Cash pay for narcotics

[wavygravy99]

Want to ask people's opinion on this. Has been a follower on this forum and have found the input and discussion valuable

Recently I have a few patients came to me, some by referral, but they don't have insurance, they want to pay cash for their visits but only want me to manage their opioid. Sometime I just don't know what to do with these patients, if I recommend procedures, it's probably too costly and they won't be able to afford or no interest in pursuing. I just don't like the optic of essentially they are giving me cash for a opioid prescription. Granted it's easy and don't have to deal with insurance reimbursement. What are people's thought on this, appreciate the input

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[SommeRiver]

Under no circumstances IMO.

I also wouldn't advise you to dispense from your practice either.

The optics are very bad, and the surrounding doctors would hear about it and may not feel comfortable sending you pts.

If it was anything other than opiates I'd say do it.

 

[thecentral09]

Ummmmm no. The DA would have a field day making You front page news.

 

[wavygravy99]

Under no circumstances IMO.

I also wouldn't advise you to dispense from your practice either.

The optics are very bad, and the surrounding doctors would hear about it and may not feel comfortable sending you pts.

If it was anything other than opiates I'd say do it.

I agree, so far I have turned them down. I even refunded the cash they paid to come see me when I find out they only want opioid. I decided to post this because I received a referral from one of my spine surgeon who send me many patients. This particular patient for whatever reason lost medical insurance after the new year. Patient just had a surgery I believe in early December. Haven't seen the patient yet, but found out the situation when we called the patient.

 

[callmeanesthesia]

I agree, so far I have turned them down. I even refunded the cash they paid to come see me when I find out they only want opioid. I decided to post this because I received a referral from one of my spine surgeon who send me many patients. This particular patient for whatever reason lost medical insurance after the new year. Patient just had a surgery I believe in early December. Haven't seen the patient yet, but found out the situation when we called the patient.

I definitely think you made the right move. Even from a good referrer it’s not worth it. I’d recommend telling your schedulers to make sure all cash pay patients know you will not prescribe opioids prior to scheduling.

 

[RM38]

If they had surgery in December why isn’t the surgeon managing? Global fee is for 90 days which should include peri-op pain. No reason for patient to pay you cash when surgeon has already been paid for what they should be doing themselves.

 

[wavygravy99]

If they had surgery in December why isn’t the surgeon managing? Global fee is for 90 days which should include peri-op pain. No reason for patient to pay you cash when surgeon has already been paid for what they should be doing themselves.

When the surgeon refered to me, I think his intent was have me do an injection because of the scar tissue irritation and possibly SCS, I could be wrong on the timing of surgery, it could have been earlier in Oct or Nov. Receive the referral late December, finally able to reach patient after patient rescheduled and that's when found out no more insurance

 

[drusso]

Most addiction doctors are cash-practices. Why discriminate against patients who have high deductible insurance plans or possibly no insurance? Cash patients can be a pleasure to with because they actually have "skin in the game."

As long as you're following appropriate guidelines, from an equity perspective, I can't justify discriminating against any payer source--Medicaid, Self-Pay, or Commercial insurance.

 

[Aether2000]

Giant red flag for the state medical board, state attorney generals, city and county prosecutors, and the DEA. If other treatments are being documented (non-opioid medications) and compliance with specific home exercise programs are consistently documented, then there may be less civil and criminal liability. Of course the elephant in the room is why are they continuing to receive long term opioids for chronic non-malignant pain given the numerous studies that demonstrate chemical dependency is being maintained and that the opioids have no demonstrable benefit.

 

[deleted480308]

Want to ask people's opinion on this. Has been a follower on this forum and have found the input and discussion valuable

Recently I have a few patients came to me, some by referral, but they don't have insurance, they want to pay cash for their visits but only want me to manage their opioid. Sometime I just don't know what to do with these patients, if I recommend procedures, it's probably too costly and they won't be able to afford or no interest in pursuing. I just don't like the optic of essentially they are giving me cash for a opioid prescription. Granted it's easy and don't have to deal with insurance reimbursement. What are people's thought on this, appreciate the input

Manage their taper or manage their “it’s not touching my pain” ever increasing chronic meds

 

[NJPAIN]

If they had surgery in December why isn’t the surgeon managing? Global fee is for 90 days which should include peri-op pain. No reason for patient to pay you cash when surgeon has already been paid for what they should be doing themselves.

