Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, November 17, 2006

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 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.)


At Fri Nov 17, 10:34:00 AM, Anonymous Anonymous said...

As someone with high deductible, I am wondering how ordering these useless tests is different from stealing? Doctors who do these tests think they really need to supplement their income because the insurance companies don't pay enough. Well, the company I work for doesn't pay me enough either. If I had only one 4% raise in the last 2 years - and this is with pretty good evaluation, does it mean I can take somebody's money by convincing them they need to buy something from me that they really don't need just so I can get my income in line with the inflation? And there is a difference between selling people something they don't need and ordering a test: at least with the former nobody believes his/her life will be in danger if they refuse.

I wouldn't put tests together with cosmetic services. If I go to a dermatologist for laser hair removal, I know what I am paying for. I know it is something that I don't need for health reasons but want to do anyway. When a doctor tells me I need a test, I have no way of knowing if I need it or not. Yes, I can refuse, but in order to do it I need to spend my time researching, worry about my doctor's reaction, and then there is also a nagging feeling "was I right?". So tell me, how is ordering unnecessary tests different from stealing?

At Fri Nov 17, 01:43:00 PM, Blogger Big Lebowski Store said...

I'd love to rant about this. People wouldn't kick my ass as hard as they do about my ED problem.

Keep up the good work


At Fri Nov 17, 11:05:00 PM, Blogger MedStudentGod (MSG) said...

I think part of the problem is this has become a CYA tactic many physicians have developed. Indeed there are physicians who use these ancillary tests to pad their bottom-lines, but I don't think we can summarily add this label to all doctors ordering PFT's and echos on patients. Being burned once or twice several physicians now just say "the hell with it" and order tests they know are superfluous, but will keep them from getting sued.

I worked with a doctor who did a lot of ancillary and unnecessary tests to pad his business, but he also had a bunch of patients who thought he was God because he actually diagnosed something that might have been missed. So he now feels completely justified - so long as they test before 4pm.

How's the book coming?

At Sun Nov 19, 05:04:00 AM, Blogger Sara said...

Man, I may be the only person every to switch FPs because I thought I was getting too many referrals. Uncomplicated shoulder dislocation - to an ortho. Obviously benign murmur incidentally found in a thin, 27 year old who has a kind of fast natural heartbeat - to an echo, Holter, and cardiologist (who of course rolled his eyes). Requested lipid profile - ends up with CBC/full electrolytes/thyroid profile/lfts and who knows what else?

I liked the guy and went to him because he made a good impression of being a very competent guy - but why didn't he think that about himself? At some point, it got to be the question of, "Why am I even going to him if he doesn't handle anything?" I wondered if he does that with everyone, or it's sort of because I'm in the medical field that he is giving me something he thinks I expect.

Part of the answer is lawsuits. Here, there was a big case that set a precedent that not consulting can make you at fault for negligence/malpractice. I'm sorry to say that this will probably turn around only after people start suing for unnecessary intervention/duress or something like that.

At Mon Nov 20, 02:43:00 PM, Anonymous Anonymous said...

the mislif, its called "defensive medicine" and ALL doctors practice it! You go with just a simple complaint, such as heartburn and they can't tell you it's only heartburn, take a rolaid. It could be a heart attack so you will have to go the route of ruling that out.

I don't think you should blame any Doc for doing this. Trust me when I say, I have just experienced defensive medicine in the extreme. I was pissed about it initially, and then I read recent posts at "Charity Doc's blog and also at "Dr. Schwab's" Blog.

You wanna get mad at someone, get mad at the malpractice attorneys! THEY are who is ruining American medicine!

At Wed Nov 22, 11:43:00 AM, Anonymous Anonymous said...

I don't know if I agree with Cathy. First of all some of the tests mentioned in the original blog entry didn't sound at all like defensive tests; they sounded more like something to do for money. I don't see it morally different from fraud or theft. Using insufficient compensation as an excuse is pretty flimsy, IMHO: a maid cleaning somebody's house may be very poor and have a hungry child to feed, but if she takes her rich employer's jewelry, we'd still consider it a theft.

