Will pain come back around?

[klumpke]

Hi All,

Currently resident looking into pain and have been seeing a lot of posts about the current state of pain- slashed reimbursement, saturation in desirable cities, etc. I also have seen a lot about anesthesiologists flocking back to the OR give the insanity of their job prospects atm.

As many of these things work sort of sinusoidally, my question is- do we think pain will come back around?

Is there a future where older pain docs get fed up with slashed reimbursements and retire en masse? I know many of the pain fellowship spots are going unfilled, is this setting up for a big supply and demand gap? Will pay/reimbursement reflect this potential need?

TIA for the insight!!

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[luckybuck]

Also very interested in this question as a current resident.

 

[lobelsteve]

Pain never went away.

 

[TheLoneWolf]

Pain will never go away. Every living person is a potential patient. In terms of saturation, yeah its a longstanding problem. Falling reimbursement is the norm in all fields. Pain is an easy target. Read ASIPP, CMS proposed 9% cuts to pain codes across the board annually and with heavy negotiation, cuts are now 4 ish percent annually. Not even factoring in inflation.

If you are thinking sinusoidal, I will tell you I don't. Most of medicine is going off the cliff with some demanding we step on the gas and others politely requesting we occasionally pump the breaks but destination is the same.

 

[Bostonspine]

So I think few people are doing pain for the money cause you can make more doing the OR or the same doing inpatient or subacute on the PMR side… still if you want a predictable work schedule with no real emergencies and light call responsibilities it’s hard to beat… outpatient neurology in My area is dead dead, Rheum is impossible sill like six pain practices

 

[MitchLevi]

By all means, if yall think pain sucks and doesn't make any money please do something else. I'm always looking for new pts, and I can squeeze in one more tomorrow if I have to...

 

[Orin]

It's hard at that stage for trainees to realize that optimizing for money now may not be be great for lifestyle or satisfaction later.

If you're ambivalent about doing a fellowship, then don't.
If you're doing it for financial stability/opportunity, then you're going to deal with the economic ups and downs.
If you're doing it because you actually enjoy and value that work, then you're going to be fine either way with an anesthesia base to fall back on.

I counsel people to make the decision based on the end they want rather than that first contract in 3 - 4 years. If you're struggling to decide, sit down and think about the type of practice setting you want to be in, academic/hospital/private/etc. Use a post-call or vacation day to shadow some attendings out there. See what the finished product is like and think about what you'd rather be doing in your 40s, 50s, etc. Compare that to the finished product in another fellowship if you want. Most of the time when you're training, you have zero idea what the attending is actually doing minute to minute, so really figure that out and see what reality is like outside the training hospitals.

 

[Agast]

I’ll echo the above. Pain is cut the same way everything else has been cut.

Anesthesiology reimbursement didn’t suddenly go up by the way. The employed salaries are higher but the billing is the same. This means whomever is hiring you is lowering their cut of your collections.

 

[RoloTomassi]

Also remember that not all anesthesia or pain jobs are the same. I know anesthesiologists that do ASC plastics/GI/pain that have really cush hours, no call. Pain jobs may have similar hours but can vary considerably. My point is choose what you enjoy, then make it fit the lifestyle, revenue you want.

 

[bedrock]

Hi All,

Currently resident looking into pain and have been seeing a lot of posts about the current state of pain- slashed reimbursement, saturation in desirable cities, etc. I also have seen a lot about anesthesiologists flocking back to the OR give the insanity of their job prospects atm.

As many of these things work sort of sinusoidally, my question is- do we think pain will come back around?

Is there a future where older pain docs get fed up with slashed reimbursements and retire en masse? I know many of the pain fellowship spots are going unfilled, is this setting up for a big supply and demand gap? Will pay/reimbursement reflect this potential need?

TIA for the insight!!

Pain will pay less than anesthesia per hours worked. True now and more so when you finish. I don’t see pain suddenly paying a lot more in 5 years, as the barrier to entry is lower with unaccredited fellowships.

But pain docs having a higher top potential pay if they are practice owners.

They also have more practice freedom.

However, I wouldn’t do a pain fellowship just to make more money.

Anesthesia still wins in $ per hours worked.

 

[powermd]

The problems that lead patients to our office are never going away, and there is no shortage of people who attempt to treat these folks and fail miserably. I think there will always be a niche for a great pain specialist. You just have to find the right community where that type of practice can thrive.

Stick with anesthesia if all you want is a job someone else hands you on a silver platter.

