I am interested in applying to PM&R programs but would like to find one with more of an emphasis on pain management and sports medicine. Any suggestions? Where do you think that pain management is heading? Will insurance continue to pay for pain management?

Is it harder to get a pain fellowship from a physiatry or anesthesiology background?

First, assume nothing.

Second, find out EXACTLY what kind of corporate structure your practice has and how it is set-up.

Third, consult extensively and frequently with an attorney who is skilled and knowledgable in corporate law and has negotiated other physician partnerships and “buy-ins.”

Medical practice structures typically include sole proprietorships, general partnerships, limited liability companies (LLCs), limited liability partnerships (LLPs) and professional corporations (PCs), which can be either C corporations or S corporations. In most states, physician groups are set up as PC’s. The primary distinctions between all these structures involve are liability protection and taxes. Depending upon your state, PC’s may be subject to special regulations and/or protections.

When it comes time to “buy-in” into the practice as a new owner, you will become a shareholder in the PC. You will have vote in the management decisions of the practice. The price of the buy-in is determined by the value of the practices “hard” and “soft” assets. If you should leave the practice, the remaining owners will be obligated to “buy-out” your shares based upon a new evaluation of the practice’s assets at the time of transaction. It is important to have a written buy-sell agreement covering the value of the stock.

In addition, it is important to have a written deferred compensation agreement to cover the value of a physician’s share of the accounts receivable. There are many ways to set up buy-ins and buy-outs using these basic principles. Consult your tax/corporate attorney for more details.

Good luck.

I can’t comment on others’ practice patterns. Certainly, it’s easy enough to do anything poorly. Personally, I find the complexity of comprehensive pain management to be incredibly challenging and based upon referrals I recieve from “mid-level” providers I would say that the typical mid-level’s understanding of pain mangement and pain physiology is poor to say the least.

I maintain that neuraxial procedures for the treatment of pain (being essentially elective procedures) are moderately risky, require skill, and should be done by those who do a dedicated practice to pain management (an obstetric epidural or a peri-operative epidural is very different than a therapeutic injection done for the treatment of a painful condition.) Any procedure will certainly be ineffective if patients are inappropriately selected.

Pain medicine, as a specialty, has its roots in anesthesiology and anesthesiologists continue to make important contributions to the field and make significant advances. Most academic pain clinics are in anesthesia departments because those departments typically have more basic science resources and grant dollars than neurology or physiatry departments.

There is a shortage of adequately trained pain physicians in the USA and tremendous burden of under-treated pain. There are proposals to create and advance a dedicated 4 year residency program in Pain Medicine for physicians. Maybe that will address your concerns.

I was somewhat surprised by your comment, “I feel like the reimbursement is commensurate with the level of complexity, skill requirement, and risk in the field.”

I work closely with the pain management group in my hospital – their clinic being in the professional building attached to the hospital – and the level of complexity and skill required is that of a midlevel provider. They take a cookbook approach to pain management, and the “procedures” such as facet and SI injections can be learnt quite quickly. The same is true of stim trials.

The facility I am at is one of the top medical institutions in the country and has 1 or 2 fellows a year in their pain program. Patients are referred here from other pain groups.

You may practice a broader approach to pain management as you appear to have a more diversified practice and have a PM&R background, but from what I have seen the ability of anesthesia docs is limited to strict pain management. You may not want to work in an “injection mill”, but that’s exactly what the majority of pain management clinics are. And, it’s all about the money. Do you think that anesthesia would be taking it up if it payed less or even the same?

It is interesting that there are no studies that demonstrate the efficacy of many of the techniques currently in use, and I would be interested in hearing a justification for the reimbursement levels for 64470, 64475, 27096, etc.

Sincerely,
David Hill