EMG/NCV cuts.

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In a way, I feel we have only ourselves and our older colleagues to blame. Many emgs are terrible studies that never should have been done. Many ncvs, which are more important than the emg portion in the majority of cases are done by techs and have little relationship to the clinical picture.

We didn't keep a clean house. Now we've forced others to do it for us.

What's amazing is that with a sweep of a pen, unless cognitive time becomes more financially rewarding, neurology is now much more difficult to practice and will fail to attract best and brightest med students - more so than is already the case. With sleep also in danger, the future will grow tight.
 
I think a big part of the problem was volume growth due to the proliferation of companies doing nerve studies in primary care offices. Many internists in my area do the studies then send the patient to me when they have no idea what it means.
 
neglect said:
In a way, I feel we have only ourselves and our older colleagues to blame. Many emgs are terrible studies that never should have been done. Many ncvs, which are more important than the emg portion in the majority of cases are done by techs and have little relationship to the clinical picture.

We didn't keep a clean house. Now we've forced others to do it for us.

What's amazing is that with a sweep of a pen, unless cognitive time becomes more financially rewarding, neurology is now much more difficult to practice and will fail to attract best and brightest med students - more so than is already the case. With sleep also in danger, the future will grow tight.
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I believe you are partially correct. However, I tend to hear this argument mostly from politicians and lawyers. Usually as an excuse to screw other people and professions and grab power. But it sure sounds good. Don't let them con you into blaming other doctors (divide and conquer, right?) for something that external forces are responsible for. Certainly, some onus of blame can be assigned to those who have failed to keep themsleves squarely in the driver's seat of performing these studies and thus being in a better position to regulate quality control and proliferation of usage.

But, in my opinion, the real causes of these cuts are ultimately going to be attributable to the Affordable Care Act, and the expectation of certain aspects of quality health care in the United States as a right and not a privilege. If you want to provide sweeping health care services to the entire population then those services are going to be more cheaply reimbursed. I'm not trying to make a political comment here, either. Procedures? They're more expensive than cognitive work, and thus are easily attacked when scanning a budget. Radiology is a big, fat, target right now. And you don't have tons of choices, either. The country is broke. If you want to pay for an expensive ACA, then the money is going to have to come from somewhere. And the law obviously makes deep slashes to Medicare (with the cutting of doctors' reimbursements through Medicare as the major item to help accomplish this). That means alot of neurology patients (who are older), and it's just the way it is. To put it more succinctly, if you supported this law, you endorsed cutting Medicare, cutting your salary, and cutting reimbursements for procedures like EMG.

As far as the future of neurology, I agree that it looks particularly grim for the future with the passage of this recent legislation. Without procedures to float their practices, alot of neurologists would at the very least be unable to financially sustain a private office and staff. Bottom line? You will likely not be able to operate independently or in groups that are single-specialty for neurology as provisions of the law (and projected cuts) progressively take effect. You can argue that this is part of an overarching drive to ultimately create a single payor system and/or turn specialists into employees at large academic hospitals or huge entities like Aetna or Baptist. Back to the topic, one way to escape and remain in private practice is to be in a multi-specialty group, though. Cardiologists, neurosurgoens, etc will still pull in enough money to keep practices afloat...for now.

neurolddoc said:
I think a big part of the problem was volume growth due to the proliferation of companies doing nerve studies in primary care offices. Many internists in my area do the studies then send the patient to me when they have no idea what it means.
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As a bit of a rant, I've always been surprised how obtuse most academic neurologists are to financial incentives in private practice and their tendency to roll onto their backs and give up when their 'turf" is threatened by other specialites. Want to learn EMG? No problem! We can teach you that!

To put it another way, ever notice how vicious radiologists get when imaging or interventional get half-threatened by neurology residents? They go ballistic. They refuse to teach neurology residents. They refuse to hire them as fellows. They let spots in a fellowship program remain empty rather than fill them with interested neurology applicants. While it is a bit xenophobic and paranoid to act this way, it does solidly protect their "turf" from encroachment (and thus their financial stream, the quality of their applicants, their standing in the administrative hierarchy of the hospital, etc).

