. Overall alot of unmet musculoskeletal needs. On the other hand i dont write for narcs so have selected the population that gets better. My choice to enjoy my work and help needy patients. Win:win except for my wallet.

It's nice that you have a medicaid population that can be helped. I do feel for the people on medicaid that are just regular hard-working people trying to support their families by working full time and need some help treating their msk pains. I would be willing to see such patient even if I didn't profit much from it.

Unfortunately in my area, those kind of patients only represented about 5-10% of the medicaid patients I saw, when I used to accept medicaid.
The other 90% of medicaid patients were crazy, drug or disability seeking wastes of skin, who consumed an enormous % of my staff's time, so I stopped taking medicaid. My staff and I were so much happier after I made this decision.

 

[Aether2000]

That was my population also! Stopped Medicaid and my practice was immediately much more tolerable.

 

[Papa Lou]

The medicaid audience is more captive. The IPM crowd - some of the most aggressive opioid
prescribers in my state - won't see them because procedures aren't covered. EDs don't really want
to see them and the PDMP will flush out the seekers. Most PCP's would prefer not to see CNP eitherand they are ill equipped to do so. Nothing prevents CCO's from electing to partner with preferred providers including pain management.

There is room for a level of specialty care like Duct talks about. One with pain management and
behavioral health bundled together. It might look something like this.

I thought of creating this system in my area before I saw it here. How long has this been going on at your state, 2012? I'm in infancy stages of precontemplation.

 

[Ducttape]

The question remains does psych or behavioral medicine work for the medicaid population. I cannot find evidence for this in a pubmed search. It would be disingenuous if not potentially damaging to embrace and recommend expensive untested therapies for a large segment of the chronic pain population simply because we do not know what else to do.

is it disingenuous and potentially damaging to embrace COT, or even IPM, since we do not evidence for benefit for these therapies?

if psych or CBT helps in the general population, should we base lack of benefit/potential harm entirely on socioeconomic status?

CBT is most likely to be less expensive, in the short and long run, than IPM +/- COT.

we do know the medicaid population is at higher risk for opioid overdose. in my opinion, providing an alternative and reducing exposure is preferable, especially if the alternative is for PCPs and those who have no interest or concern about risk mitigation to decide.

a "do no harm" model maybe...

 

[Aether2000]

I am not so sure it is a do no harm model. I also disagree it is practical or effective in this particular population that is happy to make an appointment in which opioids are involved but routinely skip out on physical therapy, IPM, and when rarely available, psychology. The psychologists and psychiatrists even in systems that accept Medicaid, limit the availability of appointments to this population because they understand their time and services are simply not valued by Medicaid, and it ends up being a waste of their time due to non-compliance and no-shows. Therefore, given a completely different moral compass than other patient groups, it is not reasonable to assume tacitly that behavioral counseling would have the desired outcome or can be equated to outcomes from other patient groups. Sometimes the answer is "we don't have an answer" rather than opening another pandoras box trying to placate a population that has a completely different agenda than most patients.

 

[Ducttape]

Yet it is fine for pain medicine to see WC patients who, for a very significant proportion, have ulterior motives for seeing us, right?

Better to do nothing for a group that has a higher noncompliance rate than to try to do something? We justify not treating because of fiduciary reasons?

They will be seen - but by providers who are not qualified or even interested. And we wonder why other physicians arent following our lead to do what we say they should be doing re opioids. "Do as pain medicine says? Why? They wont see these patients."

I think pain medicine and psych/addiction are one if the few - if not the only - specialties that refuses to see its underserved clientele because they "dont get better" or "dont show up"...

 

[Aether2000]

Perhaps it is a tacit admission that we cannot help everyone, and the sooner we realize that, the less out wasteful financial expenditures the health care system will have to bear. And it is ok to tell other specialties and insurers that opioids are contraindicated and that IPM and psych will not help.

 

[drusso]

Do you feel VALUED as a professional by Medicaid? When you pick up a phone to get help with a billing issue do you get great customer service from them? When you interact with the contract representative do you feel like they're bargaining in good faith or do you feel like they have a "take it or leave it" attitude?

Maybe the BEST way to reform ANY system is to walk out.

 

[Ducttape]

I would respectfully disagree.

first, by giving up, (especially if it is based on socioeconomic status), do we run the risk of having reimbursements cut or completely stopped? after all, if we accept that we cannot help Medicaid patients, then Medicaid and probably afterwards Medicare will stop payments for treatment. if that is the case, it is not a long shot to see that private insurances may follow suit, or at least cut back reimbursements significantly...

second, we are making assumptions that these interventions are not helpful because the data has not been "mined". as with epidurals, facet joint injections, EBM is not as robust as we would like. but because there is a financial incentive to do so, then many pain providers continue to perform these procedures. not to be too cynical, but perhaps financial responsibility should be only a small part of our decision making process...

now I am not suggesting that PP providers be required to see Medicaid. far be it. no PP should be forced to do what they are uncomfortable with.

but I am suggesting that hospital based programs, those that are reimbursed throughout the system by Medicaid, should. and I am arguing that the SOS differentials that some on this board rail about make a difference to these places, since financial responsibility does seem to predominate in discussions on whether a pain clinic stays in existence...