 

[mdo1738]

Pain isn’t dead. I think there’s something to be said for a “rising tide lifts all boats” concept. I was looking for my first job last year while the anesthesia market was hot. There certainly were jobs that paid significantly less than anesthesia, but overall there were a lot of places with competitive pay. While most of us probably wouldn’t actually go back to the OR, the anesthesia market is desperate enough that many jobs would pay good money for someone who hasn’t touched a laryngoscope for a while. So that elevates pain pay a bit as well I feel like.

And as a new grad, I had no trouble finding a pain job that paid more and required less hours than any anesthesia job I saw.

 

[Ronin1]

I make more per hour doing pain than anesthesia. Hands down. And that’s as an employee in a Hopd system. Average 32 hours a week no call /nights/weekends.

 

[MitchLevi]

This sounds like the OP is listening to the wrong ppl, namely academic attendings who are largely divorced from private practice and have no idea what an RFA probe costs. They tend to want everyone to stay in academics.

 

[BobBarker]

There was pain when we rose out of the primordial soup. There will be pain when we fall back into it.

 

[Pain Applicant1]

Hi All,

Currently resident looking into pain and have been seeing a lot of posts about the current state of pain- slashed reimbursement, saturation in desirable cities, etc. I also have seen a lot about anesthesiologists flocking back to the OR give the insanity of their job prospects atm.

As many of these things work sort of sinusoidally, my question is- do we think pain will come back around?

Is there a future where older pain docs get fed up with slashed reimbursements and retire en masse? I know many of the pain fellowship spots are going unfilled, is this setting up for a big supply and demand gap? Will pay/reimbursement reflect this potential need?

TIA for the insight!!

You're probably correct all the way around. Things will always shift and cycle. For me personally, I've always tried to find the opposite side of the crowd and it's worked out decently.

 

[drrosenrosen]

In a sense, people are always complaining and predicting how bad things are going to be in the future. When I was a resident 15 years ago, people were predicting that within 10 years there wouldn't be anesthesiology jobs anymore because we'd be replaced by CRNAs. When I was a pain fellow people were going on and on about declining reimbursements etc. We will continue to bitch and moan, collectively, about every drop in reimbursement, which will continue to happen drip by drip, while at the same time continuing to be some of the highest paid people in the country. Do what you want to be doing for the next 30+ years.

 

[drusso]

Hi All,

Currently resident looking into pain and have been seeing a lot of posts about the current state of pain- slashed reimbursement, saturation in desirable cities, etc. I also have seen a lot about anesthesiologists flocking back to the OR give the insanity of their job prospects atm.

As many of these things work sort of sinusoidally, my question is- do we think pain will come back around?

Is there a future where older pain docs get fed up with slashed reimbursements and retire en masse? I know many of the pain fellowship spots are going unfilled, is this setting up for a big supply and demand gap? Will pay/reimbursement reflect this potential need?

TIA for the insight!!

Pain was the dream of the 1990's. It peeked pre-Obamacare. Let's be honest...our field is a mess. Our fellowship programs don't innovate or produce much usable research. Pain doctors got run over by the opioid epidemic, CDC guidelines, PROP, private equity, mid-level incursion, and general government interference.

If I were you, I'd leverage my medical degree to focus on non-clinical areas--AI, informatics, genomics, and financial design--that's where the future. Bouncing around exam rooms and sticking the leads at the top of T8 is the past.

 

[epidural man]

Hi All,

Currently resident looking into pain and have been seeing a lot of posts about the current state of pain- slashed reimbursement, saturation in desirable cities, etc. I also have seen a lot about anesthesiologists flocking back to the OR give the insanity of their job prospects atm.

As many of these things work sort of sinusoidally, my question is- do we think pain will come back around?

Is there a future where older pain docs get fed up with slashed reimbursements and retire en masse? I know many of the pain fellowship spots are going unfilled, is this setting up for a big supply and demand gap? Will pay/reimbursement reflect this potential need?

TIA for the insight!!

Here's the rub -

Chronic pain is rarely a problem of nociception, and more a problem of cognition and emotion. A needle doesn't fix that. SOMETIMES, a nociceptive source can be identified and modulated temporarily with an injection. We clinicians who see the world through the "if I could just block the nociceptive source" lens will remember the one in 10 that benefited from our facet injection and promptly forget about the other 9 that had no benefit. We do this for several complicated human factors. But do you know who doesn't forget easily? The payers. They remember that they keep paying over and over for things that don't seem to work.

Look up these statistics. How much has chronic pain increased over the last decade? How much has MRI scans increased? How much have injections increased? After you find this (and here is a hint, they all have increased A LOT) - ask yourself this "If injections and getting better imaging to target the "source" worked, shouldn't the pain numbers be going DOWN?