Bingo!
My feelings exactly. I had a patient come in last week, sent by surgeon, who has a scheduled abductor longus release and sports hernia repair. She was given written material instructing her to consult a pain management physician for postoperative pain management “because state laws do not allow surgeons to prescribe opioid pain medication”.


Sent from my iPhone using Tapatalk

 

[Ducttape]

Most addiction doctors are cash-practices. Why discriminate against patients who have high deductible insurance plans or possibly no insurance? Cash patients can be a pleasure to with because they actually have "skin in the game."

As long as you're following appropriate guidelines, from an equity perspective, I can't justify discriminating against any payer source--Medicaid, Self-Pay, or Commercial insurance.

you know this...
1. most addiction doctors are prescribing suboxone, a tightly monitored Schedule 3 drug, not Percs or oxycontin.
2. the intent of addiction and pain management are very different and this is very obvious to those who are reviewing charts
3. high deductible is not cash pay. they still have insurance, which still may be "monitoring" prescriptions. these patients are motivated towards trying all forms of treatment - when they reach their deductible. different situations.

from my perspective - the optics of prescribing opioids for cash is bad, regardless of how you sugar coat it. and they will be resistant to all other forms of care - "I cant afford it, but I can afford the Percs". and they will argue about making your visits Level 2. they don't give UDS willingly, and are often too busy working at a phantom job to come in for pill counts.

take it from drusso's perspective - $43 every 1-3 months, for someone who can take your prescription, and do who knows what with them...



from the surgeon's perspective - opioids really should be used for only the first 2 weeks or so. anything longer than 4 weeks is probably too long for acute postsurgical pain...

 

[drusso]

you know this...
1. most addiction doctors are prescribing suboxone, a tightly monitored Schedule 3 drug, not Percs or oxycontin.
2. the intent of addiction and pain management are very different and this is very obvious to those who are reviewing charts
3. high deductible is not cash pay. they still have insurance, which still may be "monitoring" prescriptions. these patients are motivated towards trying all forms of treatment - when they reach their deductible. different situations.

from my perspective - the optics of prescribing opioids for cash is bad, regardless of how you sugar coat it. and they will be resistant to all other forms of care - "I cant afford it, but I can afford the Percs". and they will argue about making your visits Level 2. they don't give UDS willingly, and are often too busy working at a phantom job to come in for pill counts.

take it from drusso's perspective - $43 every 1-3 months, for someone who can take your prescription, and do who knows what with them...



from the surgeon's perspective - opioids really should be used for only the first 2 weeks or so. anything longer than 4 weeks is probably too long for acute postsurgical pain...

What happens when people are in between insurance plans or start a new job and don't have COBRA?

I don't think you should prescribe to anyone who is a diversion risk or otherwise not a candidate for COT.

Who sad cash patients don't need to give UDS's?

Why are you billing a level 2 for a pain patient? Especially one you think MIGHT be high risk?

 

[Ferrismonk]

Bingo!
My feelings exactly. I had a patient come in last week, sent by surgeon, who has a scheduled abductor longus release and sports hernia repair. She was given written material instructing her to consult a pain management physician for postoperative pain management “because state laws do not allow surgeons to prescribe opioid pain medication”.


Sent from my iPhone using Tapatalk

All. the. time.. I even have printed out the Global period definitions to hand out to patients.

Even if you have a practice that includes opiate prescribing and you must continue this for whatever reason, not engaging in appropriate multimodal treatment of pain (i.e. interventional procedures) is grounds for removal of opiates in my book. Opiates are the most dangerous and least indicated treatment for pain.

 

[paindoc007]

All. the. time.. I even have printed out the Global period definitions to hand out to patients.

