Working with an orthospine group

[inspire004]

Does any one work with a ORTHO spine group or has relationship. Does it work as an independent provider or do they like to make pain partners. Do they typically want a pmnr pain doc. How is the employment agreement usually with large orthospine groups. Do they support start up pain docs. Do you guys think there will be good referral if we join there base.

Please let me know the dynamics of joining or working for an Orthospine group.

Thanks

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[emd123]

Does any one work with a ORTHO spine group or has relationship. Does it work as an independent provider or do they like to make pain partners. Do they typically want a pmnr pain doc. How is the employment agreement usually with large orthospine groups. Do they support start up pain docs. Do you guys think there will be good referral if we join there base.

Please let me know the dynamics of joining or working for an Orthospine group.

Thanks

I just got off the phone with an ortho guy who's group is looking for a Pain doc. I need more details, but they don't care about PM&R and they are open to a start up guy and willing to offer a track to equal partnership, etc. I need to find out more about it, but on the surface, I'm interested. It sounds as good or better than anything else I'm finding out there. The devil is in the details, and I don't have those yet

 

[clubdeac]

I think it goes without saying that you have to be a little careful joining a single specialty ortho or neurosurgical group. You're gonna be the odd man out and as equitable as they make it sound, I doubt it will be on various levels. Just my opinion fwiw

 

[PinchandBurn]

This coudl be a win -win for you. Surgeons are generally good about sending injection type patients. On the flip side they can potentially 'dump' opioid patients on you after their surgeries and expect you to manage their opioids. I think if the surgeons have any ethics or are reasonable, they should manage the opioids in the post op period, not you.

Just 'educate' them on your opioid policy and this could be a great opportunity for you.

 

[jsaul]

ortho groups typically hire PMR-pain guys. Also they will expect you to take care of all the patients who still complain of back pain after their multilevel fusion (ie-cont their narcotics)

 

[lobelsteve]

ortho groups typically hire PMR-pain guys. Also they will expect you to take care of all the patients who still complain of back pain after their multilevel fusion (ie-cont their narcotics)

I think they find weak prey in the PMR coven. Any doc who has a license to lose and a brain in their head will eval and treat as they see fit. A really smart doc would keep the post-op LTOO folks happily narc'd for 2 solid years before weaning. But that's dirty.

 

[jsaul]

I think they find weak prey in the PMR coven. Any doc who has a license to lose and a brain in their head will eval and treat as they see fit. A really smart doc would keep the post-op LTOO folks happily narc'd for 2 solid years before weaning. But that's dirty.

the goal of these practices is to fuse with hardware everyone that comes in. The ortho's know that the patients will still complain of pain post op but their goal is to keep the patient "narc'ed up" so that the patients will b "happy" . And that is what the "pain guy" is for. I heard this straight from their mouth. And apparently its a strategy that many groups across the country employ.

 

[Jcm800]

the goal of these practices is to fuse with hardware everyone that comes in. The ortho's know that the patients will still complain of pain post op but their goal is to keep the patient "narc'ed up" so that the patients will b "happy" . And that is what the "pain guy" is for. I heard this straight from their mouth. And apparently its a strategy that many groups across the country employ.

i agree. its all about the hardware, then all about keeping em quiet for 5 years, till they can put hardware at the level above or below (usually for an acute HNP)

not had great success with the rationale and judgement of ortho in my area. Typically fuse first (for all and any issue, HNP, stenosis, facet pain, muscular pain) as long as it "looks bad" on the MRI, that must be the problem, and ask questions later.

ANd post-op, when they have pain, "the x-rays looks good, go see pain management for narcs, but come back and see me for another x-ray in 3 months"

 

[Gauss]

you have to super cautious, many orthos simply operate first and ask questions later. I thought I'd be first line conservative care and if they failed my treatment I'd send to surgeon. In practice it's the total opposite, surgeon first then dump

 

[inspire004]

So I have a feeling they will want me to take there narcotic dump, initially I will have to take the bad apples. I need there referral and start up and infrastructure.

I need to set boundaries. how much do I integrate these guys into my practice. I would like to have the office and carm and office staff but I would want the autonomy to practice

I should have clear dollar amount on overhead and have my productivity separated from the total cost.

Thinking how the partnership would work if they have 4 office locations and have stocks in a ASC

If they send all the dumps I would have to explain that it would be not profitable to practice or me with just med refills.

If they give me nice base salary and productivity bonus that is transparent in terns of the charges and overhead amount that is good too

What is there benefit to hire me,what is there gain.

 

[PinchandBurn]

What is there benefit to hire me,what is there gain.

They can operate on anybody. If it doesnt work, then pass it on to you for 'pain management and the pain doc will make you comfy for the next 6-9 mo until the fusion heals'.

Meanwhile, you will likely be going up and up on Narcs. Pt will gain tolerance. Then for whatever reason they will need surgery again, you will then refer back to then.

Rinse and repeat ad nauseum.

They have a huge benefit having you there....

 

[jsaul]

Inspire- I dont think you understand. The push to fuse is based on monetary gains. Orthos are fusing everyone left and right and they will then dump all the those patients on to you after telling them they are "fixed". This is some scam they have going. The patients are in the same pain or often more pain after surgery but they are "fixed according to xray" Then the tell the patient to come to you because you will take care of their pain.

 

[Louisville04]

Inspire- I dont think you understand. The push to fuse is based on monetary gains. Orthos are fusing everyone left and right and they will then dump all the those patients on to you after telling them they are "fixed". This is some scam they have going. The patients are in the same pain or often more pain after surgery but they are "fixed according to xray" Then the tell the patient to come to you because you will take care of their pain.