However, having said that - working in the pain clinic is SO MUCH better than doing anesthesia - and I do both regularly.

 

[Ducttape]

agree with you 100% epidural...



but we shouldnt let drusso read that...

he'll make some comment about being pissed...

 

[drusso]

Here's the rub -

Chronic pain is rarely a problem of nociception, and more a problem of cognition and emotion. A needle doesn't fix that. SOMETIMES, a nociceptive source can be identified and modulated temporarily with an injection. We clinicians who see the world through the "if I could just block the nociceptive source" lens will remember the one in 10 that benefited from our facet injection and promptly forget about the other 9 that had no benefit. We do this for several complicated human factors. But do you know who doesn't forget easily? The payers. They remember that they keep paying over and over for things that don't seem to work.

Look up these statistics. How much has chronic pain increased over the last decade? How much has MRI scans increased? How much have injections increased? After you find this (and here is a hint, they all have increased A LOT) - ask yourself this "If injections and getting better imaging to target the "source" worked, shouldn't the pain numbers be going DOWN?

However, having said that - working in the pain clinic is SO MUCH better than doing anesthesia - and I do both regularly.

You're making a logical error in thinking if you believe that utilization is linked to therapeutic efficacy. Those numbers are up for all kinds of reasons: Demographics, defensive medicine, site of service arbitrage, HOPD employment, etc.

If you told me my back pain was an emotional problem, I'd be pissed.

 

[jsaul]

Here's the rub -

Chronic pain is rarely a problem of nociception, and more a problem of cognition and emotion. A needle doesn't fix that. SOMETIMES, a nociceptive source can be identified and modulated temporarily with an injection. We clinicians who see the world through the "if I could just block the nociceptive source" lens will remember the one in 10 that benefited from our facet injection and promptly forget about the other 9 that had no benefit. We do this for several complicated human factors. But do you know who doesn't forget easily? The payers. They remember that they keep paying over and over for things that don't seem to work.

Look up these statistics. How much has chronic pain increased over the last decade? How much has MRI scans increased? How much have injections increased? After you find this (and here is a hint, they all have increased A LOT) - ask yourself this "If injections and getting better imaging to target the "source" worked, shouldn't the pain numbers be going DOWN?

However, having said that - working in the pain clinic is SO MUCH better than doing anesthesia - and I do both regularly.

Ok but lumbar fusions have increased as well and results are no better. Workers comp patients who get fused don't go back to work they end up disabled. Insurance patients who get fused are usually seen monthly by some doc for opiods or other treatments and really are no better either. The problem like Russo said is our specialty and lack of a significant voice unlike the orthopedic industrial complex

 

[lobelsteve]

Ok but lumbar fusions have increased as well and results are no better. Workers comp patients who get fused don't go back to work they end up disabled. Insurance patients who get fused are usually seen monthly by some doc for opiods or other treatments and really are no better either. The problem like Russo said is our specialty and lack of a significant voice unlike the orthopedic industrial complex

The voices of our specialty are busy selling Relieveant and PNS. As well as trying to push the field to surgery-Minuteman, SIJ fusions.
And no one wants to take care of the patient. Just make the money.

 

[epidural man]

You're making a logical error in thinking if you believe that utilization is linked to therapeutic efficacy. Those numbers are up for all kinds of reasons: Demographics, defensive medicine, site of service arbitrage, HOPD employment, etc.

If you told me my back pain was an emotional problem, I'd be pissed.

Well...people get pissed when they are told they have cancer. But it doesn't mean they don't have cancer.

By the way, it may sound like I am discounting interventional pain management. I am not. There clearly is a role.

But we all have a "hammer- nail" issue I think.

 

[drusso]

The voices of our specialty are busy selling Relieveant and PNS. As well as trying to push the field to surgery-Minuteman, SIJ fusions.
And no one wants to take care of the patient. Just make the money.

What's the incentive to do anything else?

#theywillneverloveyouback
#electionshaveconsequences

 

[Ronin1]

I wouldn’t knock intracept. It really seems to work. Reimbursement for it sucks though. I feel like I’m doing it as a public service almost as the time/money balance is way off

 

[Laryngospasm]

Hammer nail is more of a surgery analogy but does somewhat apply to us. We have been severely limited by what insurance reimbursed for and so those are the treatments I am relegated to,

 

[Ducttape]

What's the incentive to do anything else?

#theywillneverloveyouback
#electionshaveconsequences

the incentive is to do the right thing.

multiple injections and/or injections with little to no proven benefits are all about making money, not doing the right thing, which is ofttimes to put down the scalpel or the trocar or the 22 gauge spinal needle...

