A session on physician dispensing at last week's WCRI Annual Conference shows that, despite legislative gains in the fight against this practice, we still have a long way to go.Research indicates that doctors who are more concerned with their investment portfolio than their patients well being will get very creative in order to keep the money rolling in.

It is, in a word, disgusting. As many of you know, physician dispensing has been a point of great controversy in recent years, as these doctors have been dispensing their own prescriptions in some states at incredible markups over traditional pharmacy costs. Physicians say that this is necessary so that patients can get their drugs immediately, and start slamming those pain pills right in the office. Plus, it makes payments on the Bentley a little easier to handle, which probably eases the physicians pain a bit, now that I think of it. Some states have moved to stop this abusive practice with mixed results, but a new trend this past year shows some physicians found a workaround.

In Illinois, whose reform limited charges based on specific dosages, dispensing physicians simply changed the dosage of the medication they were prescribing. So now, when a Vicodin dose of 5-325 milligrams costs .66 cents, a new lesser dosage, 2.5-325 milligrams costs 5 times as much, around $3.04. In California they are seeing the same thing. Cyclobenzaprine, in fee scheduled doses of 5 and 10 milligrams, costs a maximum of .59 and .70 cents per dose respectively. Magically, however, physicians have come up with a 7.5 milligram non-scheduled strength, and it costs up to $3.45 a dose.

Such as it is with the continuing battle against “profit center physicians”. 

To clarify that statement, and explain exactly what a “profit center physician” is, I will simply repeat what I told someone yesterday in a conversation via LinkedIn:

A “profit center physician” is one who puts their own needs ahead of those of their patients. They dispense their own medicine, filling sometimes unneeded prescriptions with vastly overpriced prescriptions. They employ unnecessary testing using labs they own. And when squeezed by legislation aimed at curbing their avarice, they invent new ways to extract money from the treatment of their patient (whether it is needed it or not). 

In short, they are doctors who view their patients as a profit center.

WCRI reports that this is not the only area where medical fee for (bogus) services applies. They also demonstrated that states setting fee schedules artificially low may in fact be generating greater expenses through similar creative medicine. For one state where fees were frozen for a time, doctor's office visit's that had been coded and billed as “Intermediate”, tended to be billed as the more expensive “Complex” (based on CPT coding) after just three years. In one WCRI example, office visits previously billed at $46 were changed to $69 under the increased code. The frequency of those visits also increased, with the net result that the patient had to make more visits than they would have prior to those fee restrictions. And surprise, surprise, the states with low fee schedules are more likely to have dispensing physicians.

To be fair, states that try to control costs by simply slashing reimbursements have some blame in this game. Keeping revenue artificially low simply reduces supply and threatens to deny care to injured workers as a result. It is the same phenomenon seen in Medicare. The Feds “go to” cost solution is to pare the doc’s fee to the bone, with the result being a shortage of qualified Medicare doctors. I have maintained for some time that workers' comp should identify top performing physicians and pay them well, negating some of the price antics we see in the industry. For some of these physicians it is a matter of survival. 

But for the ones who insist on dispensing their own meds, that is a dangerously inherent conflict of interest featuring both a lack of safety checks and a huge upside profit potential. The patients to these physicians might simply be grist for the profit mill. The games played with dosages has no other reasonable explanation. 

Let's face it, that combination just spells scumbag, and some of them are proving it every day.

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