Even if you have a practice that includes opiate prescribing and you must continue this for whatever reason, not engaging in appropriate multimodal treatment of pain (i.e. interventional procedures) is grounds for removal of opiates in my book. Opiates are the most dangerous and least indicated treatment for pain.

Meh. That’s another form of pills for shots. “You need to do these shots for me, so if give these pills to you”

that’s not appropriate.

I’m 100% with you that a multimodal approach is the way to go. But re-engaging in PT, working in weight loss, is also fine.

 

[Baron Samedi]

If your local newspaper ran a headline saying "Dr. _______ accused of selling opioid prescriptions" how would you feel?

I agree the optics are bad. I wouldn't do it.

 

[iwumd07]

Meh. That’s another form of pills for shots. “You need to do these shots for me, so if give these pills to you”

that’s not appropriate.

I’m 100% with you that a multimodal approach is the way to go. But re-engaging in PT, working in weight loss, is also fine.

But if most of the pain groups in the community do this “shots for narcs” BS, does that make it the standard of care in the community?

 

[Laryngospasm]

I can’t recall any single issue that has been used to make pain docs look bad regardless of actual guilt more than cash pay patients getting opioids. If you want to do it fine but i know I won’t.

 

[Ducttape]

What happens when people are in between insurance plans or start a new job and don't have COBRA?

I don't think you should prescribe to anyone who is a diversion risk or otherwise not a candidate for COT.

Who sad cash patients don't need to give UDS's?

Why are you billing a level 2 for a pain patient? Especially one you think MIGHT be high risk?

- if they are not working, no opioid medication. level of functioning not appropriate for opioids, and not working means a lot more time to focus on home exercise to improve functionality.


- no one said cash patients don't need to give UDS. they do. but it is an extra cost that they will complain vehemently about. some will go so far as to complain why I require the LC/GS to quantify the results, as opposed to getting a nonspecific urine dip that "you don't have to charge me for, if you have a soul".

- no one said that you should be billing level 2 visits. patients will request you bill a level 2 visit so it is less expensive for them... "if you have a soul"...

apparently, I don't.


fwiw, this is all from personal experience of taking over a pain clinic rife with opioid prescribing, and (previously) with quite a few cash pay patients on opioids.

 

[Multimodal]

this is one of those "no good deed goes unpunished" situations. There are plenty of other non-cash paying patients that need my help and can benefit from it.

 

[drusso]

- if they are not working, no opioid medication. level of functioning not appropriate for opioids, and not working means a lot more time to focus on home exercise to improve functionality.


- no one said cash patients don't need to give UDS. they do. but it is an extra cost that they will complain vehemently about. some will go so far as to complain why I require the LC/GS to quantify the results, as opposed to getting a nonspecific urine dip that "you don't have to charge me for, if you have a soul".

- no one said that you should be billing level 2 visits. patients will request you bill a level 2 visit so it is less expensive for them... "if you have a soul"...

apparently, I don't.


fwiw, this is all from personal experience of taking over a pain clinic rife with opioid prescribing, and (previously) with quite a few cash pay patients on opioids.

The farther you remove patients from their payments (ie third party, insurance companies, the government) the less incentive (skin in the game) they have for their own health. Only seeing third-party payer patients relegates a doctor to a custodial relationship with their patient--treating patients like Medicare/Insurance ATM machines.

More doctors offering direct-pay health care

Some say they can offer patients better care through memberships rather than insurance.

www.usatoday.com

"Health care providers say they are transitioning to direct-pay medicine because they are able to spend more time with fewer patients, which allows them to drill down to the cause of a medical issue instead of ordering extra tests. The doctors are also more readily available to patients after hours."

 

[Ducttape]

so ill send all my cash pay opioid patients to you.

good luck with that.

 

[drusso]

so ill send all my cash pay opioid patients to you.

good luck with that.

If they can afford it. Some patients have no choice. At least they won't get a surpise medical bill.

