Best Places to Practice

[EvoDevo]

I'll start :

Texas
- minimal med mal
- No state income tax
- meddlesome Medical Board
- hydrocodone going schedule 2 (which means triplicates)
- because Perry refused Medicaid matching, a lot of your low income patients still cannot get insurance
- pay can be pretty great
- some simply AMAZING pathology
* last week in one shift had nec fasc, RCA STEMI in a pacemaker, walky-talky VT, saddle PE, acute appy in a 40 yo M c Aortic stenosis on warfarin, acute cholecystitis, couple of pulmonary edemas on bipap/ntg/lasix, tube in the ICU on a Mallampatti IV (Bougie baby!), plus the usual back pain, chest pain, abdominal pain nothing-omas

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[emergentmd]

If you don't care about subjective stuff like weather, its Texas Bar none.
Everything you said is correct. Plus in Texas you have options like FSEDs. The increase in FSED have made EM MDs even more scarce so our earning power goes up. The CMGs that are running those small town EDs are forced to pay outrageous rates if they want boarded docs.

MedMal is GREAT. Our 100 plus doc group may have had 5 lawsuits in the 15 yrs i have been here. You have to literally kill someone while chanting that you doing it on purpose to lose a lawsuit.

 

[HunterGatherer]

wherever you and your family is happiest.

 

[deleted206819]

I'll start :

Texas
- minimal med mal
- No state income tax
- meddlesome Medical Board
- hydrocodone going schedule 2 (which means triplicates)
- because Perry refused Medicaid matching, a lot of your low income patients still cannot get insurance
- pay can be pretty great
- some simply AMAZING pathology
* last week in one shift had nec fasc, RCA STEMI in a pacemaker, walky-talky VT, saddle PE, acute appy in a 40 yo M c Aortic stenosis on warfarin, acute cholecystitis, couple of pulmonary edemas on bipap/ntg/lasix, tube in the ICU on a Mallampatti IV (Bougie baby!), plus the usual back pain, chest pain, abdominal pain nothing-omas

Practicing in DFW now and I see that hydrocodone going schedule 2 (which means triplicates) as a positive. We don't have to prescribe schedule 2 drugs and don't have to carry triplicates if we don't want to do so. Blame goes to the federal government when patients ask. I'm not keeping triplicates for years on end and creating more paperwork headaches for myself.

 

[jaeida8]

Triplicate forms are no longer required. Just need a special DPS prescription pad and the pharmacy transmits the prescription electronically.

 

[Chip N Sawbones]

Alaska
Advantages:
-No state taxes of any kind. Borough and city sales and property taxes are generally quite reasonable. The Permanent Fund Dividend is estimated at $1,500-2,000 per person this year.
-Very, very high physician salaries.
-Reasonable med mal climate. Not as good as Texas, but none of the doctors I talked to seemed worried about malpractice. Noneconomic damages limited to $250,000; limited to $400,000 for wrongful death or injury over 70 percent disabling; limits not applicable to intentional or reckless acts or omissions.
-Hiking, hunting, fishing and other activities abound. I lived fifteen minutes from the only hospital in Alaska's second biggest city and I could go moose hunting out of my kitchen window.
-Cool Third World pathology

Disadvantages:
-Winters can be cold, dark and depressing.
-If your wife isn't as enthusiastic about moving to Alaska as you are, don't come here unless you are a bachelor or wish to quickly become one.
-Cost of living is higher than the national average, but in most places it's not unreasonable, especially when you factor in the lack of sales taxes in many towns.

 

[hoot504]

-Very, very high physician salaries.

Does this include Anchorage or just the more desolate parts?

 

[Chip N Sawbones]

Does this include Anchorage or just the more desolate parts?

I don't know for sure what the range of salaries across the state is. According to the map I posted, Anchorage has lower salaries, though I don't know how much lower they would be for EM.

 

[b-real]

Triplicate forms are no longer required. Just need a special DPS prescription pad and the pharmacy transmits the prescription electronically.

You still have to keep records of every schedule 2 Rx u prescribe, as they can be audited. It actually makes it harder w/o the triplicate.

 

[jaeida8]

You still have to keep records of every schedule 2 Rx u prescribe, as they can be audited. It actually makes it harder w/o the triplicate.

Please show me a link corroborating that info. The Texas DPS website states that the practitioner just needs to have a record of his/her control numbers in a secure place. http://www.txdps.state.tx.us/RegulatoryServices/prescription_program/prescriptionforms.htm

Regardless I will do whatever it takes to keep my ability to prescribe hydrocodone to people who are being sent home with humerus fractures, nasty wrist fractures etc.

 

[b-real]

Please show me a link corroborating that info. The Texas DPS website states that the practitioner just needs to have a record of his/her control numbers in a secure place. http://www.txdps.state.tx.us/RegulatoryServices/prescription_program/prescriptionforms.htm

Regardless I will do whatever it takes to keep my ability to prescribe hydrocodone to people who are being sent home with humerus fractures, nasty wrist fractures etc.

http://www.txdps.state.tx.us/RSD/PrescriptionProgram/documents/DPSDrugRules.pdf

Bottom of page 54. Two years is the record retention period.

 

[jaeida8]

That doesn't specify needing to keep copies of every prescription.

 

[Cheese Whiz]

I will keep my Texas license forever

 

[deleted206819]

That doesn't specify needing to keep copies of every prescription.

All schedule II prescriptions will require triplicates and retention for two years. See the Texas Medical Association writeup about it. While I feel for patients with fractures and such, I cannot justify adding to or continuing the opioid addiction in our society. In the schedule III-IVcategories, we have available to us tramadol, tylenol #3, NSAIDs and I realize that they have their own potential for abuse. I also cannot justify retaining records for a two year period such that if one is missing I will on the end of a medical board penalty -- no thanks.

