Thursday, October 10, 2013

Crossing over

A friend of mine, while traveling, recently took her son to a doctor in an unfamiliar area for a semi-urgent issue. While there the staff tried to sell her weight loss supplements (and she's slim), asked her (and she wasn't the patient) if she had foot numbness (giving her a brochure about a pseudo-NCV procedure they do), and tried to talk her into a sleep study. She hadn't raised any of these issues, but they were repeatedly brought up by the physician and his staff while treating her daughter.

Pissy and I call this "The Dark Side." And, unfortunately, it's a growing trend in medicine.

Insurance reimbursements dwindle, and so doctors try to find "alternative revenue" streams. Sometime they aren't a bad idea, but other times they're simply unnecessary tests and/or ineffective treatments done solely to increase profits. The worst are where they involve an invasive, potentially hazardous, procedure that has no proven benefit. Pointless biopsies that won't change a treatment plan, gadgets to relieve pain that aren't statistically superior to placebo, supplements sold at the front counter with extravagant claims to cure Alzheimer's, and other horseshit.

Doctors who do this likely start out as well-intentioned, and end up on a slippery slope. As the revenue stream increases they get greedy, adding more and more bells and whistles to the practice- at the cost of patient care. Like Anakin Skywalker, they become seduced by the Dark Side, needing to keep expanding their practice away from what's best for the patient.

Of course, they won't admit that. To them the new laser-magneto-hydrological thingamajig they put in to cure chronic halitosis at $100 a pop is medically necessary. It's not covered by any insurance, or even mentioned in any reputable publications, but the company that sells it has infomercials on TV and glossy booklets for the waiting room. Likewise, there are some procedures that are covered by insurance but have no real medical evidence to support them. And they're also done purely for profit.

Years of moving in that direction have convinced the doctors involved that these things are the standard of care. Like Darth Vader, once you cross the line there's no going back.

I get calls from companies selling this stuff, too. Usually Mary filters them out, but occasionally they reach me. Or fly in under the radar by claiming to be a drug rep. They show me graphs of start-up costs and how much money I can make (usually insane amounts, like $100K per month, with an asterisk noting that's only if you see patients 24/7).

I try to be polite, but in my mind I hear them speaking in a deep voice through slow, heavy, respirations, asking me to join them on the Dark Side,

Luke tossed his lightsaber aside and walked away. I just thank them and head back to my desk. I may not be getting rich, but at least after 15 years of this I can still face myself in the mirror and believe I'm doing what's right for my patients.


Anonymous said...

I guess that "explains" why my former rheumatologist prescribed supplements, which he then sold to me on my way out the door. Disgusting.

Anonymous said...

I suspect my dentist is sliding down this slope, too - almost every visit a new procedure is touted, of course each shiny new "toy" is "not yet covered by insurance" etc.

I wonder if there is a correlation with the fact that I NEVER see other folks in the waiting room any longer...we, too, are now looking for a new dentist.


Oh, and when we got our last bill and saw how little our insurance paid, the dentist's office staff said that they took insurance BUT no longer were in network for anyone as they didn't want insurers telling them what labs to use, etc and "affecting patient care".

Mary said...

Thank you for being ethical; I think the vast majority of docs are. Sadly, I have been harmed by hired guns for the insurance company (worker's comp) who make insane amounts of money writing insurance company- favorable opinions designed to deny treatment. I really appreciate the ethical providers!!

Wendy at Taking the Long Way Home said...

Thank you. My kids' pediatrician, whom I've known since he was a resident and I was a staff nurse, has been pushing "juice Plus" for a few years now. I did the homework, and the benefits he touts just don't add up. Plus it is part of a pyramid scheme, like Amway and the like! WTH? Reluctantly, I have switched my kids to the teaching practice where I now work. Where we practice evidence based medicine. It's hard to leave a trusted provider! Too bad, because that's where he trained many years ago!

evitafjord said...

My kids' doctor's office puts a questionnaire about allergies in their forms when they have a physical - if you fill it out/bring it up/discuss it (BECAUSE IT WAS IN THE PACKET), then the visit becomes a problem visit instead of preventative and you owe the co-pay. Or you can schedule another visit for another day to talk about the allergies.

Packer said...

Naysayer here: My take away at the end of the year is dwarfed by the cost of doing business. Check yours Grumpy.

Offer Cellulite Treatment , it is a gold mine.

Anonymous said...

'switched my kids to the teaching practice"

Is the teaching practice the key? My kids go to a ped in the local University's system, and I go to GP in the same system. The only thing they have ever tried to up-sell was a flu shot for me and the only "extra" treatment recommended was a reminder that it had been several years since my last check up at the gyn (who is also in the system).

tbunni said...

Maybe a "teaching practice" can be a key, because they're not geared for profit. But I think most docs are still OK. In the practice where I work, we did offer laser tattoo removal, as people were having to drive 60+ miles to get it done. Not covered by ins, as it is purely cosmetic, and was not sold as a "cure", just an option to get rid of that poorly planned tattoo. We have since stopped as others are now offering it in our area, and it took up a patient care room which we needed for real patient.

Thanks for keeping it real, Grumpy!

