Compensation For Ordering Tests

[TheSeanieB]

Before med school, I shadowed a family doctor. My shadowing experience has lead me to wonder what the incentive or disincentive is for a physician to order tests. For example, a patient would come in with an unknown skin problem. He would give the patient advice and sometimes a perscription without any testing to determine the microbe that is causing the problem. I also noticed this with blood work also.

So my questions is: do family medicine doctors get compensated for taking blood samples or other sample to be submitted for lab work? Thanks.

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[Apollyon]

Before med school, I shadowed a family doctor. My shadowing experience has lead me to wonder what the incentive or disincentive is for a physician to order tests. For example, a patient would come in with an unknown skin problem. He would give the patient advice and sometimes a perscription without any testing to determine the microbe that is causing the problem. I also noticed this with blood work also.

So my questions is: do family medicine doctors get compensated for taking blood samples or other sample to be submitted for lab work? Thanks.

I don't even know the specifics, for a few reasons, but me getting paid for ordering a test is called a "kickback" - meaning, some of the money spent on the test is "kicked back" to me. That's illegal, but I don't know the specific laws that apply. The general public believes, though, that it is a regular, accepted, and expected occurrence.

I'm not FM - I'm EM - but your question applies broadly across specialties.

Another would be, for example, someone who biopsies something - family med, derm, GI - and sends that sample to a pathologist who does some exotic and expensive test on the sample (something not routine), and if the path person sent a payment to whomever ordered it.

 

[TheSeanieB]

I don't even know the specifics, for a few reasons, but me getting paid for ordering a test is called a "kickback" - meaning, some of the money spent on the test is "kicked back" to me. That's illegal, but I don't know the specific laws that apply. The general public believes, though, that it is a regular, accepted, and expected occurrence.

I'm not FM - I'm EM - but your question applies broadly across specialties.

Another would be, for example, someone who biopsies something - family med, derm, GI - and sends that sample to a pathologist who does some exotic and expensive test on the sample (something not routine), and if the path person sent a payment to whomever ordered it.

So are doctors disincentived to run such test and investigate their patient's complaints because there is no additional benefit? Instead, there is the additional cost of collecting the sample and discussing the results with the patient.

 

[Apollyon]

So are doctors disincentived to run such test and investigate their patient's complaints because there is no additional benefit? Instead, there is the additional cost of collecting the sample and discussing the results with the patient.

That's kind of an advanced idea, and goes against the spirit of medicine. That I wouldn't order a test because I wouldn't get paid for it? That is ludicrous, because that would be grossly unethical, and, if it led to a patient injury, malpractice.

If you are a med student, have they taught you yet about beneficence and nonmaleficence? It is difficult, actually, to not do right by a patient by systematically shorting them on appropriate diagnosis and treatment.

If you want to be paid minute by minute, become a lawyer. They will charge you per minute on the telephone, by email (and by lines in the email), waiting, and anything else they can break down into quantifiable units.

And, if someone is putting into your mind about this, they are steering you clear wrong - unless you want a felony conviction, loss of licenses, and all that time down the drain.

 

[deleted87716]

There are federal laws (e.g., Stark and other) which prohibit physicians from profiting directly from labs, studies, and referrals.

http://starklaw.org/stark-law-faq.htm

That being said, physicians may be bonused indirectly by their employer for referring within their health system, or penalized in some way if they don't. Physicians can also profit from a shared ancillary service (e.g., central lab or imaging) if the profits are pooled and split equally amongst a group of physicians.

If there is ever any direct incentive to order or not order a test, there's a good chance you're dealing with something illegal.

As for your example, not every diagnosis requires a confirmatory test. The majority of derm diagnoses are made on the basis of history and physical exam alone.

 

[TheSeanieB]

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[Apollyon]

Yes, I understand all of that. If you reread my original post, I am asking because I am trying to understand some of the behavior that I noticed while shadowing. You have jumped to an insulting conclusion.

What, about becoming a lawyer? You specifically asked about being disincentived because there was no additional benefit. And I did not draw a conclusion, per se - I said "If". If that is not applicable to you, then it isn't.

If the doc knew what it was, there wasn't an indication for further testing. Not doing it because s/he wouldn't get a kickback is not the most likely conclusion.

