Posts Tagged ‘North Carolina Medical Board’

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.

 

 

Medical Board Action Against Telemedicine Buprenorphine Physician

Telemedicine

 

 

 

Telemedicine is all the rage these days. For medically underserved areas, telemedicine could help reduce physician shortages and provide care to people without medical specialists in their area.

As appealing as the idea may be, physicians must be careful to conform to their states’ medical board regulations.

Of course, buprenorphine can now be prescribed in the office setting to treat opioid use disorders. Even with the increased prescribing capacity DATA 2000 gave us, less than a quarter of people who need treatment for opioid use disorder receive it. In fact, modifications to DATA 2000, passed last year, allow buprenorphine prescribers to have up to 275 patients at a time, if they fulfil various criteria. Also, physician extenders can now get certification to prescribe buprenorphine after taking proper training.

But what about telemedicine? Can it be used to meet the demand for opioid use disorder treatment in underserved areas? We now have clearer guidance, thanks to a recent ruling by the NC Medical Board.

Here’s the condensed story:

A physician, who lived and practiced in the middle of the state, also prescribed Suboxone via telemedicine for patients in the Western part of the state. The medical board was displeased this physician didn’t examine his patients in this second location in person, prior to initiating the Suboxone. The physician stated he felt buprenorphine could be prescribed safely without an in-person exam, but the board didn’t agree.

The medical board faulted the physician for not giving adequate attention to patients’ use of other drugs, and their mental health history. The board said patients were not examined for track marks or withdrawal signs, and that the physician accelerated their doses too quickly. Patients were seen every four weeks from the start, and the medical board opined that was not frequent enough in early treatment.

In other words, there were clearly other issues besides the lack of initial face-to-face contact, but this lack was cited as a departure from the standard of care.

I’ve been contacted by at least a half dozen mental health agencies who wanted to hire me to start treating patients with opioid use disorder with buprenorphine, using telemedicine. I’ve turned them all down, mainly because it wasn’t good medical care, and also because I didn’t want to do anything to violate medical board’s telemedicine policy. They have had published guidelines surrounding telemedicine since 2010, and update it periodically. You can read it here: http://www.ncmedboard.org/resources-information/professional-resources/laws-rules-position-statements/position-statements/telemedicine

You will note that the policy says “This evaluation need not be in-person if the licensee employs technology sufficient to accurately diagnose and treat the patient…”

So it is a little confusing, in view of their recent ruling against a doctor prescribing buprenorphine.

In September of 2016, another Addiction Medicine physician got a public letter of concern from the NC Medical Board, for using the telephone to stay in contact with a patient who had moved out of state. I only know the circumstances of the case from what the medical board listed in their public letter of concern, but I do know the physician. He is well-trained, cautious, and has excellent judgment.

His patient of over three years moved out of state and couldn’t find a new buprenorphine prescriber. So his NC doctor agreed to continue to prescribe for him, and did phone sessions with this patient every two weeks for thirty minutes at a time. He issued buprenorphine prescriptions for only two weeks at a time. This happened over several years without a face-to-face visit. Apparently the physician enlisted the aid of a local pharmacist to do medication counts, and the medical board opined this was “insufficient.”

Wow. This ruling should give every physician a reason to avoid telemedicine. Because I think that doctor did a good thing. Every patient should have such a doctor, willing to go the extra mile to help. I don’t think the physician’s actions were “insufficient” in any regard, though I’ll admit I’m probably not what our NC medical board considers an expert.

I’ve used pharmacists to do pill counts for me if the patient says he is out of town when called for a pill count. Sounds like I’m going to have to stop doing that, given the medical board’s statement.

At least once at an opioid treatment program, I was pressured to admit patients using telemedicine.

Several years ago, I had surgery for a broken leg. At the time, I worked for two opioid treatment programs. One was located an hour away, and the other was two hours away. Driving was going to be cumbersome, of course.

As soon as I was able, I called the program managers of each to let them know I might be out of work for the next week or two. At the first OTP, the program manager said I should take all the time I needed, and intakes could be postponed. Obviously, this is not an ideal situation, since we want to admit patients as soon as possible, but this was one of those things that were out of our control. I was still available by phone, of course.