Ivan Ilyich said...

I'm fortunate to have an old-school family doctor and conservative neuros who can do a lot with a hammer and a pin (but who know when the high-tech procedures are needed). But I am aware of at least one case (not mine) in which it was the insurance company demanding a nerve biopsy which the neurologist didn't need or request, presumably because they were hoping to get out of paying for expensive treatments.

On the whole, I believe that physicians are far more likely to act in the best interests of the patient than administrators of hospitals and insurance companies. That's my experience, anyway. Some people are quick to accuse doctors of being motivated first by the opportunity to profit. Some are, but it isn't generally true and assuming it is makes for bad doctor-patient relations, in my layman's opinion.

Anonymous said...

Very glad you're not going over to the dark side.

My husband once went to a doctor for sinus issues and the doctor tried to give him Prozac. Prozac?! For sinuses?! Guy said 'I don't know why it works, but it does!'. Idiot. Same doctor told me I was lactose intolerant when I went to see him for a stomach issue. He never examined me or gave me any tests to see if I was lactose intolerant, and I am NOT lactose intolerant, I drink about a half gallon of milk every day with no problems, but he insisted I was. And yeah, I know that's a lot of milk, but I really like milk, always have. Same practice, different doctor - my son had to have his kindergarten physical. There was an eye chart on the wall and a piece of tape in a doorway a little ways away from the eye chart. The nurse had my son stand on the piece of tape and tell her what he could see on the eye chart. Ok, no problem, a vision screening to see if he should be referred to an eye doctor. Right. Except they billed insurance for a full eye exam as well as a physical, which meant that when it was time for his real eye exam the insurance company denied it because they said he had already had an eye exam. I was pissed and that was the final straw. We never went back to anyone in that practice, and I told the insurance company exactly what kind of 'eye exam' they had paid for.

bobbie said...

Bless you and your ilk of yak herders...

Linda Myers said...

I had my first Medicare wellness physical a couple of weeks ago. My doc ordered blood work for cholesterol (my request), vitamin D (my request), potassium and creatinine (required for my bp meds). But no complete blood workup! Occurs to me he's being reasonable.

vegakitty said...

Bless you. I'm fortunate to have medical providers who don't sell "stuff." They also don't upsell things. Not like this ad I got a couple of weeks ago: It started out, "You need a mammogram and an aortic ultrasound!" (That's paraphrasing, but that's the gist of their message.) I read on, to find that it would cost me close to $500 for their "services". The flyer was also full of testimonials about all the lives they saved with these tests. While I do get mammograms every year due to a family history of breast cancer, I go to my local hospital and it costs me $20. As for an aortic ultrasound, why? I transcribe radiology reports, and know that unless an aortic ultrasound is specifically called for (e.g. a possible aneurysm was diagnosed in a previous ultrasound, or other reasons) there's no need for it. But how many people fall for these things?

Anonymous said...

"Teaching practices" make a killing off facility fees and high fee schedules. Not morally superior to selling snake oil, IMHO.

Lisa said...

The company I work for holds a yearly health fair. We usually try to get medical professionals who are in network to come talk to employees about health issues. This year the dermatologist wouldn't discuss types of skin cancer for love or money. He only wanted to promote cosmetic therapies that weren't covered by insurance. Definitely not the reason we invited him. I will make sure he's not on the list for next year.

Loren Pechtel said...

They even get medically unsound at times.

We used to have a dentist we loved. Unfortunately she sold her practice and moved out of the country and her brother took it over.

He's pushing Invisalign. Never mind that my wife has only very minor alignment issues and I have been specifically told that Invisalign is not for me.

rapnzl rn said...

Midichlorians aside, never underestimate the power of the ability to look oneself in the mirror in the morning.

Anonymous said...

My daughter's ENT sells laser hair removal services. At least they admit they do so because it is a cash cow and they can barely stay afloat practicing medicine. It makes sense that my dermatologist offers those services, but why an ENT?

Our two previous dentists were big pushers of cosmetic dentistry. One refused to even do a cleaning unless we signed a contract authorizing all kinds of non-covered cosmetic dental work. I'm thankful we found our current dentist who pushes nothing but good dental hygiene.

The worst offense for me was when I visited the ER for a bad reaction to a new prescription and the ER doc kept pushing Medifast, even telling me I would never lose weight any other way. The drug I reacted to was NOT a weight loss drug and his sales pitch was unwarranted. I wrote a scathing letter to the CEO of the hospital. After the hospital investigated, all charges for that visit were waived. They even reversed the charges to my insurance provider. I received a letter of apology from the CEO's office.

Anonymous said...

I think I got a bit of this when I saw my OB for PPD. She gave me an Rx for a "new" drug and then a coupon for the first month b/c she knew it was expensive (her words). During my visit, she told her MA to reach out the Rep for more coupons etc. So she was clearly pushing this drug a little. To my surprise, my insurance refused to cover any of the cost the second month b/c the drug was so new and other drugs weren't tried first.

Why would you knowingly prescribe something that most insurance companies will not cover (and you KNOW the drug is expensive ($200/month)?!?!?!