 

[MitchLevi]

the incentive is to do the right thing.

multiple injections and/or injections with little to no proven benefits are all about making money, not doing the right thing, which is ofttimes to put down the scalpel or the trocar or the 22 gauge spinal needle...

Often yes, people abuse the needle for profit, but often they do it because they don't know what else to do.

 

[drusso]

I wouldn’t knock intracept. It really seems to work. Reimbursement for it sucks though. I feel like I’m doing it as a public service almost as the time/money balance is way off

The reimbursement policy was DESIGNED to work that way. It’s not an accident. The money is for the facility and manufacturer not for you.

 

[lobelsteve]

I get paid the same whether I do fancy procedure or just OV. If I do enough RFA, I can see fewer total visits.
Limited pie. No reason to over proceduralize everyone.

 

[Laryngospasm]

I agree. The more we continue to do these procedures that are underpaid while the manufacturers and hospitals get rich the worse it will get. Spending 30 minutes to do an us guided injection to get 0.5 rvu before taxes.. no thanks.

 

[hyperalgesia]

Often yes, people abuse the needle for profit, but often they do it because they don't know what else to do.

True. I would argue a major failing of our education/training process is that docs feel like they are failures if there's no medical treatment that is likely to help.

 

[Aldertonghen]

Pain was the dream of the 1990's. It peeked pre-Obamacare. Let's be honest...our field is a mess. Our fellowship programs don't innovate or produce much usable research. Pain doctors got run over by the opioid epidemic, CDC guidelines, PROP, private equity, mid-level incursion, and general government interference.

If I were you, I'd leverage my medical degree to focus on non-clinical areas--AI, informatics, genomics, and financial design--that's where the future. Bouncing around exam rooms and sticking the leads at the top of T8 is the past.

How does one leverage their medical degree in non clinical areas? Do you mean leaving medicine altogether? Or continuing clinical work and doing it on the side?

 

[lobelsteve]

How does one leverage their medical degree in non clinical areas? Do you mean leaving medicine altogether? Or continuing clinical work and doing it on the side?

Betsy Grunch. Neurosurgeon. Tiktok.

 

[drusso]

How does one leverage their medical degree in non clinical areas? Do you mean leaving medicine altogether? Or continuing clinical work and doing it on the side?

Doctors Are Increasingly Pursuing “Side-Gigs”—And It’s A Startling Commentary On The Modern Practice Of Medicine

Physicians are increasingly experiencing burnout and dissatisfaction.

www.forbes.com

 

[buddababa]

I get paid the same whether I do fancy procedure or just OV. If I do enough RFA, I can see fewer total visits.
Limited pie. No reason to over proceduralize everyone.

Do you get penalized over a certain RVU threshold? (thus the limited pie)

 

[lobelsteve]

Do you get penalized over a certain RVU threshold? (thus the limited pie)

Salary cap.

 

[buddababa]

Salary cap.

dang, interesting for HOPD, most dont have a salary cap

 

[Ronin1]

I have one as well but they just raised it to 1m. I’m not willing to work that hard though

 

[Laryngospasm]

I have one as well but they just raised it to 1m. I’m not willing to work that hard though

Yeah that’s a little too many times telling people that .. no.. mbb is just a test.. I would go insane

 

[epidural man]

Often yes, people abuse the needle for profit, but often they do it because they don't know what else to do.

I am guilty of this (not the profit thing...but just doing something that has a low probability of working because I don't know what else to do.)

 

[drusso]

Pain was the dream of the '90's...

 

[masterPain]

Pain was the dream of the '90's...

what did an ESI pay back then?

 

[drusso]

what did an ESI pay back then?

I could only go as far back at 2007.

Payment in the office site of service has been more or less flat due to the ACA. Thanks, Obama.

 

[Taus]

I could only go as far back at 2007.

View attachment 381751

Payment in the office site of service has been more or less flat due to the ACA. Thanks, Obama.

What year was fluoro bundled?

 

[bedrock]

What year was fluoro bundled?

2011 or 2012. So you could add $70 or so to the 64483 prior to that.

So even Medicare paid $400 for a unilateral single TFESI back then.

 

[RoloTomassi]

2011 or 2012. So you could add $70 or so to the 64483 prior to that.

So even Medicare paid $400 for a unilateral single TFESI back then.

Adjusted for inflation that'd be like getting $590 now. Sad.

 

[MitchLevi]

Yall need to remember this each time you put a stimulator in someone.

 

[Laryngospasm]

Stimulator pay is a joke for the risk you take with complications. As are many other procedures. Private insurance paid around 1000$ back in the oughts for an ILESI.