 

[SommeRiver]

Cash pay for an ACEi and HCTZ is a totally different situation than a chronic pain pt throwing down $50 for their Percocet.

That article describes concierge medicine run by a PCP, and can not be compared to a pain physician bc it just isn't the same.

I'd love to hear some stories about 2 AM house calls for acute on chronic pain, 90 min clinic visits when the medical decision making was done within 10 seconds which is usually the case in a pt with facet dz and axial pain that hasn't changed.

Either way you're still billing insurance companies like all concierge doctors do...

Concierge pain medicine is Michael Jackson BS. Those pts pay you for access and shorter lines. Try quarterly urines on those pts and watch them go nuts.

What happens if they violate the opioid contract and you have to fire them but they're paid up for the next 6 months?

 

[drusso]

Cash pay for an ACEi and HCTZ is a totally different situation than a chronic pain pt throwing down $50 for their Percocet.

That article describes concierge medicine run by a PCP, and can not be compared to a pain physician bc it just isn't the same.

I'd love to hear some stories about 2 AM house calls for acute on chronic pain, 90 min clinic visits when the medical decision making was done within 10 seconds which is usually the case in a pt with facet dz and axial pain that hasn't changed.

Either way you're still billing insurance companies like all concierge doctors do...

Concierge pain medicine is Michael Jackson BS. Those pts pay you for access and shorter lines. Try quarterly urines on those pts and watch them go nuts.

What happens if they violate the opioid contract and you have to fire them but they're paid up for the next 6 months?

Why do you see it as preferable or better to have more middle-men involved in patient care and the doctor-patient relationship? How does that improve access, quality, or reduce cost? The third-party payer system (either commercial or government) spawned SOS and is the root of all evil in our health care system. It is the reason the US pays 3X the rest of the world for inferior outcomes. Put the money and the responsibility back into the patient's hands.

 

[callmeanesthesia]

Why do you see it as preferable or better to have more middle-men involved in patient care and the doctor-patient relationship? How does that improve access, quality, or reduce cost? The third-party payer system (either commercial or government) spawned SOS and is the root of all evil in our health care system. It is the reason the US pays 3X the rest of the world for inferior outcomes. Put the money and the responsibility back into the patient's hands.

Because patients who want to cash pay for opioids and nothing else are looking for a legal drug dealer, not medical care. Also, high direct cost to the patient is a major reason chronic disease care in the US sucks, not something we need more of.

 

[drusso]

Because patients who want to cash pay for opioids and nothing else are looking for a legal drug dealer, not medical care. Also, high direct cost to the patient is a major reason chronic disease care in the US sucks, not something we need more of.

Coverage =/= Care.

Lot's of people have either high deductible plans, no pharmacy benefits, narrow networks (that don't offer pain management services), are trapped in HMO's, enrolled in health ministries, or to simply prefer not to use insurance to pay for their health care because they don't want "Big Brother" in their lives.

The standard of care should not be determined by the payer source.

 

[SommeRiver]

Why do you see it as preferable or better to have more middle-men involved in patient care and the doctor-patient relationship? How does that improve access, quality, or reduce cost? The third-party payer system (either commercial or government) spawned SOS and is the root of all evil in our health care system. It is the reason the US pays 3X the rest of the world for inferior outcomes. Put the money and the responsibility back into the patient's hands.

None of that has anything to do with my general point - Pain pts.

Not at all the same thing.

 

[Ducttape]

Why do you see it as preferable or better to have more middle-men involved in patient care and the doctor-patient relationship? How does that improve access, quality, or reduce cost? The third-party payer system (either commercial or government) spawned SOS and is the root of all evil in our health care system. It is the reason the US pays 3X the rest of the world for inferior outcomes. Put the money and the responsibility back into the patient's hands.

unfortunately, your system does not allow for a doctor-patient relationship that is more predicated on rules and regulations that the government puts on doctors with regards to Controlled substances.

in this case, standard of care requires that we make demands on patients that are not in line with the touchy feely vibe you are attempting to pass off as a better system.

and no, I do not want a healthcare system where the rich can get any opioid they want as long as they pull out their checkbooks. though it would lead to income equality probably faster than any wealth distribution tactic known to man.

