Are you a pill mill?

[Poetic Silence]

I got a CT scan for my lung once. After confirming my lung pathology, the radiologist made note of a gallstone I would have otherwise not known of or had any reason to suspect I had.

I always thought that was the reason the radiology profession exists. Not just to confirm a broken bone, but to point out the tumor you had no reason to suspect you had.

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[PMR 4 MSK]

I got a CT scan for my lung once. After confirming my lung pathology, the radiologist made note of a gallstone I would have otherwise not known of or had any reason to suspect I had.

I always thought that was the reason the radiology profession exists. Not just to confirm a broken bone, but to point out the tumor you had no reason to suspect you had.

I think moreso, the field exists to do things other fields and practioners lack the training and experience doing, much like any other field. In this case, it is to proivide expert eyes in reporting on films.

E.g. There is nothing to stop a Physiatrist from treating a fracture themself. If they see a patient in their clinic, they can cast them and follow them. No requirement to refer to ortho. Should they refer to rotho? Yes, if nothing else, to CYA. But if they know the fracture well enough and have appropriate expereince, they can treat it. I never would, however.

The argument to have radiology report on all xrays in order to find that 1/1000 cancer is only a CYA argument.

Let's look at another situation. If you do fluoro procedures in the hospital, most hospitals will send every image you save to radiolgy, who will give a report like "There appears to be a metallic object resembling a needle in the vicinity of the L4-5 neuroformaina, and further images showing what appears to be a radio-opaque substance infiltrating the spinal canal. Clinical correlation for epidural injection recommended."

Wow, thanks guys. You really helped me there. After I've already done the injection, you've given a hedging report of what I might have done, therefore opening the door, should litigation arise, to the plaintiff's attorney speculating it was done incorrectly. Plus you got paid, adding to the patient bill an unneccesary and unhelpful report.

What exactly does that accomplish?

Another thing is sometimes radiologists are not looking at what we look at. I periodically call them on the phone when I see something not mentioned in the report, to have them do an addendum if approriate for things they were not looking for. E.g., while the were reporting on the adenexal cysts and recommendation for "ultrasound for further evaluation", they did not comment on L4 inferior endplate defect with surrounding hyperintense signal on T2, or not reporting on the facets but going into detail about the disk bulge at L3-4.

So I guess it really comes down to what you are comfortable doing, and what you want referred out to someone with more experience or training to help treat the patient. You could read your own MRIs, but until you've read several hundred to a thousand or more that were re-read by someone above you, I would not recommend it.

 

[facetguy]

Let's look at another situation. If you do fluoro procedures in the hospital, most hospitals will send every image you save to radiolgy, who will give a report like "There appears to be a metallic object resembling a needle in the vicinity of the L4-5 neuroformaina, and further images showing what appears to be a radio-opaque substance infiltrating the spinal canal. Clinical correlation for epidural injection recommended."

Wow, thanks guys. You really helped me there. After I've already done the injection, you've given a hedging report of what I might have done, therefore opening the door, should litigation arise, to the plaintiff's attorney speculating it was done incorrectly. Plus you got paid, adding to the patient bill an unneccesary and unhelpful report.

What exactly does that accomplish?
.

We know that insurance companies love to deny claims. Do they automatically pay radiologists for reports like this? If yes, it's easy to see a day when carriers start denying what seem like unnecessary reports.

 

[Substance]

I'm not better than everyone here. Just a lot better than you. But that's your problem, I can live with it.

Wow.

If there's one thing that's certain, its that people who think they're taking the high road aren't.

Can the sanctimony. A large part of taking the high-road is humility.

Painting every physician with the broad-swath of greed is acrimonious at best.

 

[lobelsteve]

Wow.

If there's one thing that's certain, its that people who think they're taking the high road aren't.

Can the sanctimony. A large part of taking the high-road is humility.

Painting every physician with the broad-swath of greed is acrimonious at best.

Thanks for sharing.

 

[ghost dog]

Wow.

If there's one thing that's certain, its that people who think they're taking the high road aren't.

Can the sanctimony. A large part of taking the high-road is humility.

Painting every physician with the broad-swath of greed is acrimonious at best.

Whoaaa, hypocritical !

A recent post from substance:

http://forums.studentdoctor.net/showthread.php?t=753007&page=7

" Medical students are drawn to fields with money and prestige: derm, rads, ophtho, plastics etc.

Family medicine as a field has neither of these things. It pays crap, and the prestige is down there with the pathologists and psychiatrists.

The only way to attract good people is to pay them well and make them feel valued. The only way for "family medicine" to achieve this is to drastically reduce their spots so that they all fill with american graduates. Eventually demand will increase and the income will follow. When the income follows, the prestige goes with it.