I'm not saying we should all be jerks about this, but just making an opinionated observation.
 
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In PM&R all residents do 200 EMG's to graduate. We tend not to see the more esoteric ones though, and tend to focus on radiculopathy, neuropathy, and common nerve entrapments.

Most residents though don't have the brains to really master EMGs and the majority of them aren't too interested in pursuing EMGs after residency. Physically they're hard to do, hard on the back. "You have to touch people's nasty feet all day", as one inpatient doc put it. And even though they reimburse relatively well, interventional pain procedures reimburse 2-3 times better for the same time doing them (and take less cognitive and physical labor). At a lot of programs, 70-80% of residents are going into pain fellowships. But all the smart guys that I've met in PM&R do EMGs for the challenge. Many of the non-interventional outpatient musculoskeletal docs do 1-2 EMGs a day and this does make the career financially worthwhile (otherwise they would earn like a Pediatrician).

With the EMG billings being cut by 50%, I'm thinking even the older non-interventional docs are going to do an ISIS course and start chasing pain. In fact, I've seen this happening, with 75 year old docs going to these courses. And there's already too many people doing pain.

I have read reports from other offices in the community of absolutely garbage EMG studies; studies that mean nothing and shouldn't even be done. And I have seen docs that I've worked with tack on extra and perhaps unnecessary nerves to studies (like plantar nerves, superficial peroneal, etc.) likely just for billings. I would much rather they tackle that by limiting the number of nerves you can test in one day, to perhaps 8 for CTS, 8 for neuropathy, and only 4 if a screen comes out normal. And also limiting or putting in place more strict prior auths for repeat EMGs. That would have been a much more fair approach than just slashing all the billings.
 
A sensible approach is to make sure a quality service is being provided. I think that test in general should only be paid when performed by individuals with documented training. It would weed out a lot of the sketchy primary care docs who do a large portion of the studies in my area.
 
With this crackdown on reimbursements affecting procedures/procedure based specialities more, do you all think that neurosurgery would be hit hard? There are so many unnecessary spine procedures being done. If this does happen then it will affect economics for most neurosurgeons (particularly in private practice).
 
Strokeguy said:
With this crackdown on reimbursements affecting procedures/procedure based specialities more, do you all think that neurosurgery would be hit hard? There are so many unnecessary spine procedures being done. If this does happen then it will affect economics for most neurosurgeons (particularly in private practice).
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My opionion?

It's going to affect almost everyone I think, including orthopaedic surgery, cardiology, radiology, and neurosurgery. The difference between us and them is that their starting salaries are alot higher, and thus they'll likely still be able to keep afloat in private practice whereas neurologists will not have the extra capital needed to do so. I would guess that specialties like endocrinology and rheumatology will be affected similarly to us.

Plastic surgery and dermatology will probably escape relatively unscathed. They have the luxury of being able to offer boutique services if they wish - and patients will actually pay for it.
 
The articles clearly state that CMS will only respond to denial of access to care. The Academy should clearly communicate this to its membership.

A rational response for a practicing neurologist is to educate his/her patients that this cut has been implemented and inform that patient how this will impact his/her access to future care in that office.

It is harsh and not without risk but CMS is clearly playing hardball with us.
 
neurolddoc said:
The articles clearly state that CMS will only respond to denial of access to care. The Academy should clearly communicate this to its membership.
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The AAN is pretty useless. Your post is more info than I've gotten from the AAN.

I think the answer is to do an internal evaluation of the practice. I can see 3 follow ups in one hour or do an EMG/NCV and eval. Should I cut my EMG hours? Even if things are close (within 20 bucks), then obviously the answer is yes.

Will run the numbers...
 
No the EMG cuts are in effect. The SGR was a separate issue.
 
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