 

[drusso]

unfortunately, your system does not allow for a doctor-patient relationship that is more predicated on rules and regulations that the government puts on doctors with regards to Controlled substances.

in this case, standard of care requires that we make demands on patients that are not in line with the touchy feely vibe you are attempting to pass off as a better system.

and no, I do not want a healthcare system where the rich can get any opioid they want as long as they pull out their checkbooks. though it would lead to income equality probably faster than any wealth distribution tactic known to man.

Patients and society lose when doctors capitulate their knowledge and expertise to GIGO-informed Big Government Health Care rules and regulations. That's the difference between a profession and a laborer. Doctors should get paid the same way lawyers, electricians, and plumbers do.

 

[Ducttape]

standard anti hospital talk and kinda diversionary, isn't it?

are you recommending that we abandon the government "guidelines" enforced through the CSA?

 

[drusso]

standard anti hospital talk and kinda diversionary, isn't it?

are you recommending that we abandon the government "guidelines" enforced through the CSA?

I don't understand the values of your brand of socialism: Why do you defend de-personalized, third-party controlled, hospital-medical-industrial complex decision making while I advocate for patient-centered care and MD-autonomy? When you strip away all the sociological artifice medicine is just people taking care of people. Those values are grounded in antiquity.

 

[Ducttape]

I'm not defending the hospital-medical-industrial complex.


the dark side of "patient-centered care and MD-autonomy" is lack of access for a significant portion of the population where it becomes not about people taking care of people, but how much cash do they have on hand for care. I try to stay focused on helping people, regardless of their W2.


but... in this case, the government has imposed "guidelines" regarding controlled substances that, for the most part, I agree with.

 

[drusso]

I'm not defending the hospital-medical-industrial complex.


the dark side of "patient-centered care and MD-autonomy" is lack of access for a significant portion of the population where it becomes not about people taking care of people, but how much cash do they have on hand for care. I try to stay focused on helping people, regardless of their W2.


but... in this case, the government has imposed "guidelines" regarding controlled substances that, for the most part, I agree with.

Some people prefer or out of necessity to pay cash for E/M visits and/or procedures and/or prescriptions.

How is it equitable to not serve them or force them to use a third-party payer? Why on earth would involving third-party payers be safer than just a one-on-one transaction? Most "cash pay" patients are still financing their health care in one form or another (crowd-sourcing, credit cards, health ministries, etc) just not through a traditional health plan.

 

[Ducttape]

so you have a lot of ppl paying cash for your prescription for oxy? get back to the topic.

gl with that.

I have no issues with cash pay patients when it comes to everything besides scripts. I don't do cash for scripts.

 

[Ferrismonk]

 

[drusso]

so you have a lot of ppl paying cash for your prescription for oxy? get back to the topic.

gl with that.

I have no issues with cash pay patients when it comes to everything besides scripts. I don't do cash for scripts.

I don’t dispense oxycodone the pharmacy does. But, I’ve had tons of patients have to pay cash for subutex because their health plan’s pharmacy formulary adversely tiered Belbuca. Same molecule. Should I not serve those patients because some third party payer made an arbitrary rule not informed by science nor expert content knowledge. And you lecture libertarians about being cold hearted but defend a corrupt third-party payment model and promote inequitable treatment of people who take their own financial responsibilities into their own hands and finance their own doctor-patient relationship? People paying cash for their health care shouldn't be treated differently from patients who use third-party financing.

Opinion: Not What the Doctor Ordered | The Lund Report

www.thelundreport.org

"The federal government is implementing these policies for many seniors on Medicare plans -- forcing them to fight these arbitrary rules in order to access medications and treatments that their physicians have deemed most appropriate for their specific situations."




Let me guess: Warren 2020?

 

[Ducttape]

er, no. I am not defending a third-party payment model. and I'm not promoting inequitable treatment of self-pay patients.

