Shady Signs and the Corporate Practice of Medicine

Roadside Suboxone Advertisement

 

The roadsides of rural North Carolina have become littered with these signs advertising access to Suboxone prescriptions.

When I first saw one of these signs, I was appalled. These signs, more commonly used to advertise homes for sale or dating services, exude tackiness, when used to advertise for medical care. They are called “bandit” signs, for their often unauthorized use. As far as I can tell, these particular signs don’t violate any laws, when placed in the public road right-of-way, but they do seem dodgy. Their 1-800 number and the mention of “microloans” smacks of unprofessionalism to a degree rarely seen in medicine, even in these days. It reminds me of the more outrageous signage of the South Florida pain clinic scourge five or ten years ago.

 

South Florida pain management sign

One shady buprenorphine prescriber casts shade on all other prescribers. These signs make me feel embarrassed to be a doctor who prescribes buprenorphine, because the general public will lump all of us together.

I also felt embarrassed for my patients who take this medication for opioid use disorders. In fact, not long after I saw that first sign, one of my long-term patients, in relapse-free recovery for more than eight years, told me she felt mortified when she and her husband saw a similar sign while driving. She has had a spectacularly successful recovery, yet when her husband saw the roadside sign, he started criticizing her again for “still” being on that medication.

Out of curiosity, I went to the website advertised on the sign.

It’s scary.

They advertise a “mobile medical unit” that will “utilize church parking lots as much as possible,” for privacy reasons. The website says the clinic is staffed by a physician assistant and no medications are dispensed on site. Prescriptions for twenty-eight days will be called in and patients seen by telemedicine. (I assume this meant patients could get counseling via telemedicine.) Twenty-eight cities are highlighted on a NC map on the website, so presumably these are the target areas. The price listed for this monthly visit from a mobile medical unit was about twice what I charge my buprenorphine patients for a routine office visit, so it’s not cheap.

I suspect this business is not going to be owned or operated by a physician, though I could be wrong about that. From the way the content on the website is written, I can almost guarantee no one with medical training had a role in its composition.

This may be its downfall, since NC’s corporate practice of medicine act states that non-physicians aren’t allowed to own medical practices or employ physicians. This means that physicians employed by non-physicians are subject to sanction from the NC medical board.

Let us take a moment to go down this interesting rabbit hole known as the Corporate Practice of Medicine Act, or CPOM.

This antiquated law was a bit of legislation passed many decades ago, when lawmakers had the quaint and rather touching idea that physicians should be the only people to own and operate medical services, since they are the only people trained to know what’s best for the patient.

How can this law still exist, you ask, since about half of doctors’ offices are owned by hospital corporations? Because the medical board doesn’t enforce CPOM law for practices owned by non-profit entities, or for practices owned by hospitals. The medical board’s reasoning is that these hospital corporations, many of them for-profit, are likely to have the patient’s best interests at heart and therefore not be likely to make decisions based on profits alone, unlike other for-profit, non-doctor-owned entities. To me, that seems a bit arbitrary, but I’m not privy to their discussions on the matter.

Ten years or so ago, I quit working for a non-profit opioid treatment program to work for a for-profit OTP. Worried about the CPOM law, I called one of the NC medical board’s lawyers, to ask for information about the legalities of doing this. The board lawyer told me that if anyone reported a doctor for working for a for-profit, non-hospital agency, the medical board would “take action.” I tried to ask about specifics, and told him most of the opioid treatment programs in our state and in most states aren’t physician-owned. I asked if all of those programs were in violation. He kept saying that if they were reported, action would be taken.

He recommended I hire a lawyer who could give me specific legal advice, saying that since he worked for the medical board, he couldn’t give specific advice to the people whose licensure is controlled by that board. He gave me the name of a lawyer in private practice who used to work for the medical board and would be knowledgeable about these laws.

I called this lawyer and explained my situation and asked him how much it would cost to have him figure this out for me. To his credit, this lawyer gave me what felt like good information. He said I shouldn’t have to hire a lawyer to figure this out.

He said that since opioid treatment programs are ordered by law to have a physician as medical director, this puts them in direct opposition to the corporate practice of medicine act, and that this was an example of two laws contradicting each other. He said something to the effect that a medical facility that’s so closely regulated by the state can’t be outlawed by the state. This made sense. He said this needed to be figured out at a much higher level than me. He said it was an issue that needed to be worked out between the NC medical board and the state opioid treatment authority.

I liked that answer, since I wasn’t eager to shell out big bucks to hire an attorney. I contacted people at the state opioid treatment authority, and also the board lawyer to tell them what this attorney had said. Then I quit worrying about CPOM since, since this issue was too big for me to take on.

I doubt the issue has been resolved, because I still hear rumblings about how some opioid treatment programs are in violation of the CPOM. All I can say is that this is NOT a new topic, but it is a complicated one.

OK….. let’s pop our head back out of the rabbit hole, and talk about possible positives of having road signs advertising buprenorphine prescriptions.

Maybe the signage I find appalling is a means to harm reduction. We have mobile syringe exchange units, so why not mobile buprenorphine units? Far too many patients are dying of opioid overdose, so maybe roadside advertising is a novel way to reach people at risk for dying from this disease of opioid use disorder. Maybe we need to accept a little tacky advertising in the name of saving lives.

I don’t know – I know I don’t have all the answers. But I question the harm reduction motives of this particular business, based on how much they are charging, and their offer of “microloans.”

I hope somewhere in this business model there’s a conscientious physician tasked with overseeing quality of care. I hope that physician is truly involved, and not just providing a signature on a form every three months.

 

 

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7 responses to this post.

  1. Posted by axegrinder30033 on May 7, 2017 at 5:11 pm

    The thing is: This is a good thing. Suboxone is as close at it comes to benign. If it was Methadone, I’d be more concerned, but Suboxone is nearly impossible to OD on, has very little ‘addictive’ properties, and is basically worthless as a ‘high’. They should sell it OTC.

    Reply

  2. Posted by DigitalMatt on May 7, 2017 at 8:03 pm

    These are all over the Tampa Bay Area in Florida too, although without the microloans. My girlfriend told me about them before I saw them. It made me ashamed of my treatment.

    Reply

  3. Posted by Kristy K. on May 8, 2017 at 4:04 am

    I think this person/company is ethically challenged to say the least! “Treatment” doesn’t roll up in a church parking lot and start passing out scripts for opioids. Isn’t that how, as a society, we got here in the first place?? Doctors have other choices besides Suboxone Film! I do the urine screens where I work. Not my only job, just part. There are about four (?) others just like it. Narcan spray, Bunavail, Zubsolv, a shot vivitrol, envzio a spray and a implantable one. I’m on another one and doing tefferic. Zubsolv has been a life saver for me. I work at an addiction office. I hear the reps w my doctor and staff all the time at lunch and in the back. No one knows I was selling mine. I would be fired. To be honest, I was selling half my script of subs, 2- 8/2. I’m a single mom and I needed the $$. People don’t $ film b/c they can’t get into a program some where, they do it pay for heroin or pills to play on the weekends with our friends. If you’re so concerned about stigma w subs, then write something else besides it. You got all the power with your pen. Doctors are such suckers. F&F substitute docs for our dealers. Docs will write whatever you tell them you want. How is that any different? Makes you feel like you are trying to help your community… please! Then take our insurance instead of making us pay cash. When docs don’t think of us as a business, we’ll stop selling it to. It’s all business. And make them go to a real counselor. If you really want to help then write something else besides subs and take our insurance and counsel us like you care. I relapsed two months ago. I needed $. I knew it was wrong. See it, live it. Hard to tell F&F no. I’m good know. I now what works for me. Anyway, I just being honest not trying to hurt you or anyone. Thanks for blog. Someone at work was talking about it and that you are pretty cool.

    Reply

  4. Posted by William Taylor, MD on May 8, 2017 at 2:49 pm

    The CPOM laws are a swamp that needs draining. Can you be an employee health physician for Bank of America? Can you work for a state-licensed plumber? How about a plasma donation company. Is being an independent contractor different from being a W-2 employee? How about doing utilization review for Aetna?

    Reply

  5. Posted by Lisa Hall on July 4, 2017 at 2:07 pm

    I don’t understand the thinking behind thinking that Suboxone should be an OTC drug. To me, any drug used used for an addiction should be dispensed with a social program, individual drug counseling, individual psychological counseling, and drug monitoring- for both the screening of other drugs, and for levels of Suboxone in the system.
    There is SO much more to getting off street drugs than just handing out OTC or prescribed drugs.

    Reply

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