This was the first time I ever felt that she was thinking about her profit before her patients and it was very disappointing.

Moose said...

Many years ago, when it was still a very new drug, I had some idiot prescribe Prozac as a weight loss drug.

I've never had a doctor try to push psuedoscience crap on me and I'd hate to be one who does. I've had doctors try pull outright illegal moves (opthomologist refusing to hand over my prescription) to clearly unethical acts (refusing to discuss the reason I came because of their bias - I'm running a 101F fever and cannot hear out of my left ear; no I do not want to talk about weight loss surgery now, what do you mean you won't treat my ear until we discuss it?). But no outright snake oil. Yet.

Anonymous said...

Anonymous at 9:07

How in the world was your Ob/Gyn profiting by prescribing this admittedly expensive drug?

Anonymous said...

Nice picture of Vice President Cheney.

The Critical Mom said...

Oh, does this ever remind me of docs at my local university hospital in Germany. But I can see things are the same in the U.S. of A. Here in Deutschland they ran tests on my normal heart, since all my normal docs told me to get my Mitral Valve Prolapse "checked out" every two years. It's never bothered me. It's never bothered them, either . . . until I hit this playground for med students, whose head honcho wanted to do an angiogram. WAITASEC! I said. I'm feeling fine, I have low blood pressure, I have low cholesterol, there's no diabetes, I go to ballet class twice a week, tap too . . . and OH, were they ANGRY when they could not do their TEST. For further details see my blog, The Critical Mom

Anonymous said...

There was time when drug companies were looking for population data on newly FDA released drugs, and they wanted people to actually use the drug for the intended purpose, hence the reps pushing free samples. Hmm. That wasn't so long ago, now. I remember one of the last papers I wrote in pharmacy school was about tissue plasminogen activator, alteplase. It seemed to me that because there was no doubt it would save lives, that the drug reps should be handing it out like hotcakes. Only that time, each treatment cost many more thousand of dollars (relative to now) than the alternative. I still think about 'death panels', and realization that no such thing exists. It's more like the expediency factor of priorities.

That was about the time that the widespread discussion of which of the antihistamine-2 blockers (like Tagamet, Zantac, Axid, etc.) were more efficacious and sucralfate was almost head-to-head on the concept of acid proton pump inhibitors versus the 'chemical bandage'.

No more memorizing equivalent doses of 30 mL Maalox every 2 hours and 1 hour before and 1 hour after meals to Alamag, Wingel, Alka Seltzer, Tums, Gelusil, etc. dosing regimens, length of therapy, least number of drug interactions, which antihistamine-2 blocker was the most convenient to take as an advantage over frequency of antacids doses, and Zollinger's disease.

The 'good ol' days'.

Anonymous said...

^Agreed, I don't understand why you "anon 9:07am" think your OB is benefitting from that.

Jedi Master Ivyan said...

The only docs I've run into who do this are veterinarians (so far, anyway). The ones who work at chain pet stores seem to be the worst.

Anonymous said...

It's sorta like the hospital chain I work for.

When they were involved with a particular health insurance firm and PBM (pharmacy benefits managing) group, we'd get newsletters along with their pay-out for covered provider visits. These newsletters provided coupons for brand name food supplements, lotions, 'natural' products extolling their commitment to healthy healthcare workers, but sheez! We are a hospital. We already have access to this knowledge e.g. junk mail to the various professional providers, and the advertised products were brand name expensive unnecessary and unnecessities. Plus, there was no end to the holy heck this insurance company provided in adjudicating coverage for beneficiaries, especially for children who needed proper testing and diagnoses for illnesses that were going to need long-term follow-up.

The cardiology group of the hospital chain I work for is highly regarded in the country, and I attend their symposium every year. Well the hospital chain got a deal with one of those schemes that do some whole body something or other X-rays, and blood tests and advertised themselves as wonderful conveniences to locating the ubiquitous almost-ruptured aneurysm -saving countless lives and such. The cardiology group in the symposium said the tests were not valuable, yet the hospital chain keeps offering the 'service' at bargain basement costs. Like, it's only $49.99 so if it saves your life, it's worth it, yes? Like it's a substitute for a good patient-provider relationship?

Anonymous said...

Thanks Luke for this analogy.

(I am curious, though, do people of Jewish faith consider the opinions of the Apostles? I'm a Catholic that believes in the value of all religions and atheism as well as secularism, so am not asking out of 'idle' curiosity. On the other hand, some people would say I cannot be a good Catholic!)

Anonymous said...

Dr. G - I usually come on here and make some offhand, snarky remark.

This time, though, I want an honest answer.

You are inside the Petrie dish, doc. You know what is and is not reasonable, sound, medical and necessary.

How can the layperson know such things? Beside the obvious - if it sounds cray-cray it is? And when you are desperate/frightened, even cray-cray can be spun in your head to sound like a good idea.

Obviously, most of these suggestions are made to sound just reasonable enough that patients need it...else, there'd be no revenue stream.

But how do the collective 'we' know they are? How do we discern? How do we know the doctor we've been seeing for years hasn't suddenly decided to up his/her revenues through some kind of witchcraft?

It is endlessly frustrating when you're the patient, believe me.

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