I am saying only and explicitly I do not write narcotics for patients who put down cold hard cash as payment for my services.




finally, you clearly have not read any of my posts. leaning towards Buttigieg.

 

[drusso]

er, no. I am not defending a third-party payment model. and I'm not promoting inequitable treatment of self-pay patients.

I am saying only and explicitly I do not write narcotics for patients who put down cold hard cash as payment for my services.

finally, you clearly have not read any of my posts. leaning towards Buttigieg.

Buttigieg has no chance of winning because America is not ready for a First Gentleman in the White House...not that there's anything wrong with that.

And, the SJW's, Millenials, and other liberal tribes think he's too establishment.

 

[promethius]

I agree with no cash for narcotics. I tell them that if they do not have insurance, I will be happy to see them, but I cannot prescribe them any narcotics. The last patient who called in this situation hung up because she was supposedly getting oxycodone 30 mg for cash.

For any newbies out there, you will eliminate a ton of headaches if you do not accept cash for narcotics. Patients who pay cash for narcotics will not be able to do any other treatments that a multimodal pain practice will use to treat pain including physical therapy and procedures because they are too expensive. They will also be upset about the cost for a confirmatory urine drug test. The confirmatory urine drug test is not optional in my opinion and is to protect you the physician from patients who are either lying or trying to game the system. I have had on more than a few occasions obtained point-of-care urine drug screens on patients that are consistent for oxycodone and returned on confirmatory testing with just oxycodone and no metabolites, indicating those patients have been shaving their pills into their urine cup rather than actually taking them. If you just do the point-of-care urine drug screen on those patients, you will never catch that.

Narcotics are different from prescribing blood pressure or diabetic medications. Narcotics are actually worth something on the street. They are being diverted unless the patient convinces me otherwise. Unless you raise the cost of your office visits for cashing paying patients to more than the going street value of the narcotics you prescribe, you will be flooded with "patients" who are looking for narcotics to divert. You may actually be turning down a few true pain patients who have legitimate pain and can only afford to pay for narcotics with cash, but that is not worth the risk to your license in an already inherently risky specialty. Just do not accept cash for narcotics.

 

[lobelsteve]

I agree with no cash for narcotics. I tell them that if they do not have insurance, I will be happy to see them, but I cannot prescribe them any narcotics. The last patient who called in this situation hung up because she was supposedly getting oxycodone 30 mg for cash.

For any newbies out there, you will eliminate a ton of headaches if you do not accept cash for narcotics. Patients who pay cash for narcotics will not be able to do any other treatments that a multimodal pain practice will use to treat pain including physical therapy and procedures because they are too expensive. They will also be upset about the cost for a confirmatory urine drug test. The confirmatory urine drug test is not optional in my opinion and is to protect you the physician from patients who are either lying or trying to game the system. I have had on more than a few occasions obtained point-of-care urine drug screens on patients that are consistent for oxycodone and returned on confirmatory testing with just oxycodone and no metabolites, indicating those patients have been shaving their pills into their urine cup rather than actually taking them. If you just do the point-of-care urine drug screen on those patients, you will never catch that.

Narcotics are different from prescribing blood pressure or diabetic medications. Narcotics are actually worth something on the street. They are being diverted unless the patient convinces me otherwise. Unless you raise the cost of your office visits for cashing paying patients to more than the going street value of the narcotics you prescribe, you will be flooded with "patients" who are looking for narcotics to divert. You may actually be turning down a few true pain patients who have legitimate pain and can only afford to pay for narcotics with cash, but that is not worth the risk to your license in an already inherently risky specialty. Just do not accept cash for narcotics.

No. You are greatly overestimating the number of people who will go to a real physician to try and obtain narcotics for diversion. Diversion on any profitable scale requires organizing a crew. The docs involved run cash only and do not treat any real conditions. Only pain. Care is unimodal and Rxs are written for resale. Based on value of drug. A few years ago after a lot of work by DEA, the survivors upped their paperwork game. They have 50 page contracts, rules, and clinic policies. They put in exam room supplies. They brought in PT equipment. They Rx nsaid and gabapentin to make it look better on paper.

