1. B. Todd Sitzman, MD, MPH Hattiesburg, MS Building a Collaborative Program: Neurosurgeon and Pain Specialist

2. 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)

3. 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

4. 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

5. 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

6. Ideal Steps in Specialty- Referral Process: Pain Specialist Neurosurgeon

7. 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

8. 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)

9. Financial Implications * 2012 MS Medicare fee schedule

10. 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

11. 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

12. Collaboration “The strength of the team is each individual member. The strength of each member is the team.” - Phil Jackson, LA Lakers