The High Volume Pain Clinic Problem or “Churn and Burn”

Chris Centeno, MD - There’s a disturbing trend recently covered by a news piece I just read. While I had planned on another blog this morning, when you try to write almost every day, you have to go with what gets you going. Today that’s the high-volume Pain Clinics that have been springing up all over the country. Let’s dig in.

knee osteoarthritis

The Lags Story

There is a news piece that was published yesterday that goes over a troubling trend – the rise of high volume Pain Clinics usually staffed by mid-levels that perform pricey in-house testing and expensive Interventional Spine procedures in desperate Medicare-covered pain patients. This piece focuses on a huge chain in California that was shut down by the state, called Lags Medical Centers. There were some interesting things going on:

  • Frequent punch biopsies looking for small fiber neuropathy that were sent to in house labs (despite this being a VERY uncommon test)
  • Many patients on high-dose opioids with expensive drug testing that was sent to in house labs
  • The frequent use of Radiofrequency Ablation, well above peers
  • Heavy reliance on mid-levels who were bonused based on promoting specific expensive tests and procedures
The story is an interesting read, but for me, it brings up much bigger issues that I see all over the country. High volume Pain Management clinics.

The High Volume Dilemma

If you’re a Pain Management doctor, you have to make a choice. You can either run a low or high-volume clinic. These are two very different animals.

In a low-volume clinic, your life is sane. You see between 10-15 patients a day (clinic time + procedures) and spend more than enough time with every patient. You don’t employ mid-level providers like physician assistants or nurse practitioners, as every visit is face-to-face with the doctor. Your exam can be extensive and the diagnoses can be detailed and well thought out. There’s just one problem. This type of clinic will quickly bankrupt you. More on that below.

In a high-volume clinic, your day is hair on fire insane. You see between 20-40 patients a day and heavily rely on mid-levels to churn through that patient volume. Few patients get your time and attention and decisions on what’s wrong and what to do must be lightning quick. Your exams are skeletal at best. This type of clinic can be quite profitable.

How to Have a High Quality-Low Volume Clinic

As you’ve read many times on this blog, traditional Interventional Pain Management is often barbaric. It focuses on harmful steroids, burning nerves, and inserting invasive devices into patients. I had that type of practice 20 years ago. It was never super high volume, but it was focused on expensive procedures that never really helped my patients. As a result, I made a switch and began to focus on Regenerative Medicine well before this was “a thing”. I like to say that it was either that or become a real estate agent.

Back then my dream was a practice where patient volumes would be kept low and the time taken with patients would be maximized. My physical exams would be detailed and long. There would be no mid-levels, only doctors. Finally, this would all work out financially because patients would pay for my time.

20 years ago that kind of practice seemed like fantasyland, but ultimately it became reality. Now I’m part of one of the world’s most successful Interventional Orthobiologic clinics. We have a fellowship program, perform lab and clinical research, and patients travel from all over the globe for our expertise and time.

Insurance Focused or “Churn and Burn”

Going back to the high-volume clinic model, if there’s one thing that defines that clinic model its insurance. Meaning, how well an insurance company reimburses for various procedures decides what gets done. These days that’s Radiofrequency Ablation, stimulators, and implanted devices. I call this the “churn and burn” approach. Are any of these great and elegant solutions to help patients recover from pain? Not really.

Insurance Agnostic

In our clinic, we’re insurance agnostic. Meaning, the best choice for the patient is the most elegant solution to treat their pain and not what their insurance company will reimburse. Let’s look at an example that shows how that works in day-to-day practice.

A patient walks in with moderate knee arthritis. They don’t want surgery, but they have been told by an Orthopedic surgeon that they will soon need a knee replacement. In the high-volume clinic, a cursory exam is performed by a mid-level who tries to sign the patient up for Radiofrequency Ablation of their Geniculate nerves. That’s the definition of “churn and burn” as the plan is to burn the nerves that transmit pain from the joint. Why? This is covered by insurance and pays well. The downside of destroying critical nerves is never discussed with the patient. It’s also never discussed that you’re only likely buying some time and that given their knee joint won’t feel anything, it will likely rapidly degenerate and the patient will be forced into an early knee replacement. Between co-pays, co-insurance, deductibles, and a trip to the practice-owned ambulatory surgery center, the patient is out of pocket $2,500.

That same patient who walks into our clinic will get an extensive exam. That hands-on time defines multiple loose ligaments that are causing knee arthritis. They are signed up for a Platelet-Rich Plasma injection of the joint and the damaged ligaments. Why? Because it is an elegant solution for their pain, destroys no nerves, and will probably leave their joint better off than before they came in. They will pay out of pocket for that procedure as it’s not covered by their insurance, but now their knee is stable and less likely to quickly progress to a knee replacement. Their out-of-pocket expense is less than if they had the Radiofrequency procedure.

What Kind of Practice Do You Want?

If you’re a patient, obviously you want to find a low volume practice that puts your needs in front of what reimburses well through your insurance plan. Meaning a doctor that will spend time with you and treat you and not your insurance. If you’re a physician, we would all rather have a low volume and sane practice.

Insurance Reimbursement?

One of the reasons that physicians don’t choose a low-volume approach is that they feel that their patients would never be able to afford that type of practice. However, increasingly, that’s no longer true. Two trends have moved that needle.

First, the huge jump in the amount insured patients are required to pay out of pocket. This skyrockets when there is a physician-owned ASC involved. Meaning that when you actually do the math, in most instances your existing high-volume practice is likely costing your patients more out of pocket than a low-volume practice.

The second is shifts in reimbursement for doing the right thing by patients. For example, Regenexx has secured direct contracts with over 500 companies as of 1/1/22. Meaning these companies have decided to allow their employees to access Interventional Orthobiologics instead of traditional Interventional Pain Management. Meaning the doctor no longer has to put up with the high-volume churn and burn approach.

The upshot? Again, some mornings I have to write about what gets my goat up. I see countless patients every year who have been treated in churn and burn practices. They have gotten little physician attention and are often miserable and misdiagnosed because high-volume practices don’t permit the time needed to figure out what’s really wrong. Hence, if you’re a patient or a provider, there is a better way to treat patients, but it does require you to slow down and focus on what’s best for the patient.

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