family practice issues and general life events

Posts tagged ‘physicians’

The Problem with it only takes 90 seconds- or why Oklahoma HB1820 is a bad idea

The Daily Oklahoma seems to be refusing to address both sides of the issue as to why physicians are against HB1820 and why they don’t want to check the Physician’s Monitoring System (PMP).  I think you would be hard to find a physician who would say that it is a bad idea to check it on new patients, or a occasionally or when there is a reason for suspicion.  The PMP is a tool for helping to find that patient that is “doctor shopping” but it’s creators at the Oklahoma Bureau of Narcotics and Dangerous Drugs even admit that it is inaccurate and treatment decisions should not be based on it.  So why are we wanting to require physicians to check every time on every patient on a tool that is known to be inaccurate?

There is a Pugh study that was flawed trying to show how the PMP decreases the amount of narcotics on the streets and this is what the state legislature is stuck on following.  Subsequent studies have shown that it does not decrease the amount of narcotics on the streets.

As for Dr Cox stating that it only takes 90 seconds, I would disagree it probably takes 2-3 minutes, but we can say 90 seconds.  The average patient is scheduled for 15 minutes in my practice.  Say they are diabetic but take hydrocodone for their arthritis.  So of the 15 minute encounter, I am down to either 13:30 or 12 minutes to discuss her diabetes, as well as document a pain scale.  Doable, maybe?  But maybe this patient has a form to fill out, or they are here for their once a year physical or they need an EKG?  That 15 minutes is a lot more cramped, even more so if you believe my actual time, and on average I would get to do this probably 22 times out of my 30 appointments a day.

The legislatures argue that my ancillary staff could do that.  OK, my nurses who are rooming patients, doing EKGs and drawing blood could possibly do that.  Not sure when.  Before we start?  Even if you accept the 90 second theory, at 30 patients a day, they had better start 45 minutes early for their day just to make sure they don’t miss someone.  Or and that is just my patient, they will also have to look up my partner (husband) so they will need to come in 90 minutes before patients start arriving.  Except for the fact I am not allowed to have staff with over time, so that will now mean 45 minutes times 4 days, that I lose 3 hours on Friday.  And since most of my staff hit overtime slightly afternoon usually, that means I will now be able to see patients for exactly one hour on Fridays, from 8 am to 9 am.  Fantastic, guessing my boss won’t like me using the staff that way, so it’s back to me.

I usually arrive at the office fairly close to 8 am when I start.  I have children to get to school, and while I understand that the OBNDD doesn’t care about my personal life, I do.  And if they are still rooming patients, I can start with the checks.  But rarely will I have time to check more than one or two of my patients.  So I take the high risk ones, seems reasonable.  Rarely have I been surprised.  I will admit sometimes one will, but it is few and far between.  And many of those, actually tell me about it when I walk in the room.  See I like to have an honest relationship with my patients.

Then there is the question of accuracy.  Tuesday, I checked the PMP on a patient who calls for refills every month, and I could guarantee that she picks them up.  Strangely, her last prescription was in February.  Now this system is supposed to be in real time, 3 months is quite a time span.  And while I am at it, on average we probably have 30-40 prescription that flood our system daily.  (more on mondays)  Most of these refills I do between patient visits as I am walking down the hall.  Since half are now hydrocodone due to the state not allowing refills on the medication, under this new law, my refilling scripts walking down the hallway will stop.  I will have to be using my lunch break, looking up each prescription which say 15 are hydrocodone, no telling what are lyrica, benzodiazepines or other medications, but let’s say 15-30, at 90 seconds a check, almost 30 minutes at the upper end.  So if I am running behind in the morning, my lunch break is gone, and those that come in after lunch, well they will wait until I get finished for the day, and now the patient will have to wait for the next day.

Oh and they didn’t exempt the nursing home patient.  So I get a call that they have just given Ms. Smith her last norco, can I call it in.  (They always call as they are giving their last pill, I don’t know why), there is another 90 seconds in addition to the time to call the nursing home pharmacy to refill her med.  One that she has little to no ability to divert.

Additionally, I live on the state line.  I understand that the state line is a magical line that medication NEVER crosses over, but maybe one day it will.  Some of my patients live in Texas.  And some people who live here go to Texas doctors.  Though I am sure there is no crossing that magical Red River with narcotics.  So why am I even discussing the fact that the Oklahoma PMP refuses to share data with other states and they don’t share with us.  So no need discussing the magical state lines.

