Cash pay for narcotics

[DrSpine]

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Cash pay for opioids? Sounds like a great idea. What could possibly go wrong? 🤔

 

[Ferrismonk]

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?

Nope.

 

[drusso]

Nope.

Then payer source is irrelevant as it should be.

 

[RM38]

I think the point is that most patients that want to come to us and pay cash are expecting high dose meds because that is typical of what I have been seeing from those types of practices when I was in FL and now in the Carolinas as well. Less prevalent in Carolinas, but those types of places still exist. My current and last practice does not accept cash pay patients unless they had been our patient and lost insurance for a temporary period of time. They understand we will not escalate meds if other things (PT, injections, work up, etc) are better suited for management of the issue and that they will be expected to pay for UDS and LCMS if needed. They are also told they need to work on obtaining insurance sooner than later.

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...

I get the surgeons perspective on acute post surgical pain, but if they have a surgical issue or even a non-surgical issue that they are managing, I expect them to manage it. I am not going to manage pain from a humerus fracture that happened 1 week ago that is non-op. Ortho can do that. Also I am not going to see a patient 3wks s/p TKR to manage pain meds because the surgeon doesn't want to. If they don't think the patient should be on opioids anymore, they should tell them that and offer alternatives. If they do then they should prescribe it. Neither of which require my involvement. If we accepted these types of patients I would be flooded with dumps very quickly. I would be busy all day, but the wait for the patients that could really benefit from me would be longer. My procedure volume would drop a bit I am sure as well.

 

[lobelsteve]

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?

Sure. And I have documentation to back it. The only patient I currently have on that regimen has a rare incurable and fatal disease.

 

[swamprat]

My first year out I didn’t like cash pay for opioids mostly bc I said no and then patients would be pissed they paid money and didn’t get what they wanted. Well I worked in the ghetto. I also never gave their money back

Now I have a few cash pay patients with pathology with appropriate UDS who has been maintained on whatever regimen for years and so and so retired or lost insurance or whatever. Yes I will take 300$ for a med refill. If the UDS is appropriate, which I do randomlybut frequently, the pathology is there as well as the history of being on the meds I don’t see a problem with cash pay. Heck if they had a Medicaid I took it’d be like 28$ for a 99214

 

[emd123]

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

Are they going to pay cash for the drug screen, MRI, procedures, PT, abuse resistant formulations and everything else you need to safely take care of them?

No.

Have your schedulers tell all patients, "Patients paying cash are not candidates for opiate treatment."

The only exception would be a long standing patient that had insurance, who has UDSs, imaging, etc, already in place and they lose their insurance temporarily.

Nearly all illegal pill mills are cash-only, by the way. Cops aren't stupid: The more cash pay patients you have, the more likely they are to be suspicious.

 

[deleted131481]

Despite all the pathology, UDS, etc there are patients that will fool you. For every +UDS there is probably several that we miss. Those paying cash are (anecdotally) much more likely to be aberrant. You are less likely to do harm by simply screening these.

If you have 1 or 2 exceptions with strong indication, fine. If you have dozens of these patients, then it's much more likely to be a problem.

 

[Ducttape]

Why describe prescribing for this cohort as zero sum? The CDC has built in risk tiers.

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.

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?

I would make the argument that none of these examples are patients who require opioids.

When they finally stop having to see you, you have successfully done your part.

this is the problem. once someone is on opioids long enough at high enough dose, they become Legacy patients and cannot stop use.

 

[Ferrismonk]

Sure. And I have documentation to back it. The only patient I currently have on that regimen has a rare incurable and fatal disease.

I have a few legacy patients on high-dose therapy as well in similar situations. However, I would argue that your patient should likely have a greater amount of thier MMED be from long-acting meds and smaller prn dosing. Nobody needs 45MMED in one shot for chronic pain.

 

[lobelsteve]

I have a few legacy patients on high-dose therapy as well in similar situations. However, I would argue that your patient should likely have a greater amount of thier MMED be from long-acting meds and smaller prn dosing. Nobody should need 45MMED in one shot for chronic pain.

Fixed it for you.

 

[ahmedt]

I would make the argument that none of these examples are patients who require opioids.


Fair enough...just out of curiosity what do you do in these situations for the cash pay or WC guy on ~20MED? Tell them they need insurance or to tell them to take it up with their adjuster and follow up PRN? Does it make a difference if the guy has cirrhosis and a mechanical heart valve and your relative risk for injections/nsaids/Tylenol is now higher than baseline?

 

[Ducttape]

your guy with cirrhosis and mechanical heart most likely qualifies for Medicare. that's still not a reason by itself to start opioids, but it does mean that non-opioid medications are covered.

WC in most states covers some baseline medications. there is a specific drug formulary in my state, for example that lists covered drugs.

I would argue if you are on that low an MED, the medications may not be doing so much for you that you cannot manage without them, or manage with non-opioid medications.