The problem with my own suggestion is that "family medicine" by its very nature is primary care, and the primary care model is based on ease-of-access which runs counter to cutting the spots.

Maybe the specialty of "family medicine" could change to "rural medicine" and rural practitioners be paid exorbitant amounts for being both isolated and the community's physician (I'm talking combined the income of OB, ER, and FP into one huge 600k a year thing). Urban primary care could be taken care of by nurses and the occasional physician.

But since none of these things will come to pass, and family medicine(the specialty with the lamest name, by the way) will continue to be underpaid and undervalued, good students will continue to avoid it, and it will be the haven for the carib grads and FMGs as it is now.

There is no hope for family medicine."

Dx:

Axis I: deferred
Axis II: Toolus Maximus

 

[Tenesma]

i have not allowed my rads to read my fluoro films for the last 6 years ---
1) pts didn't understand why they were getting rads bills
2) the rads reports were 100% a joke (ie: "spinal procedure w/ 8 seconds of fluoro", "epidural placement visualized" when in fact the proc was an MBB, and the list goes on) - not once did they ever comment on spinal or non-spinal pathology
3) the rads advised me that I am assuming liability for missed pathology - which is a joke as well because A) they never mentioned pathology before in their reports B) all of my patients getting procedures have already had official Xrays, CTs or MRIs - how do they think a fuzzy fluoro image is now going to reveal a tumor when it wasn't evident on XR/CT or MRI?

 

[facetguy]

This is kind of related to the docs-dispensing-meds idea, this time with anemia meds (e.g. Procrit):
http://www.washingtonpost.com/busin...at-what-cost/2012/07/19/gJQAX5yqwW_story.html

"In this case, drugmakers worked diligently to make sure that doctors had an incentive to give large doses — that the spread was large. They offered discounts to practices that dispensed the drug in big volumes. They overfilled vials, adding as much as 25 percent extra, allowing doctors to further widen profit margins. Most critical, however, was the company’s lobbying pressure, under which Congress and Medicare bureaucrats forged a system in which doctors and hospitals would be reimbursed more for the drug than they were paying for it."

“It was just so easy to do — you put this stuff in the patient’s arm, and you made thousands of dollars,” said Charles Bennett, endowed chair at the Medication Safety and Efficacy Center of Economic Excellence at the University of South Carolina and one of the critics of the use of the drug in cancer patients. “An oncologist could make anywhere from $100,000 to $300,000 a year from this alone. And all the while they were told that it was good for the patient.”

 

[mille125]

Hmm...

http://www.medassoc.com/Services/Diagnostics/Diagnostics Front Page.html
http://www.medassoc.com/Services/Physical Therapy/PTHome.htm
http://www.medassoc.com/Services/North Georgia Endoscopy Center/MainEndoscopy.htm
http://www.stevenlobel.com/procedures.html

oh my...

 

[mille125]

how does the cost of medication compare to an outside pharmacy?

if the physician is dispensing, and they are charging the exact same price as a pharmacy, personally that seems to be less concerned with profiteering than, say, some of the cancer physicians who charge significantly increased cost.

the other aspect of this situation that concerns me is opioid prescription therapy. i dont know, but to be a physician that dispenses oral meds... that goes beyond the slippery slope, given the abuse potential.

Interesting discussion here and interesting NYTimes article pulled up by Steve....

I owe a pharmacy and I really would like to know where they are getting their data. First of all pharmacy reimbursement is similar to physician reimbursement on the insurance side. Insurance patients pay the same no matter where they get their prescription filled. It is determined by a term called AWP. If I charge 10 million dollars and walgreens charges 100 dollars but AWP is 100 dollars then reimbursement will be AWP - some percentage. Walgreen more than likely has a better contract than me and will get reimbursed more. Patient pays the same 20 or 40 dollar copay.

Every last one of my private pay patients pay less than they would at any pharmacy. I have talked to other physician pharmacy owns and for the most part this is true in their pharmacies as well.

I offer free delivery to all of my customers/patients and our customer service rivals anyone. Many folks appreciate this. No one has to stand in line. Greater than 50% of my patients DO NOT use my pharmacy.

My pharmacy is not heavily opioid based. There is a mix of topical compounds and commercial non opioid meds as well. Make money in the pharmacy business is NOT easy despite popular convention.

Walgreens et al. and the Government want physician dispensing and small independent pharmacies eliminated. They make it next to impossible to get contracts. I call this the Walmart effect. Walmart is very adept at eliminating small business competition by any means necessary. It is sad when our colleagues have bought into this as well by reading and quoting excerpts from the ill informed our those with hidden agendas.