Don't most surgeons not guarantee pain relief with surgery or give a probability of success (i.e 80% chance of pain relief)?

Why can't Inspire agree to care for their pain with interventional procedures or make recommendations for opioid management that the PCP can take over?

 

[lobelsteve]

The in house pain guy pays for himself in keeping patients so narc'd that they reduce litigation costs by keeping the patient incoherent in opiate bliss until the 2 year statute of limitations is up.


(I'm just making this stuff up, but it wouldn't surprise me if it were mentioned at a large Ortho group business meeting.

 

[inspire004]

I might start making an intake policy on narcotized pts, might help them trouble shoot like the pcp and onch in university setting. Pick out all the abuse pts and have the discretion to not take pts from intake history. That might piss my dumpers. I should get independent financially and infrastructurally to have this choice.

As long as any entity supports you they have vested interest in your productivity

I will bill and code and pay overheads and have things in the contract clearly mentioning that i am independent decision maker on who I take and not take in my practice, you have right to refuse as aphysician and help them find some one who can help them, in A politically rite way

 

[lonelobo]

Worked for 25 person ortho group for 4 years.

I was brought in as their 1st pain guy. Never felt any pressure to prescribe Narcs and for
the most part if they were on something for post-op pain I told them to get them from
the referring surgeon.

They were just happy I was making them money with procedures at the sx center.
Became full partner after 16 months.

Maybe I was just lucky to find a reasonable group, just couldn't stand the Iowa winters though.(do miss the the Pork though)

 

[PMR 4 MSK]

It all depends on the group and their ethics. A good group will utilize the PM&R or pain guy not only for pre- and post-surgical injections (e.g. a needle-monkey), but will consult them for cases, use them for triage, help to off-load the non-surgical cases so that they spend more time seeing surgical cases.

If they have no pain guy currently, and they have a high-rate of surgery per consult, walk away.

As PM&R, you can also enhance the practice's economics by bringing EMGs in-house, as well as fluoro and US fees.

It is difficult to make PM&R a full partner in a surgical practice. Salaries will be quite disparate. You may not want to be a partner - buy-ins could be very high, depending on what they own. salary + bonus, structured right, can work out very well for both sides. Don't sign anything that you don't agree with.

 

[inspire004]

You feed back/ advice was helpful

 

[inspire004]

Details : 300k+ bonus % of net collections above the base, w2 ,has ASC and 4 clinics, c arm in Asc only. Currently anesthesia does only lumbar Epi injections. Want me to do 5 days 7- 3pm anesthesia for ORTHO asc and 3-5 pain in asc for 6 mths . Then they plan to hire a full time anesthesia doc for asc and make the pain full time as numbers increase.
They are hesitate to make a pain anesthesia guy a partner for now as per the by laws. But the last ORTHO guy did well and made him partner in 18 mths. They are interested in making a full time pain facility over a 1 yr period.

My net collections will not include facility fee, mri, PT, only professional fee. No idea on the overheads of running an anesthesia pain service- dollar amount/ mth

 

[lobelsteve]

Details : 300k+ bonus % of net collections above the base, w2 ,has ASC and 4 clinics, c arm in Asc only. Currently anesthesia does only lumbar Epi injections. Want me to do 5 days 7- 3pm anesthesia for ORTHO asc and 3-5 pain in asc for 6 mths . Then they plan to hire a full time anesthesia doc for asc and make the pain full time as numbers increase.
They are hesitate to make a pain anesthesia guy a partner for now as per the by laws. But the last ORTHO guy did well and made him partner in 18 mths. They are interested in making a full time pain facility over a 1 yr period.

My net collections will not include facility fee, mri, PT, only professional fee. No idea on the overheads of running an anesthesia pain service- dollar amount/ mth

You just might break 400k per year...

 

[SIIMS]

I work in an ortho spine group with 3 spine surgeons and 4 PM&R Pain

This model could not work out better for me, some of the hasty generalizations of spine surgeons on this thread are certainly warranted (even saw this on the academic side of things during fellowship) thankfully I work with very conservative surgeons, no multilevel spine fusions for 23 year old females with slight disc dessication (puke)

All of us take "all comers" and meet somewhere in the middle, some of the surgeons will order injections and "manage" patients that aren't surgical others will refer to the physiatry and vice versa for patients's that are surgical, no one expects large take-overs or dumps of opioids, all of us see "difficult" patients, this comes with the territory we tread in

We do weekly spine conference, all are open to all therapies and approaches. Again, very conservative.

I am a newbie (less than a year), guarantee first year, very acceptable, (partner at one year), buy in for everyone is same, year one to two eat what you kill, year 2+ eat what you kill plus proceeds from ASC, this keeps buy in relatively low. Have seen books, all do very well including the doc who has been there three years and still building his practice.

It is not one sized fits all for this practice set up, you have to ask very pointed questions and also "go with your gut" If it doesn't feel right or the set-up in tenuous or you work with one of those famed surgeons who multi fuses the young and impressionable or doesn't buy in to multidisciplinary treatment of spine/pain patients you will be up ****s creek with a turd for a paddle

But it certainly works in some cases

 

[PMR 4 MSK]

Want me to do 5 days 7- 3pm anesthesia for ORTHO asc and 3-5 pain in asc for 6 mths .

So where are these pain patients being evaluated? ASC does not noromally have clinic space. I take this to mean someone else is deciding what procedures you will do for 10 hours per day. E.g. Pt's sent for "series of 3" for generic back pain, you take the role of needle monkey.

I would not do this. 75% + of the patients referred to me for "ESI" do not end up getting them after I evaluate them.