The physicians of the state tried to talk to legislatures and discuss the best practices that would benefit the patients and help decrease the diversion of narcotics in this state.  We understand the cost.  However, this bill ignores best practices, the original bill (SB 1821 which was killed in the house committee) wanted $2000 fines per prescription for failure to use the system.  And guess who levied and received the fines, the creator of the PMP, the Oklahoma Bureau of Narcotics and Dangerous Drugs.  And in the original bill, physicians were supposed to keep a file on patients that they couldn’t see.  My understanding about the patient chart is that it is a dual ownership, the patient and I, and yet it originally created a secret patient file they were not allowed access to.  Fortunately this was removed.

The Daily Oklahoman is taking a biased stance, apparently since Dr Cox is a physician, they feel his opinion as the author of the bill qualifies as getting both sides of the issue.  And they allowed the OBNDD and the Department of Mental Health who are pushing for this bill to create the physician as the bad guy.

I do have a question for OBNDD.  What do you do when a physician calls about a “doctor hopper”?  We have called before and were told to call the Ardmore office.  So we did, and we were told they were too busy to take care of the problem.  This patient had visited 7 doctors in less than a month.  I stopped calling 3 or 4 years ago, because this was their answer every single time.

Patient care advocates are against this bill because it has the potential to prevent much needed pain medication at the end of life.  It will also decrease access as those in rural areas become required to see their controlled chronic pain medication patients every single month.  It interferes with the ability to give that claustrophobic patient a valium or two prior to that MRI that they need.

Oklahoma always ranks in the bottom 5 for health related issues, and passage of this bill will not help it.  Instead, I will be spending precious time that should be spent on diabetes on whether they are abusing medications that they were clean on their urine drug screen that I do perform.  Or else I will be forced to have them come back for multiple visits.  One for their diabetes, and one for their pain medications.  This will not help the cost of medical care, instead it will sky rocket.

18% of hydrocodone on the streets comes straight from the physicians script pad, the rest come from other sources.  I guess focusing on that 18% and not on those that are actually diverting the drugs makes the legislature feel like they are doing something.  And while I don’t disagree as physicians we have a duty to decrease that 18% as much as possible, that still leaves 82% that we are ignoring.  Not really sure they are focusing on the correct goal.

And while the public might say, “Well just refer to pain management.”  That is a fantastic idea, but the closest pain management doctor to me, is 30 miles away in another state.  The next closest?  2 and a half hours away.  And all require that I see the patient at least 3 times prior to referral.  And I have many patients who don’t have the transportation to go 30 miles much less 150 miles.  So is that good patient care?  Or are we punishing those that have legitimate need for those few that divert it?  I am sorry, but I can’t accept that.

And these opinions are my own, and not on behalf of anyone else.

Why the FDA/DEA ruling on Vicodin may not matter

Several weeks ago, the FDA made a move to re-examine whether Vicodin (hydrocodone) should be moved from a schedule 3 narcotic to a schedule 2.  This was looked at in 2008, but decided that it would not be done.  However, since Vicodin is currently the most written prescription in the United States and it is one of the most overdosed drugs/medications they decided to take another look at the issue.

 

To begin with, a brief lesson in classification of what schedules are in the DEA.  The DEA uses a 5 classification schedule for narcotics.  Medications such as antibiotics, blood pressure medications, and other medications are not on this list and are not considered scheduled.  If you have a medical license (or NP or PA) you are allowed to prescribe these medications.  No authority or licensing from either your state or federal DEA agency are required.

Schedule 5 medications are considered to have the least potential for abuse.  Most of the cough syrups are in this group.  They are used for a limited amount of time and there is very limited amount of drug in the prescription.

Schedule 4 narcotics are considered slightly more addictive, but not as much.  This includes the muscle relaxer Soma, and the benzodiazepines (Though I would argue these are terribly addictive, this is based on the DEA DOJ site.)  Also recently added is the medication tramodol.  Lyrica, a medication for nerve pain also falls on this list.

Schedule 3 narcotics is where Vicodin and the other hydrocodone products fall.  This group also includes anabolic steroids like Testosterone, diet pills (Didrex and Phentermine), some tylenol with Codeine products, ketamine and Suboxone (bupropriene)  These are more addictive than schedule 4, but can currently be called in, and technically refills can be given, but many providers are not due to issues I will discuss later.

Schedule 2- the category they are looking to move Vicodin and other hydrocodone products.  This group is considered to have a high potential for addiction.  A monthly visit and hard script (in most states) is required.  There has been some change in federal law allowing for E-prescribing, but many states have not converted, and those that have, few if any pharmacies meet the criteria to e-prescribe.  This group contains the Oxycodone, morphine, dilaudid, methadone, and demerol.  It also contains most of the ADHD stimulants ritalin, adderall, vyvanse, etc.  This group also contains phenobarbital.

Schedule 1 is considered to have no medicinal benefit.  They are considered to have a high potential for abuse.  This group contains LSD, ecstasy, marijuana (this is not for argument, but how classified) and peyote.

