family practice issues and general life events

Posts tagged ‘family practice’

Addiction in Family Practice

I had a conversation with a patient yesterday.  Well many of them actually, about 40 different encounters, but this one struck in my mind.  We have recently updated our controlled substance agreement to make it more strongly worded, and emphasize that there will be more random drug testing, and monitoring their activity on the State’s narcotic and dangerous drugs data base, and he, like many others had some questions about it.  I am not really certain why this update inspired so many more discussions than previous updates, but everything from the selecting a pharmacy to how the drug screens will be done and how they had Severe pain this weekend so they found an old Diluadad from a previous provider that they took so it might be in the screen.  Or they smoked a joint, and they are really sorry, but what is going to happen to them.

But back to this particular case.  He was wanting to know what if another patient of mine had a positive drug screen for something else.  Methamphetamine.  He has been worried about her, and would really like her to get help.  The problem with an addiction to something like methamphetamine is that it changes chemistry in the brain, so people appear to be willing to lose everything for that drug.

Unfortunately I see a lot more chronic pain patients in my practice than I would like, I struggle to decide who is truly in pain, and who is not.  I was referring them all to pain management specialists but the one I was using has put up barriers making it almost impossible to refer people there.  The next closest places are 2 and a half hours away making it almost impossible for those that are legitimately in pain to obtain the treatment that they need.

In an attempt to be in compliance with the state drug laws we screen patients, we look them up in the data base and we try to monitor what they take, but we are often left wondering who is truly in pain, and whose pain is due to the narcotics that we are giving them.  We do diagnostic studies to find the cause, but unfortunately unlike blood pressure and temperature, the pain scale is very subjective.  One person’s four is another’s 8.

Drug contracts are necessary and may help provide a means for conversation with the patients that might not have been otherwise.  And yet the next question is what to do when there are medications that are not supposed to be there, or even worse, what happens when the screen is completely negative?

I live in the state that is ranked first in the abuse of prescription medications, and it bothers me that I may be contributing to that number.  We take calls reporting someone selling their medications seriously, and attempt to investigate.

But then there are those that are truly addicted to narcotics of any type?  Those that truly want help.  There are supposed programs around here.  A program that does rapid detox that has turned into a program for a weekend fix.  A methadone clinic that I have never seen decrease the dosage of methadone on a single patient.  That is it.  And honestly, I don’t have the training to treat addiction in my practice.  We look at best practices, but I was trained to treat diabetes, not pain management.

It is estimated by the National Center on Addiction and Substance Abuse that only 10% of alcoholics receive the treatment they need.  I would guess that the number is even less for those substances that are illegal.  In the war on Drugs, we have created a group that cannot find treatment because their addiction is to something illegal, so there is a fear of incarceration.  And yet despite all of the laws we have against drug use, we have not decreased usage at all.

There are a few medications approved for detox and to treat addiction, but I am not trained well enough to deal with such a complex disease.  And while I would be willing to obtain such training, I don’t know that I would have time to treat these patients with all of the other requirements on the disease processes that I am qualified to treat.

So we are at a crossroads in treatment.  What do we do with those that are addicted, but want help?  We need to have an open dialogue with our patients that we can treat them.  It has to be honest.  If I have a patient who is honest about their addiction, I will do what I can to help them, but unfortunately my training is not enough for what they need.


Dear Center for Medicare and Medicaid Services

This is an email that I would send to the Center for Medicare and Medicaid Services, but since they don’t have an email address for themselves, unless I want to report fraud on either myself or another, well I will have to make do.


Dear CMS-

I would say that you don’t know who I am, but you have used my picture for the last year advertising your EHR Incentive program as the first clinic to receive the Incentive Bonus from Medicaid.  So you must at least have an idea of who I am.  That being said, you probably don’t care, but at least you know that I have tried to play by your rules in order to win that honor.

Couple that with the calls a couple times a month from the Office of the Inspector General looking for the physician whom we  agreed to become custodian of record for, well you have talked to at the very least my office staff.  And we have given you all of the information we have.  OR have at least indicated just let us know what you want, we believe that she left the country, given you the email addresses we have, but we don’t have what you are looking for.  Well other than the patients version of what she did.  But otherwise you have not had many dealings with me.

I have a practice of 45% Medicaid and 25% Medicare.  So all together about 70% of my practice is receiving “insurance” from your office.  Over the past year, we have done all of your recommendations for 5010 conversion, and per you and our systems passed them all.  We have performed the required updates, installed the needed hardware, software, implemented the required training, all that you have indicated as necessary.  So based on those, we were ready for the conversion January 1, despite the delay to March 1, 2012.  However, you decided to implement the conversion on December 19, 2011 and installed a firewall.  This firewall blocking all new claims from going through.  We didn’t notice it right away, due to a 2 week to 45 days delay from date filed to date paid.  So we didn’t notice.  Add to that the notification that claims would be delayed about 2 weeks, well it took a little while.  25% is a large chunk of income, but it would have been ok, for a short period of time.

On December 28, the firewall went up for Medicaid.  Again there was a slight delay in noticing, since the turn around is two weeks, plus we were told that there would be a two week delay.  However, this was somewhat more painful.  Added to that the insurance companies have all installed required firewalls, however, after three weeks, we are finally through and getting paid.  So we are receiving payment for 30% of the work that we do.  That does not even cover my staff or overhead.