 

[Ducttape]

apples to oranges...

you own a pharmacy, and a pharmacist dispenses the prescriptions based on what is covered by insurance.

they are talking about a physician dispensing meds from their own office, from the prescription the physician wrote for the patient, and marking up the price to dispense these medications, or charging a "small" dispensing fee.

i believe that this is similar to a practice previously used by many oncologists for chemo drugs... (this is from private conversations with oncologists), who would buy large quantities of these drugs at discount, charge for the drugs at max return, and charge dispensing fees.

 

[mille125]

apples to oranges...

you own a pharmacy, and a pharmacist dispenses the prescriptions based on what is covered by insurance.

they are talking about a physician dispensing meds from their own office, from the prescription the physician wrote for the patient, and marking up the price to dispense these medications, or charging a "small" dispensing fee.

i believe that this is similar to a practice previously used by many oncologists for chemo drugs... (this is from private conversations with oncologists), who would buy large quantities of these drugs at discount, charge for the drugs at max return, and charge dispensing fees.

thanks for the clarification.....definitely apples to oranges.......

 

[PMR 4 MSK]

So people here are against a physician making a profit on a drug he dispenses. How many of you only bill insurance exactly what it costs you for your steroids? Or Synvisc? Or any other injectable.

Oh, wait a minute, that's different! If I inject it, I can make a profit. If I sell it, I can't!

WTF?

 

[bedrock]

gets a bit holier than thou around here sometimes

 

[Ducttape]

So people here are against a physician making a profit on a drug he dispenses. How many of you only bill insurance exactly what it costs you for your steroids? Or Synvisc? Or any other injectable.

Oh, wait a minute, that's different! If I inject it, I can make a profit. If I sell it, I can't!

WTF?

im not trying to be holier, but i bill insurance for exactly what it costs... im trying to be honest. working in a hospital outpatient department also "helps"...

how i make money is on the procedure itself, not on the cost of stocking the drug in the office. i suppose if a doctor is selling the medication for what is billable, like a pharmacy, that i would deem that acceptable. but if the same physician charges a "handling" fee above that amount, similar to what is happening with the gas and oil business, that seems to go counter to integrity, as the physician is also the same person that is prescribing...

 

[PMR 4 MSK]

im not trying to be holier, but i bill insurance for exactly what it costs... im trying to be honest. working in a hospital outpatient department also "helps"...

how i make money is on the procedure itself, not on the cost of stocking the drug in the office. i suppose if a doctor is selling the medication for what is billable, like a pharmacy, that i would deem that acceptable. but if the same physician charges a "handling" fee above that amount, similar to what is happening with the gas and oil business, that seems to go counter to integrity, as the physician is also the same person that is prescribing...

At least you are consistent with your charges.

Medicine is a business. When I started, I had my own solo office. I watched as one company after another screwed me out of many thousands of dollars, finally totalling over $200K over 5 years. Every other entity you deal with expects to make a profit.

Your landlord - making a profit off your rent.
Your supply companies - making a profit off what you buy.
The insurance companies you contract with - making a profit by denying your claims.
Uncle Sam - taking the money you earned and giving it to those whom they deem to need it more, like Senator's cousins, mistresses, those who donate to their re-election campaign, etc.

Everyone wants a piece of your money, and every year they want to receive more or give you less.

Something they paid you $100 for last year, they'll pay you $80 this year. Next year $75. Or maybe $82, depending on what congress does. And they'll try to make you think that $2 raise was something special. Be grateful.

Now I have learned that in order to get what was promised in a contract, I have to "play the game." Inflate costs. Overbill. Appeal denials. Write LOMNs. Say "Mother may I please?" to some peer-to-peer doc who gets paid to deny my request for an MRI.

Failure to play this game results in less money going home with me, more to CMS and insurance companies, and patients who don't get what they want and/or need.

Medicine used to be all about the patients. Now, too often, it becomes all about the Benjamins.

 

[mille125]

At least you are consistent with your charges.

Medicine is a business. When I started, I had my own solo office. I watched as one company after another screwed me out of many thousands of dollars, finally totalling over $200K over 5 years. Every other entity you deal with expects to make a profit.

Your landlord - making a profit off your rent.
Your supply companies - making a profit off what you buy.
The insurance companies you contract with - making a profit by denying your claims.
Uncle Sam - taking the money you earned and giving it to those whom they deem to need it more, like Senator's cousins, mistresses, those who donate to their re-election campaign, etc.

Everyone wants a piece of your money, and every year they want to receive more or give you less.

Something they paid you $100 for last year, they'll pay you $80 this year. Next year $75. Or maybe $82, depending on what congress does. And they'll try to make you think that $2 raise was something special. Be grateful.