 

[lobelsteve]

DOJ Takes Down 'Pill Mill' Network for Millions of RXs

In less than 15 months, one Houston-area doctor allegedly prescribed about 2 million pills of controlled substances, including over 800,000 oxycodone pills and almost 450,000 hydrocodone pills.

www.medscape.com

 

[lobelsteve]

Imposter Doc Guilty of Prescribing Over 200K Opioid Doses: DOJ

A Houston-area man who posed as a physician was found guilty of conspiring to unlawfully prescribe hundreds of thousands of doses of opioids at a "pill mill."

www.medscape.com

 

[drusso]

I agree with no cash for narcotics. I tell them that if they do not have insurance, I will be happy to see them, but I cannot prescribe them any narcotics. The last patient who called in this situation hung up because she was supposedly getting oxycodone 30 mg for cash.

For any newbies out there, you will eliminate a ton of headaches if you do not accept cash for narcotics. Patients who pay cash for narcotics will not be able to do any other treatments that a multimodal pain practice will use to treat pain including physical therapy and procedures because they are too expensive. They will also be upset about the cost for a confirmatory urine drug test. The confirmatory urine drug test is not optional in my opinion and is to protect you the physician from patients who are either lying or trying to game the system. I have had on more than a few occasions obtained point-of-care urine drug screens on patients that are consistent for oxycodone and returned on confirmatory testing with just oxycodone and no metabolites, indicating those patients have been shaving their pills into their urine cup rather than actually taking them. If you just do the point-of-care urine drug screen on those patients, you will never catch that.

Narcotics are different from prescribing blood pressure or diabetic medications. Narcotics are actually worth something on the street. They are being diverted unless the patient convinces me otherwise. Unless you raise the cost of your office visits for cashing paying patients to more than the going street value of the narcotics you prescribe, you will be flooded with "patients" who are looking for narcotics to divert. You may actually be turning down a few true pain patients who have legitimate pain and can only afford to pay for narcotics with cash, but that is not worth the risk to your license in an already inherently risky specialty. Just do not accept cash for narcotics.

Think about the consequences of making the doctor-patient relationship a third-party enterprise. Doctors should be paid like lawyers, electricians, and plumbers.

Patients paying cash for health care (which is usually financed on credit cards, crowdsourcing platforms, etc) empowers people to break free from the chokehold of the insurance companies, pharmacy benefit managers, and health plans.

Standards of care should not vary by payer source. And, treating people differently based upon payer source is inequitable. Every good Liberal knows that.

 

[lobelsteve]

Dollars for Docs

ProPublica has compiled the disclosed payments from pharma companies to doctors and other health care providers. Search for your doctor in our interactive database.

projects.propublica.org

Just saying...

 

[callmeanesthesia]

Think about the consequences of making the doctor-patient relationship a third-party enterprise. Doctors should be paid like lawyers, electricians, and plumbers.

Patients paying cash for health care (which is usually financed on credit cards, crowdsourcing platforms, etc) empowers people to break free from the chokehold of the insurance companies, pharmacy benefit managers, and health plans.

Standards of care should not vary by payer source. And, treating people differently based upon payer source is inequitable. Every good Liberal knows that.

Keep it simple and don’t prescribe opioids to anyone. I have very few cash pay patients, - Less than one a month.

 

[ahmedt]

Why describe prescribing for this cohort as zero sum? The CDC has built in risk tiers. Assuming there is real objectively verifiable pathology, consider low dose ( <20MED) Management. Require patient to pay for gc/ms. Confirm that this is a monthly expectation. If they can’t afford that, be available for random pill counts like any other patient, then you wouldn’t be able to provide controlled substances as part of your treatment plan. Explain to them that with these costs monthly long term it is likely in their best interest to obtain health insurance as premise of the practice is multimodal therapy with a focus on interventional treatments.

Ideally this shouldn’t rise to more than 5% of your practice. If it does, then re-evaluate that policy.