My understanding is that I am not alone in this problem.  It is neither EHR vendor specific nor clearinghouse specific.  The only constant is that they are plans paid for under your umbrella, Medicare, Medicaid and Tricare.  And one message received was that I was fortunate, at least my problems only started in mid-December, not early November like some physicians.  Whatever.  I have not taken a paycheck since the middle of December.  That is no paycheck for either my husband (also a physician) and me.  Still had to make payroll for the staff of eight that I employ.  Well currently seven, due to a recent death.  But even she received a paycheck this last pay period.  So I have had enough to pay 8 people, well up until this week.  This week, I had to pay some staff out of personal accounts.  So now, not only am I working for free, I am paying for the privilege to deal with government regulations and bureaucracy.

Oh and did I mention that I experienced the privilege of an audit by Oklahoma Medicaid during this time, which other than a few minor problems, I passed.  One of those being something that I have no control over, being specialists not sending their consult notes to go with the referral that they got paid for, but somehow that is my deficiency, DESPITE CALLING AND ASKING FOR A NOTE!!

So anyway back to the point of this message that you will neither read, nor receive, but maybe someone out there will hear me.  I paid for the pleasure of working last week, PERSONALLY!!  And I wonder why I constantly have a headache, and the gnawing of an ulcer in my belly.  I own my clinic, and am personally responsible for the debt to go into business.  I don’t have a big corporation that can afford a short period of time to cover not being paid.  My clinic sees 68 patients on average a day, so I should not have a negative balance sheet, but I do because for 70% of them, I have not seen a dime since December 28, maybe a few more due to the small amount of TriCare that I also see.

I know that I am not the only one who is experiencing this, since this week we were 2017 in line when calling to see where the problem was.  (We were 1700 last week, and that ended with 7 and a half hours on hold, only to be told to check online for solutions, WHICH WERE NOT THERE!!!)

I scraped enough for payroll this week.  In two weeks, I may be able to do it again, even without payment.  But after that I will be done, I will have no choice but to close my doors.  I understand the theory that you should love what you are doing so much that you would do it for free, but I did that the first 18 months in practice, and 6 months in 2010, and an occasional pay period here and there.  But I cannot afford to do that for much longer.  And I definitely cannot afford to do it and pay to do so.  Currently I have $120,000 in Medicaid Accounts Receivable since December 28, and another $60,000 in Medicare. (that is not what I will receive, only what I am billing)  And if by some miracle that were to come through tomorrow, I now have back bills and creditors who would also like to be paid, so even if you were to fix it tomorrow, I will be working for free until May or June.  So my husband will have to spend more time away from his boys, and work more shifts in the ER so we will survive.

I know to some, this is what I deserve being a greedy doctor, though I have yet to make over $100,000 personally since graduating residency.  (My declared income is higher only because of my husband working in the Emergency Room)  I have bills to pay, and cannot afford to continue floating the payroll for the clinic.  So I am asking CMS to look at their firewall, and attempt to fix it, or the looming doctor crises will come in about 2 or 3 months instead of the 3-5 years that is currently anticipated.


P.S. If this is your plan to save Medicare, it is a really crappy thing to do.  You should look closer at where your biggest incidences of fraud occur, and not cause those who are playing by the rules to become financially ruined.

It is the little things that matter

It is too easy in medicine to overlook the simple things. Or what you think is not that big of a deal. With the never ending media around you at all times, it is hard to escape people talking about how doctors are greedy, people committing fraud, new rules and regulations, potential cuts of 29.4% from Medicare. It is easy to forget why one might have gone into medicine. And not the joke reason I told people the summer before medical school started as to why I was going to medical school either. I didn’t really go to medical school so that I could marry a doctor. I was just really annoyed by what seemed a ridiculous question at the time. (though that proved to be a self-fulfilling prophesy as well)

But really is it a ridiculous question? It is not about the money, and those that tell you it is, well there are easier ways to make a lot of money or to make a comfortable living, and I would not have gone over $150,000 in debt to do. Most of us go into medicine at least on some level with the desire to help people. Sure there are those that might have gone into it for the prestige or some other less noble reason, but for most at the core, it was probably the desire to help people. However, for those of you applying to medical school, everyone says some variation of that answer, so you might wish to find a more eloquent way to do so.

However, in the hustle and bustle of a medical practice it is easy to forget why. Even though that very reason is sitting in front of you wanting some reassurance, wanting answers, wanting, well some not knowing what they want, only that something is not quite right. And sometimes all they want is the what or a name for whatever is ailing them. And sometimes they want more than you can give them, answers you don’t know, or if you find them for them you have to send them to a specialist. And sometimes they come back from that specialist with a smile and a thank you, and sometimes with tears.

As a family practice doctor, I get to tell all kinds of news from pregnancy (which is hard to decide whether it is good or bad the day you are telling them) to cancer (which I really hate) to maybe they are being overmedicated and some of their side effects are due to medication that they are on. So why don’t we stop some medications, those are one of my favorites. But I get to share with them in everything. They still come back to me after they are told they need back surgery for my opinion. Sometimes I wonder why (on really bad days) but mostly it is flattering. Or sometimes, I find them a second opinion from another specialist especially on a major procedure.

I get to be silly with kids who are frightened because they don’t want a shot, and get to see the relief in a parent’s eyes when their sick kid starts feeling better. My day is filled with highs and lows, and my attention is constantly stimulated, which really helps my ADD more than any medication could. And most of the time I am just an ear, especially with my older patients. There are visits, I have no idea why I saw the patient when I leave the room, other than maybe they are lonely, and that is ok too.

Medicine is a calling where people let you into their most intimate moments, though sometimes drag you in would be the more appropriate way to describe it. IT is an honor to be there for them, even when giving them the bad news. And as computers continue to enter/invade the field of medicine, there is something to be said about the human touch, the compassion that a machine just cannot give.

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