So now with that description of schedules, I will discuss why changing may not matter.  

I write pain medications.  I never wanted to be a pain doctor, but there are limited avenues to get pain management in the area.  And half the time when I do, if they patient is not willing to do procedures the pain doctor refuses to see them.  So there is that problem.

I know the potential for addiction, in fact, looking at new guidelines coming in the near future for licensure, prescribing vicodin (hydrocodone) probably won’t be done without a monthly visit.  In fact, few if any of my patients on chronic pain medications get to go over a month without seeing me.

Currently, if you are writing the medications, pain contracts are to be in place.  My contract also includes those for benzodiazepines and ADHD medications.  I have enough forms that I believe in consolidating them whenever possible.  Additionally, those that write them frequently are expected to drug screen randomly or whenever suspected occurring at least every 3 months or as close to as possible.  And you should have a documented pain scale.  Sadly this pain scale means little, but I have it on the chart.  Patient are smiling saying they have a 10 out of 10 pain, while the little old arthritic grandmother says her pain is a 4, when it looks so painful I want to cry.

And I look for causes of pain.  Unfortunately I am being told that I write both too much and too little pain medication, and in doing both I am not doing a good job.  I am the reason for people to have too severe of pain, and I am the reason that the casino down the road is full of business due to my patients selling their pills despite the best stops I can put in place.  The states narcotic board wants me to be a cop, and the rest are yelling about patient confidentiality.  And for those that are addicts that want help, there is neither the facilities in the area nor the payers to pay for the rehab.  And sorry if I don’t think that I went to medical school to become a cop, nor do I think most addict benefit from jail.

Many have argued that the moving the vicodin to schedule 2 will not improve the recreational use of the drug, and will only result in those with legitimate cause of pain having more pain with greater difficulty for help.  While I don’t necessarily disagree with this assessment, I think the other problems with the system actually make this almost moot.  

Licensure and boards are discussing the introduction of requiring six to ten hours a year in narcotics prescription courses.  While I am all for education, new requirements for board certifications and malpractice and other issues have recently been implemented.  And for those specialists who write pain medications for a week or two after surgery will decide to then fall back to the primary physician writing the medication.  Because who wants the headaches.  

And in the end, none of this will really work anyway.  Studies after studies show that the more difficult you make a drug to get, the sooner the next black market drug will appear.  The drug ban on marijuana has helped to lead to the rise in methamphetamine and Mexican cartels into the inner cities.  

The physician is not a cop.  They are already overloaded with paperwork and government regulations.  Most of my patients on hydrocodone, well I already see them monthly, and those that don’t, well my nurses are talking to them once a month prior to filling their medications.  This law, while I don’t think it makes sense, it won’t make that much of a difference in the long run, not when all the other regulations are considered.  It is time to stop trying to make the physician a cop, and instead give tools to help with addiction and help the patient actually return to functional.

In response to GSK verdict

The recent verdict of Glasco Smith Kline really should mean little to me.  After all, I have never taken payment from them.  There might be the occasional lunch so they could pitch their product to me, but I finished residency after the first set of Pharm D laws were passed.  Actually I think that I might have been in medical school when they were passed, but in residency when they went into effect.  What does this mean?  Well, I have never taken a trip to Hawaii on a drug company, I have never gotten a membership at a fancy golf course, nor did I ever accept any money from them.

In the interest of full disclosure, I believe that either Merck or Pfizer paid for my graduation from residency (It has been 7 years, and the program was responsible for details) I have received numerous meals, and pens, and writing tablets.  Did these items influence me?  Maybe, if I am writing a blood pressure medication, and the pen that I was writing with was for a blood pressure medication.  But I would have to believe that it was effective.  I wouldn’t write Norvasc (amlodipine) for a patient in heart failure for example, because they already have problems with swelling.   But most of the time, I didn’t even think about the pen in my handle.  Mostly because it is a stylus that only works on a computer and is black without label.  I rarely use a pen except to sign the few prescriptions that I cannot send electronically.

As for samples, yes I utilize them.  Before the antidepressants started going generic, it was nice to be able to give a patient a two week supply to see if a certain medication was going to work, prior to putting out cash for a high dollar prescription.  Now that there are generics, well that is typically the first choice I write for.  If the generics don’t work, well then I make my next selection with what I can give the patient a sample for, because it is nice to try a medication without spending an ungodly amount, only to find that it doesn’t work.

Now why the verdict means something to me.  With the announcement the Dr Drew Pinsky took at least $275,000 to “provide services for Wellbutrin” (whatever that means) the internet has lit up with claims that this is what physicians do.  They are all on the till for Big Pharma.  Slate online discusses Dr Drew and then implies that most doctors collect checks from Big Pharma.  Lew Rockwell (the founder of the Mises Institute) actually says on his blog “Here is much of the medical profession in a nutshell, since most doctors are in the pay of Big Pharm from medical school onwards.  They get commissions for all those drugs they tell you to buy.”  I guess my check is still coming, since I have yet to see one, yet.

