B. Todd Sitzman, MD, MPH Hattiesburg, MS

Building a Collaborative Program: Neurosurgeon and

Pain Specialist

Disclosures

Nevro Corporation Principal Investigator Protocol CA2011 US

Senza™ SCS System

Society Affiliations Past-President (AAPM, SPS, MSIPP, MPS)

Board Member(NANS, SPS, MSIPP, MPS)

Overview

Health systems research on referral patterns

Objectives of a Collaborative Relationship

Managed Care versus Medical Home models Benefits to the Pain Specialist

Never underestimate Teamwork and Access

Referral of patients to specialists: Factors affecting choice of specialist by primary care physician.

Kinchen K, et al. Ann Fam Med 2(3):245-52, 2004.

• cross-sectional national study design, n = 1252

• ratings of 17 items affecting referral

• Top 4: medical skill, experience w/ specialist, appt timeliness, quality communication

• Bottom 4: office location, return referrals, medical school, fellowship training

Dropping the baton: specialty referrals in the US.

Mehrotra A, et al. Milbank Quarterly 89:39-68, 2011.

• Referrals often lack transfer of information

• Specialty care is poorly integrated

• PCPs rarely know if patient went to specialist and recommendations

• Confusion in specialist role: consultation only vs co-management

Ideal Steps in Specialty- Referral Process:

Pain Specialist

Neurosurgeon

Managed care, access to specialists, and outcomes among primary care patients with pain.

Grembowski DE, et al. Health Services Research 34:1-19, 2003. Managed care:

•not associated with decreased access to pain specialists

• only PCP financial withholds were associated with reduced referrals to specialists

• no evidence of adverse outcomes

• associated with lower patient ratings

Medical Home Model:

Managed care (HMO) model

• PCPs are gatekeepers

• Managed care overriding goal: managing costs

Medical Home model

•Four core functions: accessible, comprehensive, coordinated, longitudinal care

•Relies on EHRs, seamless, specialist referrals

•May actually increase costs (JAMA 308:60-66, 2012)

Financial Implications

* 2012 MS Medicare fee schedule

Trial SCS Lead Implantation (Point of Service):

Hospital ASC Office based63650 X 2 Implant trial SCS $ 600.37 $ 600.37 600.37$ L8680 X 16 16 Contacts -$ -$ 6,720.00$ 63685 Implant SCS 334.83$ 334.83$ -$

Office Expenses: Supplies/Staffing 775.00$

Trial SCS Leads 1,700.00$ Billing Expenses 366.00$ Total Expenses 2,841.00$

Financial Benefits

In-Office SCS Trial Lead Placement:

1.45 minute intraop + 1 to 2 hours postop

2.* Net reimbursement: $4000

Facility (ASC/HOP) Permanent SCS Implantation:

1.30 min wait, 90-120 min intraop, 30 min travel

2.* Net reimbursement: $600.37 + $334.83 = $1,000

* 2012 MS Medicare Part B Physician Fee Schedule

Referral Documents

Letter of Medical Necessity

• Brief history, Diagnoses (ICD-9), Procedures (CPT)

SCS Trial Op Note & Post-op Note

Fluoroscopy Images

Supporting Documents

• Initial Consultation• Radiology reports• Psychological Evaluation report

Collaboration

“The strength of the team is each individual member. The strength of each member is the team.”

- Phil Jackson, LA Lakers