Now I have learned that in order to get what was promised in a contract, I have to "play the game." Inflate costs. Overbill. Appeal denials. Write LOMNs. Say "Mother may I please?" to some peer-to-peer doc who gets paid to deny my request for an MRI.

Failure to play this game results in less money going home with me, more to CMS and insurance companies, and patients who don't get what they want and/or need.

Medicine used to be all about the patients. Now, too often, it becomes all about the Benjamins.

I have no problem with anyone making a profit. However charging a patient $3000 for a chemotherapeutic drug that cost you $100 or charging a patient 6 dollars a pill for something that they can get at Walgreens for 20 cents per pill is not ethical in my book. Just because you can do something doesnt mean that you should. Patients do put trust in you to make decisions that are in their best interests.

I have a good friend who has had a tough time recently and unfortunately fell into the realm of payday cash advances. Talk about taking advantage. $5000 loan. Has paid $1200 per month for 4 months and still owes over $4800 in principle. This is a true story.......Yikes................

 

[Substance]

Whoaaa, hypocritical !

A recent post from substance:

http://forums.studentdoctor.net/showthread.php?t=753007&page=7

" Medical students are drawn to fields with money and prestige: derm, rads, ophtho, plastics etc.

Family medicine as a field has neither of these things. It pays crap, and the prestige is down there with the pathologists and psychiatrists.

The only way to attract good people is to pay them well and make them feel valued. The only way for "family medicine" to achieve this is to drastically reduce their spots so that they all fill with american graduates. Eventually demand will increase and the income will follow. When the income follows, the prestige goes with it.

The problem with my own suggestion is that "family medicine" by its very nature is primary care, and the primary care model is based on ease-of-access which runs counter to cutting the spots.

Maybe the specialty of "family medicine" could change to "rural medicine" and rural practitioners be paid exorbitant amounts for being both isolated and the community's physician (I'm talking combined the income of OB, ER, and FP into one huge 600k a year thing). Urban primary care could be taken care of by nurses and the occasional physician.

But since none of these things will come to pass, and family medicine(the specialty with the lamest name, by the way) will continue to be underpaid and undervalued, good students will continue to avoid it, and it will be the haven for the carib grads and FMGs as it is now.

There is no hope for family medicine."

Dx:

Axis I: deferred
Axis II: Toolus Maximus

You are a very defensive individual. Cool it down a notch.

The fact that the most popular specialties are the most lucrative does not indicate greed, it indicates that people like to be paid for their work. Also notice that prestige and self-actualization play a big part in job satisfaction. The popular specialties have those things too, as does pediatrics, which is paid little. The least popular specialties have neither income benefits nor prestige, which make those fields unpopular.

Greed is when people try to circumvent ethics to gain wealth. Big difference, unless of course you think that derms rads and ophthos are by definition circumventing ethics, and if you do, that's just madness.

 

[PMR 4 MSK]

I have no problem with anyone making a profit. However charging a patient $3000 for a chemotherapeutic drug that cost you $100 or charging a patient 6 dollars a pill for something that they can get at Walgreens for 20 cents per pill is not ethical in my book. Just because you can do something doesnt mean that you should. Patients do put trust in you to make decisions that are in their best interests.

I have a good friend who has had a tough time recently and unfortunately fell into the realm of payday cash advances. Talk about taking advantage. $5000 loan. Has paid $1200 per month for 4 months and still owes over $4800 in principle. This is a true story.......Yikes................

I agree with only charging fair market value. Overcharging when someone does not know the FMV is unethical.

 

[ghost dog]

You are a very defensive individual. Cool it down a notch.

The fact that the most popular specialties are the most lucrative does not indicate greed, it indicates that people like to be paid for their work. Also notice that prestige and self-actualization play a big part in job satisfaction. The popular specialties have those things too, as does pediatrics, which is paid little. The least popular specialties have neither income benefits nor prestige, which make those fields unpopular.

Greed is when people try to circumvent ethics to gain wealth. Big difference, unless of course you think that derms rads and ophthos are by definition circumventing ethics, and if you do, that's just madness.

Originally Posted by Substance

"Wow.

If there's one thing that's certain, its that people who think they're taking the high road aren't.

Can the sanctimony. A large part of taking the high-road is humility.

Painting every physician with the broad-swath of greed is acrimonious at best."

This joker posted the above rant in the Family med forums. He's got some nerve speaking of "humility".

And thus, my Dx.

 

[Substance]

Originally Posted by Substance

"Wow.

If there's one thing that's certain, its that people who think they're taking the high road aren't.

Can the sanctimony. A large part of taking the high-road is humility.

Painting every physician with the broad-swath of greed is acrimonious at best."

This joker posted the above rant in the Family med forums. He's got some nerve speaking of "humility".

And thus, my Dx.

Cool story, brah.