Now it is easy to blow off the likes of Lew Rockwell, since I don’t know if there is a conspiracy that he doesn’t believe (that is my opinion) but his large following is where the problems come in.  He has some of the most rabid of followers and even helps to continue the vaccines cause autism fallacy.  But he is only one of many that are helping to spread the idea that all doctors accept payment from Big Pharma.

Why Dr Drew accepted money from GSK to promote Wellbutrin should even register is beyond me.  He is one of a growing number of charlatans who have traded their respect for media fame.  Dr Drew is worse than most, in that he has also traded on the fame of his patients who are struggling with addiction to create television.  The man let’s face it appears to be a media whore.  I don’t know where in the Hippocratic Oath the statement of except in the case of a television show comes in, but apparently it is there.

I don’t have a problem exposing those that do take commissions, maybe we should be more transparent.  I don’t mind discussing with patients why certain medications would work better for that patient than others.  It is part of my job.  But there are times that the generic is not the best choice for the patient, or maybe there is not a generic equivalent, but this should be a conversation that I have with the patient because it is for the good of the patient, not because some blogger without a medical degree has decided that the whole profession is suspect just because there are a few (alright more than a few, but no where near the majority) corrupt practitioners.  Based on the blogs I have seen on the issue, I have been convicted merely because I hold a medical degree.

Few physicians receive payments from the pharmaceutical companies.  An occasional meal for listening to a drug lecture or spiel but rarely anymore than that.  In fact, I don’t know the last time I accepted a dinner from a drug rep due to preferring to spend my evenings with my children and running them to their activities.  As for those who are paid to promote their drugs, there is supposed to be disclosure for doing so, both in lectures at Continuing Medical Education events.  And believe me, every rep tells me their drug is better than their competitors and all of the generics, I have a medical degree, I think I can figure out that they are in my office to sell their product.

To all my friends in the medical field

Dear friends-

This blog is for you.  while there is no difficulty in others reading it, this one concerns you all directly.  Well at least those of you who accept Medicare, Medicaid and TriCare.  (If there is a federally funded carrier that I missed, I apologize, and advise you to check on them as well).  Look and see if any of your Medicare claims submitted after December 19, have been received, paid or rejected.  And then look at your Medicaid claims and see it they have been paid.  (In Oklahoma, look after December 28).  If the answer is yes, well then never mind.  If not well, it is your attention that I am seeking.

I understand this does not affect physicians that work at the VA, many of the Indian Clinics, and possibly those that are federally funded, but for the rest of you, this absolutely affects you, whether in practice for yourself, a small group, or those employed by a hospital.  CMS has installed firewalls blocking claims from getting through.  This is not just for providers who are not 5010 compliant.  I went through all the steps required to be compliant, and my payments have been blocked.  This is not just the 2 week delay we were told to anticipate for the 5010 conversion.  This is a complete block that appears to not be vendor specific nor clearing house specific.  

After checking those of you who have found this to be true that you have not been paid by those under the umbrella of CMS, I am asking for your help.  I have attempted to contact CMS and cannot get through.  Their email addresses are only for those who wish to report fraud either on themselves or someone else.  I am asking you to take the time to write your Senators and Congressmen/women, in order to get this situation fixed.  If not, many of us in smaller clinics have only a small amount of time left.  

This is not about greed, this is about getting paid for services you provided.  Last week, I had to pay my staff’s payroll partially out of my own bank account.  If you want to write it off as bad business decisions that is fine.  I have made some, but realize that if you are not getting reimbursed, at some point you will find that you also are unable to practice medicine.  I am not asking for money that is not mine, only what I have earned.  I cannot continue practicing without income coming in.  My practice is 45% Medicaid and 25% Medicare.  How long could any of you go without receiving payment from 70% of your patients?  

And for those of you who accept neither, ask yourself what will happen if Medicare and Medicaid are allowed to get away without paying?  What will happen to the rates to your private insurance payments?  And those in the Emergency Rooms- where do you think that those patients that can no longer see their physician will end up?  I am just asking that you write your Senators and Congress for help to end this block so that we as physicians can get paid for what we have done.  I have not committed fraud, and I have followed the rules.  And following the rules has led to me being within two weeks of being forced to close my office, because that is the reality.  I cannot afford to bankroll my staff any longer than that.  They say you should find a career you would do for free, I have been doing that since the end of December, I cannot see myself paying to do this for long.

Thank you for your time and any effort you put towards my cause, and for many of you, your own cause. 

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