Thursday, August 25, 2011

Contingency Fee for Physicians

"We've already established what you are, ma'am. Now we're just haggling over the price." - George Bernard Shaw

The debate rages: Should physicians charge a fee for non-clinical tasks such as completing FMLA and disability forms, utilization (peer) review, and prior authorization for reimbursement for drugs, tests and procedures? As physician reimbursement plummets physicians increasingly wonder how they will pay the overhead, much less take home enough to pay off the student loans and still make a living. Many physicians now charge a nominal fee, maybe $50, or an hourly rate which barely covers the loss of time entailed.

Keep in mind that in many cases a third party like a disability carrier or pharmacy benefit manager exploits the physician's wish to help the patient in order to obtain free service from the doc. Physicians rarely obtain payment from the third party, and billing the third party raises ethical and role questions. The physician should work for the patient, but the third party foots the bill. Who does the physician work for anyway? And yes, the same question arises when the physician accepts money from insurers for rendering ordinary medical care, especially under contract.

Plaintiff's attorneys can collect as much as 30% or more of damage awards as contingency fees when they win a case. Not only does this practice assure an income, it also provides an incentive for them to take a case and spend their own money on trial expenses, like hiring expert witnesses, that many of their clients cannot afford.

Why don't physicians do the same? Let's say a patient applies for disability, and the policy allows for $1000 per month. If the physician completes the application, but the carrier rejects the claim, no one pays the physician either. But if the policy is awarded, the physician takes 30%, or $300 per month. It could work the same way for prior authorization for an expensive new atypical anti-psychotic. The physician would take 30% of the retail price as a reward for having obtained reimbursement.

This could change the game, giving physicians an incentive to increase skill at obtaining reimbursement. Experts with proven track records would sponsor courses. Physicians would publish their success rates on their Web sites. Patients would choose physicians, not by bedside manner or quality of medical care, but instead by how well they perform to obtain reimbursement.

What? You say there may be an ethical problem with this approach?

"We've already established what you are, ma'am. Now we're just haggling over the price." - George Bernard Shaw

Thursday, August 18, 2011

Voir Dire and HIPAA

Yesterday I presented myself for jury duty for the first time. It did not surprise me that the attorneys for a personal injury case rejected me after subjecting all the candidates to the process known as voir dire. The other prospective jurors, however, did surprise me by their willingness to discuss their medical histories openly in court. Not one refused to answer questions about injuries and treatment.

Truth be told, during the voir dire we identified ourselves only with large numbered placards, but the jury attendants had previously assigned numbers with names announced to as many as 100 prospective jurors, and selected jurors would likely introduce themselves during deliberation. I planned to refuse to provide what in any other venue would qualify as protected health information (PHI) under HIPAA, but neither judge nor attorney ever asked. I admitted only that I have never sustained an injury in a motor vehicle accident.

I still wonder whether the court can compel a prospective juror to reveal medical information. If so this would seem to represent a double standard of sorts and would seem to conflict with or even invalidate medical privacy safeguards.

All prospective jurors also dutifully stood, raised their right hands, and said, "I do," when ordered to swear the oath. (No one seemed to notice that I did not raise my hand or say, "I do.") In that situation most seem to accord great authority to judges, sometimes assuming judges possess authority they may not really have. I doubt that a judge can compel me to swear an oath. If this is true, and if judges lack the authority to compel release of medical information, they should inform prospective jurors of this fact.

Sunday, August 7, 2011

Need Help With Drug-of-the-Day Tweets

If you had to think of two or three words to remind a potential prescriber or even a patient about some important aspect of a drug, what might they be?

Every day (repeating on the same day annually) I will tweet a different CNS drug with a link to the drug's page and a few words to remind of a key property of the drug or aspect of it's use. This is intended as an educational tool.

Yesterday's tweet: 

"BehaveNet® Clinical Capsule™ #Drug of the Day: #risperidone #prolactin"

I am soliciting suggestions. More examples lithium: kidney, thyroid; bupropion: seizure. 

What might you suggest for amineptine? trifluoperazine? The list currently contains more than 365 drugs including many from the DEA controlled substances list. I am also looking for suggestions on which drugs I should drop to get down to one drug per day.

You can view the list at the link below. You may need a gmail account. Please mention suggestions with comments here or at

Thursday, August 4, 2011

Hung Up on Drug Classes

This WSJ article on increasing use of antidepressants illustrates at least part of the problem: Readers naturally start thinking about patients with depressive disorders, and the article alludes to recent media attention to possible lack of effect on mild cases. Only near the end of the article does the author remind us of the wide variety of uses of these drugs beyond treatment of depressive illness, some of which enjoy FDA approval. Bupropion helps with smoking cessation. Fluoxetine gained approval for Bulimia Nervosa. I frequently prescribe mirtazapine, off label, for insomnia. FDA has approved various SSRI's for anxiety disorders like Panic Disorder and PTSD.

Did I say SSRI? Here comes another dimension. SSRI refers to a mechanism of action, or just action. SSRI's (starting with fluoxetine in the US, fluvoxamine in Europe) represented an apparent improvement over the older tricyclic antidepressants. But tricyclic, like tetracyclic (trazodone) refers to chemical structure. Other chemical classes include benzodiazepine and barbiturate.

Had enough yet? I struggle with yet another category of drug class. Even if you leave out chemical class and action, and attend to what I call clinical class, which clearly includes antidepressant, anxiolytic, and anti-psychotic, several other classes seem distinct. These include sedative-hypnotic, psycho stimulant, and neuroleptic. To my way of thinking clinical implies illness or symptom. Antidepressant means attacks depression, a symptom. But neuroleptic refers to no illness or symptom, even though we usually use that class of drugs to treat psychotic disorders. I propose calling these "effect" classes and separating them from the clinical classes. Should clinical classes be a subset of effect class or a separate class on the same hierarchical level?

Clinical classes also suffer from the too frequent assumption of all or none status. Once FDA grants approval for treatment of depression few would argue with membership of the drug in the antidepressant class. Enter the controversy surrounding the evidence that antidepressants can precipitate mania in patients with Bipolar Disorder, and take for example the anti-epileptic drug gabapentin. Anecdotal reports in the literature describe cases of apparent antidepressant effect. Should we classify the drug as an antidepressant based on such scant evidence? Does inclusion in the antidepressant class imply risk that the drug may precipitate mania in Bipolar? Just how should we determine whether a drug deserves admission to a given clinical club? For many drugs it seems the original category sticks despite evidence for inclusion in other categories.

We can see the same problem with action. We may call a drug a dopamine antagonist because that action seems to dominate, but the same drug may have histamine antagonist (anti histamine) action, and others, as well.

Sometimes the context determines the category. FDA first approved divalproex for treatment of epilepsy (Think clinical class.), but when discussed in psychiatric circles we usually classify it as a mood stabilizer (Think effect class: There's no direct mention of illness or symptom.).

Separating effect classes from clinical classes will not solve the problem. Ultimately we must maintain awareness of the limitations of the designations. The need to categorize and the complexities of the task permeate human psychology and language. For an exhaustive and fascinating exploration read: