Physician Ancillary Services Questioned

November 16, 2014

Ancillary services, like toxicology screening, are part of good patient treatment. So let’s stop scolding docs for getting paid for doing it.

"Doctors Cash In on Drug Tests for Seniors, and Medicare Pays the Bill," trumpets a Nov. 10 Wall Street Journal expose by Christopher Weaver and Anna Wilde Mathews.

OK, guys, you've got my attention, but slow down. Doesn't everyone, including repairmen, waiters, plumbers, and yes, doctors, "cash in" for services rendered. Otherwise, they wouldn't be repairmen, waiters, plumbers, or doctors for very long. Medicare promises every senior it will pay its portion of all covered services for them, so it seems natural that doctors would make money from services rendered.

According to Weaver and Mathews, the shocking news is, "Now, some pain doctors are making more from testing than from treating."  This, of course, assumes that "testing" isn't part of "treating" - more on that in a minute.  

Historically, opiods were used sparingly to relieve chronic pain.  Without proper monitoring, self -administered narcotic pain medication can be dangerous. Patients tend to "creep" up prescribed dosages, while others might mix prescribed painkillers with illegal drugs. Still others won't take any of their medication at all. Their prescriptions end up being sold on the street.   

While acknowledging these risks, many felt it cruel and unnecessary to withhold relief from all patients who are in excruciating pain because a few won't behave; especially since there are perfectly good tests to monitor a patient's toxicology (a term taken the Greek word for "poison").  There are in fact, according to Weaver and Mathews, two kinds of tests: simple urinalysis and a more sophisticated mass spectrometry test. The simple test reveals the "presence" of toxins; the more sophisticated test reveals "how much" is present.

After much hand wringing, it was decided that opiods could be used more frequently, provided the patient was carefully monitored for too much, too little, or the wrong kind of drugs in the patients urine. Many state medical boards adopted strict rules regarding pain management, both to prevent overdose and diversion. 

Great, problem solved, let's move on.  Um, not so much. Seems while no one has a problem paying for drugs which relieve pain, paying to actually keep the patient alive and well is another matter.

According to Weaver and Mathews, when the number of simple urine test skyrocketed, CMS did what any insurance company would do when it comes to treatment which costs money. They labeled the simple testing "abusive," and cracked down on reimbursements. Beginning four years ago, Medicare officials capped payments for simple screenings, including test strips that change color when exposed to drugs in urine.

Now Weaver and Mathews suggest doctors must use the more expensive tests, if they want to get paid for the test. And that's the point of the article. Medicare's spending on 22 high-tech tests for drugs of abuse hit $445 million in 2012, up 1,423 percent in five years. The article quotes Raleigh, N.C., pain specialist Robert Wadley, who started doing high-tech drug tests in his office in 2010 with equipment he installed there. Drug testing accounted for 82 percent of his medical practice's Medicare payments in 2012. "Urine drug testing is how I pay the bills," Wadley said.

That's the subtext of the article; there must be something wrong with a system in which doctors get paid for services, and then pay others who have billed doctors. What the article doesn't mention, is that any doctor you ask will likely agree: Ancillary testing of any kind is the only reason they are still able to pay bills.

Finally, I am not letting Weaver and Mathews off the hook for suggesting that "testing" isn't "treating." Now, more than ever, doctors are being asked to deliver positive outcomes, not simply "diagnose and dose." What could be more important in treating a pain management patient, than knowing how much of an opiate, or anything else, is in the patient's system? You can't get that from a cheap litmus test.