Steven Richeimer wrote in Pain Medicine Vol 11(1) about “Interventional” pain practices and their weaknesses- Are We Lemmings Going Off a Cliff? Donald Taylor and Rollin “Mac” Gallagher brought this manuscript back to mind in their comments in the most recent Vol 11(11) issue. I have some ambivalence about the issue but in essence I don’t disagree with Drs Richeimer, Taylor, or Gallagher. One unstated vector in Dr Richeimers erudite perspective is the impact of “Interventional” providers on all the other providers in Pain Medicine.
Many leaders in academic centers and otherwise have embraced wRVU benchmarks as their Raison d’être. Salary, bonus, recognition is based on meeting RVU benchmarks. Two of the most common procedures done in pain centers are epidural steroid injections (ESI) and medial branch blocks (MBB). An ESI done under fluoroscopy is worth 2.14 RVUs. MBBs at 3 levels can be worth 3.37 RVUs. Either of these procedures can easily be done in 30 minutes or in many practices 20 minutes. Billed by time, a 60 minute outpatient consult is worth 3.02 RVUs. A 25 minute follow-up appointment is worth 1.5 RVUs. It is easily possible to earn 2 or more times as many RVUs doing procedures compared to seeing patients. Two MBBs in an hour produce 90% more RVUs than a one hour new patients evaluation billed by time! You can make 90% more RVUs doing simple procedures than by seeing complex patients.
The benchmarks for doing procedures come from a variety of sources but the Medical Group Management Association (MGMA) may be the most common source. The MGMA will not divulge who the practices are that they derive their numbers from but for Pain Medicine, their numbers are virtually impossible for a non- ”Interventional” pain specialist to achieve. For example, the 60th percentile of MGMA pain practices produce 7,794 RVUs. Another benchmark organization which is rarely chosen is the University HealthSystem Consortium (UHC) benchmark where the 60th percentile is 4,028 RVUs. We do know who the UHC centers are, many of them American Pain Society Center of Excellence awardees. The MGMA number is 93% higher than the UHC number.
Getting back to Dr Richeimers article, the further injury is to physicians trying to provide comprehensive care to their patients being penalized by leaders trying to improve their bottom line or even worse keeping their institutions afloat. Hospital administrators in both academic and private practice settings can only attribute the discrepancy between a comprehensive pain centers productivity and a “block shops” productivity as a problem with efficiency, effort, or outright laziness of their providers. I can meet MGMA goals by doing procedures but not if I have to see patients. The pressure on comprehensive providers to produce at “Interventional” levels will undoubtedly reduce the number of great centers and physicians providing comprehensive pain care in America.