Here’s a new one – I have some newfound Rachmanus for the payers…that’s an Italian word (wink wink) for compassion. But as they also say in Italian, con amore ma non troppo (with love but not too much). In other words, I have some compassion but not too much empathy.
The payers are bleeding, or maybe “peeing”. What causes bleeding in the insurance industry? Hemorrhaging is caused by unanticipated innovations in the way of drugs, devices, or tests, but more particularly unanticipated utilization and submission for payment. And right now, unanticipated utilization of urine drug testing is causing a hemorrhage. It is through the roof. So much so, that there are several policies on the table that could jeopardize the availability to state of the art lab tests for those of us who treat pain and addiction and use laboratory testing only as medically necessary. Trying to stop the bleeding with a tourniquet that might sacrifice their arm, some of the Blues have been threatening to turn the clock back 50 years and revert to out of date technologies and take the kind of information that pain and addiction clinicians need out of their hands. Reverting to a strictly immunoassay (IA) based policy and denying confirmatory testing either entirely or of IA negative specimens, the re-instituting of this forensic testing method and mindset is a desperate effort on their parts to curb skyrocketing lab costs. And of course, this is from the very same folks that often deny abuse deterrent formulations, other branded extended release formulations, limit of physical therapy, deny procedures such as acupuncture, limit chiropractors or alternative therapies, behavior health, diet/exercise, and healthy lifestyles – yet, third party payers seem to slither away unscathed without blame for the presumed “opioid epidemic”.
It is tempting to think that the big “confirmation” labs are behind these increases. Certainly their utilization has increased in this era of expanded legitimate opioid prescribing, misuse, abuse and overdose, in an altruistic attempt by clinicians to render opioid treatment safer for pain patients or to offer recovery support to the huge influx of newly recovering addicts in treatment centers.
If this were all it was, my compassion for the insurance industry paying for these lab tests would be zero!
But good patient care is not the only reason that labs are ubiquitously ordered. And the reason that I don’t have full compassion for the payers is because they are using their policies as a blunt instrument to curb bleeding without fully understanding the bloodletting source. And as is often the case in these scenarios, it is this blunt instrument that can have many unintended consequences, one of which is indiscriminately taking down the good doctors (and patients) with the bad. Undeniably, the payers’ “spend” of billing from this illegitimate source is orders of magnitude higher than the frequency of necessary testing.
Without a doubt, I believe that most pain clinicians who choose to treat with medication management as part of an overall armamentarium certainly have their heart in the right place. They care for medically complex patients that are frequently outcast by other providers. They carry a high liability, much anxiety, deal with political issues, the DEA and state regulatory agencies, and are often living in a nerve wracking nightmare for providing compassionate care. Indeed, they could come under scrutiny for ordering such tests without adequate documentation for need or for lack of follow-up and actionable outcomes based on the lab test results.
Nevertheless, while we have all heard about fraud and abuses in the industry, perhaps it also exists, in some cases, on the provider end. There are providers in some instances who used to test urine infrequently but now test patients over and over again with large and expensive panels, as this has become a huge revenue source. These entrepreneurs are not doing anything illegal; in fact they are driving through a loophole in Stark Laws so big you could drive a Mack truck full of urine through it. Some greedy labs are threatening the availability of a tool that many of clinicians rely on in our clinics. But interestingly no one seems to regulate or write about this aspect of unethical practice (interesting in a time when regulating pain practice is at a Zenith) and I find this transgressive and embarrassing for the professions. You’d think payers would lobby for a law and media muckrakers would be all over this…but when you are talking about the sacred cow of revenue, you are talking about one of the last few topics that make payers, reporters and congressman quake in their boots. And the poor patients, afraid of losing access to their medications, who need urine drug testing to help them objectively demonstrate their adherence in an era when they are constantly stigmatized, are often frightened to question [over-the-top] testing themselves even if they recognize it as excessive. At a time when fewer and fewer patients can rely on finding prescribers willing to treat them with the opioids they need, if they get the message they can only have their medications with frequent testing, they will do it – they are over a barrel.
So many politicians railing about prescription drug abuse and wanting to do something about it and no one wants to be the next Pete Stark? You see it seems there are a lot of chicken mavericks out there who claim to be fraud busters and the like; but to understand why they don’t step up is to need to know something about Pete Stark, the father of the laws that forbid physician self-referral who just left his congressional district in California after serving 40 years. (who by the way was recently quoted as saying that with all the exceptions rendering his law ineffective he himself wouldn’t now vote for his own law!).
Stark clearly was pretty much immune to fears about being re-elected for much of his time serving, but it doesn’t end there. While he had to apologize on many occasions for ill-advised and offensive comments over the years, Stark was his own man. The first openly atheist member of Congress he was vocal about taking unpopular positions. He was for national healthcare reform….in 1990. He voted against the Iraq war. He was against the government buy out after the crash. Whether you agree with these positions or not, he was his own man, an iconoclast and someone not afraid of taking on powerful and sacred cows.
Stark, as many others, knew that physician ownership and fractional ownership of imaging centers and labs and other forms of self-referral were bad for healthcare and bad for healthcare costs. Studies have shown for example, that when doctors have a financial interest in imaging centers they order a lot more imaging…and particularly a lot more negative imaging. See for example, Doc financial interest may influence MRI referrals or Inquiry Challenges Doctors On Ordering Diagnostic Tests. Exceptions were made for labs to provide instant and point of care information and facilitate providers to work together and share cases in large institutions. But doctors running analyzers on a day’s or week’s specimens at 11pm or on Friday afternoon hardly qualifies, nor does billing for point of care IA, analyzer IA and chromatography all in office with 3 separate charges being generated.
This is the stark reality. And we need a solution other than a blunt, ill advised, regressive set of payer policies that will render pain and addiction treatment far less safe for people with these already stigmatized problems.
As usual, chime right in folks!