I think it’s one thing for the board of medicine or DEA to go after a practice that caters to this cohort as the main means for their revenue compared to a practice that is generally trying to employ best practices and documenting recommendations for alternative care and risk mitigation strategies.

Feels unfair to me that we would make a distinction between a self pay patient and a worker’s compensation patient where the carrier continuously denies every med and every procedure outside of an opiate.

 

[MilknCheerios]

I'm a pharmacist and so my scope of practice is limited to dispensing. We get a fair amount of prescriptions from patients who are in real chronic pain and they are handled meticulously. I check the patient's history for early fills, proper diagnosis, reasonable doses, offer narcan, etc. The pharmacy will call you if we feel something is amiss and refuse to fill if we don't hear back from you.

Some of our patients don't have prescription insurance for whatever reason (premium cost, high copay, just being a pain in the ass to use- no pun intended), but if the RX is legitimate as above, I would fill it. Can you as a prescriber spend some time with your patient, as I have, and evaluate whether or not they are a drug seeker or someone who really needs your help? Can your colleagues rely on you as being a member of the healthcare team or just a repository for their problematic patients?

The answer to what you should do probably lies somewhere in the middle. For example, if there's someone who you're not sure is an abuser, you can decide to see them every 2 weeks to make sure their pain is being managed appropriately and effectively. You can have them bring in their pharmacy bottle and back count how much is in there. If the patient doesn't follow your pain regimen or something doesn't seem right, they're out. If a patient is faithful for say 6 months, then ease up a bit. Being able to treat pain must surely be a rewarding experience. When they finally stop having to see you, you have successfully done your part.

 

[Ferrismonk]

I'm a pharmacist and so my scope of practice is limited to dispensing. We get a fair amount of prescriptions from patients who are in real chronic pain and they are handled meticulously. I check the patient's history for early fills, proper diagnosis, reasonable doses, offer narcan, etc. The pharmacy will call you if we feel something is amiss and refuse to fill if we don't hear back from you.

Some of our patients don't have prescription insurance for whatever reason (premium cost, high copay, just being a pain in the ass to use- no pun intended), but if the RX is legitimate as above, I would fill it. Can you as a prescriber spend some time with your patient, as I have, and evaluate whether or not they are a drug seeker or someone who really needs your help? Can your colleagues rely on you as being a member of the healthcare team or just a repository for their problematic patients?

The answer to what you should do probably lies somewhere in the middle. For example, if there's someone who you're not sure is an abuser, you can decide to see them every 2 weeks to make sure their pain is being managed appropriately and effectively. You can have them bring in their pharmacy bottle and back count how much is in there. If the patient doesn't follow your pain regimen or something doesn't seem right, they're out. If a patient is faithful for say 6 months, then ease up a bit. Being able to treat pain must surely be a rewarding experience. When they finally stop having to see you, you have successfully done your part.

Agree, however as I'm sure you know and have also read here, this is a huge time and money sink that the patient hates you for. Helping people with their pain is a very rewarding experience; managing an opiate wean and always saying "No" to crazy demands while repeatedly looking over your shoulder for the next auditor is not rewarding in the least. Definitely not worth a 99213/99214.

In my experience, cash pay patients, other than those temporarily in between insurances, aren't looking for Tylenol #3 twice a day, they're looking for Oxy 30 four times a day.

 

[drusso]

Agree, however as I'm sure you know and have also read here, this is a huge time and money sink that the patient hates you for. Helping people with their pain is a very rewarding experience; managing an opiate wean and always saying "No" to crazy demands while repeatedly looking over your shoulder for the next auditor is not rewarding in the least. Definitely not worth a 99213/99214.

In my experience, cash pay patients, other than those temporarily in between insurances, aren't looking for Tylenol #3 twice a day, they're looking for Oxy 30 four times a day.

Would you prescribe Oxy 30 mg QID to a patient who's insurance picked up 100% of the cost or only required a $5 co-pay for brand-name Oxycontin?