I do understand testing to avoid lawsuits, and it is possible that had I been the doctor I would be hard pressed not to do the same, but is it morally and ethically justifiable? Does protecting yourself give one the right to take other people's money or, more importantly, potentially harm them? If a doctor sends a 5-year old for an unnecessary CT scan and increases this child's risk of getting cancer later in life, is doctor's fear of a lawsuit sufficient justification for potentially harming this child?Hypothetically, if an invasive test X has 1% risk of potentially fatal complications, is sending a person for it to rule out .01% chance of some condition without informing the person of both probabilities ethical or moral?
Surely a doctor shall at least warn that a perticular test is defensive: "here is the handout describing the risks of the test. I think your chance of having this desease is X, but I would like to send it to rule it out just in case. You have a right to refuse, and if you do, I'd like you to sign this form". Wouldn't this approach be more honest?

At Wed Nov 22, 12:07:00 PM, Anonymous Anonymous said...

The difference between "defensive medicine" and "padding your income at patients' expense" can be determined by following the money. The doc who refers out everything to specialists, or gets MRIs and CTs for every burp and twinge gets nothing back but a good night's sleep, as any physician who has ever been sued will agree (we do not get kickbacks for referrals- that is illegal and unethical if you are an MD. It's SOP for attorneys). The opposite may be true for the docs who do their own "ancillaries." If they get questionable xrays using their own facilities, or PFTs in the office, there is reason to question what they are doing, as the example above demonstrates, but even so, I don't know the standard of care in pulmonology, and all he has to do is cite a lawsuit that was based on failure to obtain a PFT in a similar situation to justify getting one on everyone. It's easy to judge others' behavior, but if all we did was strictly evidence based medicine, most docs would play golf every afternoon, and sleep late to boot. Give your doc, and your colleagues, the benefit of the doubt, but if he's demonstrated to be a "padder," his credibility will be shot and his reputation will and should be worthless.

At Sat Nov 25, 05:21:00 PM, Blogger Medicine Man said...

I'll add my 2 cents. There's a Cardiologist I send my patients to, and I've noted over time that there is a pattern that even the healthiest patient with the lowest risk-factors somehow gets funneled onto the stress test treadmill, besides getting echo's. It's a cash machine. To boot, a gastroenterologist I know once was giving me a tour of his office, when we got to the procedure room, the endoscopy suite, he turned with a smirk, and called it "a.k.a. THE ATM." It's a shame medicine is going this way. I'm not sure whether it's lawsuits that have sprung up the unnecessary tests, or otherwise. Like jb above, I don't think I can judge that. However, PFT's are not part of the standard of care in an otherwise asymptomatic, healthy PPD (+) patient with no history of smoking or pulmonary disease. Well, here's another reason the cost of medical care is going up in this country. The sad thing is that the specialists who are ordering these apparently superfluous tests are not the ones taking the greatest income hits from falling reimbursements -- it's the PCP's. Go figure.

I do have to disagree about adding certain ancillary testing to a PCP's office. For example, if you can add Bone densitometry in your office, which is convenient to your patients, and provide a valuable, evidence-based service, screening only those who should be screened, then by all means do. Just don't start screening 45-year old women with no risk factors for early osteoporosis just because you can bill for it.

At Sat Nov 25, 06:05:00 PM, Blogger #1 Dinosaur said...

Unfortunately, the evidence does not support office based densitometry of the heel, as it has been shown to have no correlation with axial DEXA scans. A patient can have a normal heel scan and marked osteoporosis of the hip and/or spine, or an abnormal heel scan and normal axial bone density readings. This means that both the positive and negative predictive value of the test is basically nil. Everyone who needs screening needs a DEXA scan; hence the office test is meaningless.

Doesn't stop the GYNs from doing them, though.

At Tue Nov 28, 11:11:00 PM, Blogger Aisling said...

Nice post. The examples you use do sound more like cash-making methods rather than defensive medicine, but agree with above posters that the latter is a huge reason for excessive documentation, laboratory studies, and imaging studies. Even when clinically NOT warranted.


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