 

[Prncssbuttercup]

Yes, I understand all of that. If you reread my original post, I am asking because I am trying to understand some of the behavior that I noticed while shadowing. You have jumped to an insulting conclusion.

I did not see an insult in what was said...

FWIW, if that is you in your avatar picture, I will strongly advise you to change it.

 

[VA Hopeful Dr]

Yes, I understand all of that. If you reread my original post, I am asking because I am trying to understand some of the behavior that I noticed while shadowing. You have jumped to an insulting conclusion.

I didn't see an insult either.

You don't have to "run a test" on everything to get the answer.

 

[deleted87716]

I don't see the perceived "insult," either.

Frankly, I would find it insulting if a med student thought that I was financially motivated in terms of how I approached my patients.

Just sayin'.

 

[lowbudget]

There are federal laws (e.g., Stark and other) which prohibit physicians from profiting directly from labs, studies, and referrals.

http://starklaw.org/stark-law-faq.htm

That being said, physicians may be bonused indirectly by their employer for referring within their health system, or penalized in some way if they don't. Physicians can also profit from a shared ancillary service (e.g., central lab or imaging) if the profits are pooled and split equally amongst a group of physicians.

If there is ever any direct incentive to order or not order a test, there's a good chance you're dealing with something illegal.

As for your example, not every diagnosis requires a confirmatory test. The majority of derm diagnoses are made on the basis of history and physical exam alone.

Agree.

To add, whoever does the blood draw can bill the venipuncture procedure fee. If a 3rd party lab does it, then they bill it. If you or your designee does it, then you bill it.

I think as students move through training, they'll learn that there are some diagnoses that are "clinical" diagnoses, some diagnoses that can only be picked up by "lab" or "biopsy" or "imaging". They'll also learn that sometimes "tests" will take you down the wrong path, which is why they should be ordered judiciously; and at the end of the day it takes an educated judgement to make a diagnosis. That's why only physicians (by law, at least in my state) can make a diagnosis.

 

[deleted87716]

To add, whoever does the blood draw can bill the venipuncture procedure fee. If a 3rd party lab does it, then they bill it. If you or your designee does it, then you bill it.

Venipuncture fees are so minimal (typically <$10) that they barely cover the cost of the technician and supplies. They certainly aren't enough to provide any sort of motivation to order tests.

 

[ghost dog]

Before med school, I shadowed a family doctor. My shadowing experience has lead me to wonder what the incentive or disincentive is for a physician to order tests. For example, a patient would come in with an unknown skin problem. He would give the patient advice and sometimes a perscription without any testing to determine the microbe that is causing the problem. I also noticed this with blood work also.

So my questions is: do family medicine doctors get compensated for taking blood samples or other sample to be submitted for lab work? Thanks.

No, but I do get $100000000 for every Oxycontin "perscription" written ( please note that the pinky finger is raised).

For lipitor its double that, playa.

Please don't tell patients I get paid for writing "perscriptions".

 

[Apollyon]

I don't see the perceived "insult," either.

Frankly, I would find it insulting if a med student thought that I was financially motivated in terms of how I approached my patients.

Just sayin'.

But there's an attending in my home forum that does think like that (seriously) (although it's not money in his pocket, but making monetary value judgments about people's lives).

 

[Shinken]

I think the issue is that the OP is a medical student that does not yet quite understand clinical medicine in real practice (which is perfectly OK...that's why she's a student), and perhaps she - like most of us at that time - has some idealistic "everything must be done for the patient because we're doctors" mentality. She incorrectly assumed her attending did not order a test because the attending would not get any financial reward for it.

In reality, as so many mentioned here, many diagnoses are clinical. For example, any kid with otitis media I treat with antibiotics without any aspiration of middle ear fluid for culture and sensitivities. Acute sinusitis, the same. Rashes I treat according to what I think they are (fungal? eczema? scabies? psoriasis? cellulitis?). If a rash does not respond to a couple of treatment attempts THEN I biopsy. But I don't biopsy every single rash that I see. It has nothing to do with financial incentives.

To the OP: give it some time, and what you think is unethical behavior from your attending might very well be the way you will practice medicine in a few years. As a matter of fact, if every physician ordered cultures, labwork, CT scans, biopsies, etc. without using clinical judgment, the cost of health care would quadruple (and that's probably a conservative guess).

