Ancillary My Ass
Ancillary: (adj) serving as a supplement or addition.Much has been written about adding "Ancillary Services" to outpatient office practice. Bone density testing, radiology, counseling, cosmetic services...you name it; someone has looked into what it takes to add it to a practice. Follow the money, they say. The problem is that there are perilously few controls preventing utilization that is not only excessive but downright inappropriate.
I recently encountered this situation, which really pissed me off:
Patient who works as an MRI tech comes back with a positive PPD. (I saw and measured it; it was a true positive.) The chest x-ray is perfectly normal. She needs six to nine months of isoniazid prophylaxis. Piece of cake.
But because this comes under the heading of "Workmen's Compensation" she has to go through Occupational Health at one of the hospitals she works at (where I'm not on staff, not that it makes much difference.) Occupational Health is privately contracted to one of the FP offices (cool) but the hospital's policy is that their pulmonologist needs to be involved in treatment of positive PPDs.
So my patient goes off to see him as required, and I get a nice cc of the pulmonologist's letter to the Occupational Health FP -- which includes pulmonary function tests on my patient.
Why? She has no history of pulmonary problems or complaints. She's never smoked. She has a normal chest x-ray. There is no clinical justification for PFTs on this patient.
But apparently this guy does them on everyone. That's just the way he does things, tells me the Occupational Health FP. ("I can't tell him what to do in his own office," the guy tells me.)
Well someone should, dammit!
GYNs do useless heel DEXA scans to screen for osteoporosis; Cardiologists do echocardiogramss for every murmur; and everyone who possibly can offers cosmetic services like Botox injections and laser hair removal. For those of us trying to run evidence-based solid primary care practices, this is intensely frustrating.
To paraphrase the Abraham Maslow quote on DB's sidebar: let someone loose with a hammer and everyone is going to get nailed!
(Update: More here.)