 

[jaeida8]

All schedule II prescriptions will require triplicates and retention for two years. See the Texas Medical Association writeup about it. While I feel for patients with fractures and such, I cannot justify adding to or continuing the opioid addiction in our society. In the schedule III-IVcategories, we have available to us tramadol, tylenol #3, NSAIDs and I realize that they have their own potential for abuse. I also cannot justify retaining records for a two year period such that if one is missing I will on the end of a medical board penalty -- no thanks.

You guys still haven't shown me any evidence that you have to keep copies of prescriptions with the new forms. By the way the new forms are not triplicates. The new forms are just special prescription forms in a pad ordered from DPS. The newest version has barcodes as well. As per the instructions from DPS on my pre-2010 prescription pad the only record keeping it asks for is "Carefully record the control number appearing on your prescription forms in a secure place apart from the forms."

The TMA link you sent me says the following. There is no mention of triplicates or keeping copies of the new forms for 2 years:
On Aug 22, 2014, the US Drug Enforcement Administration (DEA) published a final rule in the Federal Register reclassifying drugs that contain hydrocodone combinations from Schedule III to Schedule II. The change will take effect Oct 6, 2014.
What does the new rule mean for physicians?

• Prohibits physicians from delegating to advance practice nurses (APNs) and physician assistants (PAs) authority to prescribe these drugs outside of a hospital or hospice setting.
• Prevents physicians from calling in prescriptions for these medications to pharmacies (except in emergencies, in which case oral transmission must be followed up with written prescription within 7 days- see Texas Health and Safety Code, Ch. 481 Controlled Substances Act. Sect 481.074. PRESCRIPTIONS);
• Physicians must use the official prescription pads from Texas Department of Public Safety (DPS) for written prescriptions;
• Prohibits refills of prescriptions for these drugs without a patient visit or consultation; and
• Physicians may issue prescriptions for Schedule II drugs for a maximum 90-day period. *

If I write a prescription for a hydrocodone combination product on Oct 5, 2014 (while it is still a Schedule III drug) and specify refills, will pharmacies honor those written under the Oct 5, 2014 prescription, or must I rewrite the prescription as a Schedule II drug with no refills?

Prescriptions for hydrocodone combination products (HCPs) that are issued before Oct 6, 2014 and that have authorized refills, may be dispensed in accordance with DEA rules until April 8, 2015. Both DPS and the Texas State Board of Pharmacy have indicated that refills authorized on prescriptions dispensed prior to Oct 6, 2014 will be honored.



How do I order the Official Prescription Program pads?

Forms may be ordered from DPS using the official order form for prescription pads for practitioners. APNs and PAs (hospital setting or hospice only) must use this official order form. Pads of 100 forms cost $9. Unfortunately, DPS does not offer an option for online credit card orders. The standard time frame for fulfillment is 30 days, however, the DPS has diverted additional personnel to process orders and is fulfilling orders in 15-20 days, on average. The form may be emailed, faxed to (512) 424-5380, or mailed to DPS:

Texas Prescription Program
PO Box 15888
Austin, TX 78761-5888

Contact DPS Prescription Control Program at (512) 424-7293 or the Regulatory Services Division at (512) 424-7293.



Do federal and state laws allow for e-prescribing of Schedule II drugs?

Yes, e-prescribing of controlled substances (EPCS) is legal. However, physicians need to use an EPCS-certified e-prescribing vendor and ensure the pharmacy in receipt of the EPCS is able to receive the prescription. Currently, EPCS in Texas is in the very early stages and still fairly rare.

Check which e-prescribing vendors are certified for EPCS. Check which pharmacies are able to receive EPCS.

For more information about e-prescribing of controlled substances, see A Necessary Pain: e-Prescribing of Controlled Substances is Worth It from the July 2014 issue of Texas Medicine magazine.

Can residents in a medical residency program in Texas write prescriptions for Schedule II drugs?

According to DPS, the physician-in-training (PIT) must contact their permit office, staff coordinator, or department in charge of approving its PIT prescribing authority. The medical training institution will provide to the DPS' Texas Prescription Program a letter or list on company letterhead (or via electronic document) the names of authorized PITs along with the Texas Medical Board PIT permit numbers. As a validation, the Texas Medical Board provides the Texas Prescription Program a monthly electronic file exchange with all current PIT permit holders. DPS has posted FAQs on their website regarding the reclassification of HCPs.




- See more at: http://www.texmed.org/Template.aspx?id=31794&terms=hydrocodone#sthash.CcFQfJQD.dpuf

 

[JGlueck]

Any info on practicing in South Florida?

 

[Dre8]

Texas has Ebola, so ...Nope!

 

[richnathan]

Any other states offering similar compensation to Texas?

 

[HunterGatherer]

Barbara Katz should be coming out with her yearly articles soon "Compensation" and "Location" trends in ACEP Now this and next month.

 

[Old_Mil]

I'll start :

Texas

- because Perry refused Medicaid matching, a lot of your low income patients still cannot get insurance

Just a word of advice to you all who are considering jobs. Medicaid expansion is a very big deal with regards to the practice of emergency medicine. I'm currently practicing in a Medicaid expansion state. Our volumes have risen 25% over the past year. Unfortunately, our collections have decreased. Our personal experience, at least, has borne out that research that medicaid patients use the ED at a rate 40% higher than all other patient groups and reimburse worse than self-pay.

My expectation is that in the future, avoidance of medicaid expansion states is going to be almost as big a deal for physicians looking for a good place to practice as avoidance of states with a hostile malpractice climate.