 

[Prncssbuttercup]

I think the issue is that the OP is a medical student that does not yet quite understand clinical medicine in real practice (which is perfectly OK...that's why she's a student), and perhaps she - like most of us at that time - has some idealistic "everything must be done for the patient because we're doctors" mentality. She incorrectly assumed her attending did not order a test because the attending would not get any financial reward for it.

In reality, as so many mentioned here, many diagnoses are clinical. For example, any kid with otitis media I treat with antibiotics without any aspiration of middle ear fluid for culture and sensitivities. Acute sinusitis, the same. Rashes I treat according to what I think they are (fungal? eczema? scabies? psoriasis? cellulitis?). If a rash does not respond to a couple of treatment attempts THEN I biopsy. But I don't biopsy every single rash that I see. It has nothing to do with financial incentives.

To the OP: give it some time, and what you think is unethical behavior from your attending might very well be the way you will practice medicine in a few years. As a matter of fact, if every physician ordered cultures, labwork, CT scans, biopsies, etc. without using clinical judgment, the cost of health care would quadruple (and that's probably a conservative guess).

How many people do you see with mange (scabies)?

 

[VA Hopeful Dr]

How many people do you see with mange (scabies)?

Personally? A few/month. The clinic as a whole... 3-5/week.

 

[Prncssbuttercup]

Please tell me there is a reason for this... (homeless I assume??)

 

[VA Hopeful Dr]

Please tell me there is a reason for this... (homeless I assume??)

Poor hygiene, lots of people living in a small house (most common), pretty contagious.

 

[Prncssbuttercup]

I am familiar with it in veterinary applications, which is why I was figuring homelessness as a cause, but I can see that... What kind of system or setting do you work in? I would think the community health centers I worked in in Denver would see similar cases, but I am not sure, thoughts?

 

[VA Hopeful Dr]

I am familiar with it in veterinary applications, which is why I was figuring homelessness as a cause, but I can see that... What kind of system or setting do you work in? I would think the community health centers I worked in in Denver would see similar cases, but I am not sure, thoughts?

Resident clinic affiliated with a 450-bed community hospital.

 

[Prncssbuttercup]

What kind of precautions do you have to take with those people in the office? I would think you'd have to be careful not to spread it...

 

[Shinken]

How many people do you see with mange (scabies)?

Maybe about once every month or so, enough to be on my differential for an "itchy rash."

 

[Prncssbuttercup]

My former in-laws got it from a stray dog they rescued... They said it was wonderful...

 

[WEBB PINKERTON]

Look up "client billing" on the internet. Physician collects a specimen to be sent to the lab (blood, tissue, pap test) and pays the lab a small fee. Then the physician office turns around and marks the test up and bills the patient. It leads to test overutilization and has been around for years. Kickbacks do occur in medicine but they are underreported by the media. Wall street journal did an article about this years ago but it fell on deaf ears for the most part. Its illegal to do this for medicare/medicaid patients but legal for other payers. I've worked in pathology for many years and it has always made me feel ill.

Its a slap in the face to have an office tell you to lower your "client price" 50 cents for a test or we wont send you specimens anymore. They only want the price lowered so THEY can make more money.

 

[TPBC]

Look up "client billing" on the internet. Physician collects a specimen to be sent to the lab (blood, tissue, pap test) and pays the lab a small fee. Then the physician office turns around and marks the test up and bills the patient. It leads to test overutilization and has been around for years. Kickbacks do occur in medicine but they are underreported by the media. Wall street journal did an article about this years ago but it fell on deaf ears for the most part. Its illegal to do this for medicare/medicaid patients but legal for other payers. I've worked in pathology for many years and it has always made me feel ill.

Its a slap in the face to have an office tell you to lower your "client price" 50 cents for a test or we wont send you specimens anymore. They only want the price lowered so THEY can make more money.

Webb Pinkerton, I don't quite follow what you said in the last paragraph. Can you explain that in a little more detail? (I know, I'm a billing/financial dummy!).

 

[deleted87716]

No lab in their right mind is going to offer reduced client pricing to solo or small practices. if you're a large group or have some kind of huge test volume, you might have some leverage.

You'll never be able to collect any more than a patient's insurance company will reimburse, anyway.

Client pricing is not a "kickback." If it was, it would be illegal.