Saturday, January 23, 2010

Restriction of Practice: Fear or Anger?

I recently suggested to the leadership of my local branch of the American Society of Addiction Medicine that as a way of protesting the DEA's unnecessarily disruptive and wasteful methods of conducting audits, that we encourage members to do as I have done: I have made a decision to stop accepting new opiate addicted patients for treatment with buprenorphine and to make that fact known. One of them replied,

"I'm not sure I understand your recommendation to stop accepting patients(?) We are fully within our rights to treat patients. It is unnecessary to curb our professional activity unless any individual MD is exceeding the 100 patient limit; or if, of course, a given physician simply wants to discontinue for their own purposes such as retirement or the pursuit of other professional goals.

"I think that it is also important to underscore (to you) that treatment access remains a problem, and to the extent we magnify the impact of this situation, it may have the effect of discouraging physicians from pursuing this path in a manner that is disproportional to the regulatory risk of the prescribing activity. We have an ethical obligation to both our patients and our colleagues to not let our fear or [sic] audit translate into excessive fear of obtaining a SAMHSA DATA Waiver."

Doctor, it is not fear, but anger, and the wish to draw attention to, and possibly solve, a larger problem that motivates my decision. I still recall sitting in a lecture hall in medical school in the early 70's when one of my classmates briefly spoke out to challenge a legitimate wrong, but quickly withdrew. Out of fear. Since then it has seemed to me that medical schools, whether intentionally or not, select for conformists and cowards. Surgeons may represent an exception. Most physicians seem to fear that rocking the boat or taking action or an unpopular position will threaten their status or income. The rest might cite the rationale that we must fulfill an ethical obligation to treat all those people in need. And the legislators and regulators take full advantage. I can hear them now: "Let's just add a few more regulations. The doctors will just suck it up."

I chose not to risk being accused of Medicare fraud: I opted out. The result: I care for few older patients who enjoy more privacy because I am not required to bill Medicare for my services to them.

I dislike the terms of insurance contracts, including managed care: I enter into no such contracts. The result: Patients either pay cash or go elsewhere. And my patients do not need to worry that I will compromise their care to enhance my standing with the insurer.

I prefer not to be bound by HIPAA: Because I do not bill electronically, HIPAA does not apply to me. The result: State law, case law, and ethical considerations, not govern most of my privacy practices. The rest is between myself and my patients.

I choose not to be subject to the FCC's Red Flag Rules by not meeting the FCC definition of a "lender." The result: I cannot let my patients carry a balance.

For most physicians these and other distractions from patient care already lead to limitations of practice, increased time spent on non-clinical duties, and manipulation of physicians to "fill out forms" many of which address questions with which physicians should not be involved. Some doctors retire when they've had enough. Others stop accepting any new patients. For still others a patient may have to wait six months to get an appointment. Some become administrators, forensic experts, journalists, or legislators, or learn how to inject Botox. At the same time we hear that we as doctors should take better care of ourselves, spending more time with family, getting "therapy", or working shorter hours. You cannot have it both ways. You don't want rationing of health care? You already have it.

Of all specialties a physician in addiction medicine should recognize "enabling," a core concept in Alanon, in action. By continually giving in to these encroachments on patient care we become responsible for their perpetuation. The ultimate consequence for this obedient acquiescence to over-regulation is reduced access to care, which I read recently may have contributed to the deaths of 40,000 people. A doctor has a choice: She can spend 10 minutes treating a patient or she can obediently, and without charging, complete a preauthorization for a drug so an insurer can make more profit. He can perform a medical procedure or spend two hours reading about how to avoid going to jail for improper coding.

The net result for me is that while I could probably care for 100 patients per week I may care for 10. After all the public invested in my education and training I spend my time writing blog posts when I could be practicing medicine. You cannot hold a gun to my head to force me to practice. If you convict me of a crime and/or revoke my license, who will care for those patients? Send me to jail, and I have a right to medical care. For free. Make my day.

Perhaps we cannot ethically go on strike. Or perhaps ethically we should. You can certainly limit your practice. But if you do, do it out of anger, not out of fear, and make it known. I would stop practicing altogether today if I could, and when I think of how many other docs probably feel the same way, that scares me, and makes me angry.

And what about the doctor who says I should not stop accepting new buprenorphine patients? He also mentioned he's on sabbatical.

2 comments:

  1. From: http://www.blogger.com/profile/02375405646064588550

    I will own some of the statements above, and challenge others, as what is posted by the blogger has been distorted under the magnification of emotion. Here is a verbatim account of what has resulted in the above blog entry

    I pushed this over to , along with a summary of the 2 most recent investigations I have knowledge of.
    Due to the legislative session, I doubt a fast turn around, but I request that 80% of our questions get a response in 7-10 days.
    Re: having another Doc present, if you have agents arrive and you would like a colleague there, call my number below. I am currently on sabbatical so when I am not traveling, I have a very flexible schedule.
    I'm not sure I understand your recommendation to stop accepting patients(?) We are fully within our rights to treat patients. It is unnecessary to curb our professional activity unless any individual MD is exceeding the 100 patient limit; or if, of course, a given physician simply wants to discontinue for their own purposes such as retirement or the pursuit of other professional goals.
    I think that it is also important to underscore (to you) that treatment access remains a problem, and to the extent we magnify the impact of this situation, it may have the effect of discouraging physicians from pursuing this path in a manner that is disproportional to the regulatory risk of the prescribing activity. We have an ethical obligation to both our patients and our colleagues to not let our fear or audit translate into excessive fear of obtaining a SAMHSA DATA Waiver."

    With this out in the open, let me clarify some points that I think you missed the first time around.

    1) "If, of course, a given physician simply wants to discontinue for their own purposes such as retirement or the pursuit of other professional goals" acknowledges your autonomy to discontinue seeing patients, or my autonomy to choose to discontinue seeing patients. There is a suggestion, through your medical school story, that challenging the idea of discontinuing seeing new patients is nearly equivalent to being afraid to speak up. I'm not afraid to speak up, as much as I am afraid that when people are angry it is not the best frame of mind for designing choices.
    2) In response to the reasonable question "I'm not sure I understand your recommendation to stop accepting patients(?)" what I hear you saying, is that collective action, in the form of a strike, is one tactic that you would like to see utilized as a means for drawing attention to the problem and bringing about change. On this point I respectfully disagree. The reason is that it has a very certain outcome of directly harming patients, and have a low likelyhood of helping anything.
    3) Given that you yourself are not sure if a "buprenorphine prescribing strike" is a good idea, It seems reasonable to challenge the idea, for the sake of discourse.
    4) My main point is that I would like to see the ranks of buprenorphine providers increase. If there are certain DEA actions, federal laws, this that and the other, that limit the attractiveness of addiction medicine, then as veteran prescribers, we should work to effectively bring about change as a worthwhile focus. As you have pointed out yourself, your practice is unique in that you are a soloist and often there may not even be a front desk staff present. Therefore the effect of these regulations may be uniquely detrimental to your practice situation, and thus my offer to get in my car and drive down the street, should you need a witness.

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  2. Michael:

    The difference here is between more talk which gets us nowhere, and action which draws attention to the problem and focuses the blame on DEA and other regulators where it belongs. If society wants us to use our medical skills to fight addiction, we can and should demand that we do so on our terms. All DEA has to do for me to start accepting patients is to schedule my audit. Maybe you should talk to them about that.

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