At the second, the program manager said being out of work for several weeks was “not acceptable.” The program manager pushed me to admit patients via Skype or other technology. I refused, citing quality of care issues. In retrospect, I made the right decision.

I hear about “Doctor on Demand,” advertised by Dr. Phil on his show, and I wonder how these doctors get around this telemedicine issue. These doctors aren’t examining patients face to face on the first visit. Also, to practice medicine in NC, you must have a NC license, and surely all these doctors don’t have NC licenses.

I sent an email to Doctor on Demand asking about these issues. They sent me an email back, saying someone would be in contact with me. This was about four weeks ago and I haven’t heard anything else. I’ll let you know what they say in the unlikely event that they do contact me.

In the meantime, I think all physicians, and specifically buprenorphine prescribers, need to be very careful with telemedicine. Given these two recent rulings by the NC Medical Board, we could be cited for improper medical practice. Telemedicine seems like it could be a wonderful way to get care to people with opioid use disorders who live in remote places, but physicians need to protect their medical licenses first, or we won’t be able to prescribe anything to anybody.

 

 

Action by the North Carolina Medical Board

aaadrug OD rates

Last month, the North Carolina Medical Board (NCMB) announced they will query our state’s prescription monitoring program and investigate physicians identified as having worrisome prescribing habits. In order to help combat the prescription opioid overdose death crisis, this is part of an action that the NCMB is calling the Safe Opioid Prescribing Initiative.

Announced last month, the initiative will focus on three groups of physicians. This is taken directly from the NCMB’s website:

  1. The prescriber falls within the top one percent of those prescribing 100 milligrams of morphine equivalents (MME) per patient per day.
  2. The prescriber falls within the top one percent of those prescribing 100 MMEs per patient per day in combination with any benzodiazepine and is within the top one percent of all controlled substance prescribers by volume.
  3. The prescriber has had two or more patient deaths in the preceding twelve months due to opioid poisoning. (The initial group of prescribers under investigations were reviewed for the period beginning July 2014 and ending June 2015.)

The NCMB also says letters were issued to the first 72 prescribers (physicians and physician assistants) in April, most of whom were identified under the third criteria. Since nurse practitioners are also allowed to prescribe controlled substances, they will be scrutinized by the North Carolina Board of Nursing.

Responses to this new NCMB initiative have been mostly supportive. In my local newspaper, an editorial applauded the board’s actions, and advocated more such actions, to reverse the crisis of opioid overdose deaths in the state. The Charlotte Observer carried an article that said the NC General Assembly criticized the NCMB for not doing enough to combat prescription opioid overdose deaths

I’m probably not the NCMB’s biggest fan, but I don’t think it’s fair to blame that board for not doing more about the prescription overdose death crisis. The medical board wasn’t even allowed to access the prescription monitoring program’s data until the law changed last year to allow them to do so. Before that, they had no authority to do what the Safe Prescribing initiative outlines. In the past, they could investigate a physician only if they received a complaint about him or her.

Members of any state medical board have a thankless job. They are asked to make perfect judgments about medical professionals who may present a danger to the public. If they appear to be too lenient, they are criticized by the public for “protecting their own.” (This isn’t accurate anyway, since at least in my state, over one-third of board members aren’t physicians.) If they take strongly punitive stances, they are criticized for overstepping their authority and ruining the livelihoods of the professionals they license.

The professionals on my state’s medical board spend hours evaluating cases, for little or no pay. I think they may be paid nominal reimbursements for travel expenses, but I’m certain it doesn’t come close to making up for the time these people lose from their own businesses and practices.

Contrary to public opinion, state medical boards exist to protect the public, not to advocate for the doctors they license.

The NCMB initiative won’t be easy to implement, either. Just because a physician prescribes a whole lot of opioids doesn’t necessarily mean he’s a bad doctor. For example, a physician working with hospice patients, doing end of life care, should be expected to prescribe large amounts of opioids, and have frequent patient deaths.

Peer review of physicians will be essential. The NCMB will send charts of doctors identified by the three criteria above to be reviewed by other doctors in the same subspecialty. That means, hopefully, that doctors will be judged by other doctors in the same field of medicine.

This is important. This means that good pain management doctors may have to be evaluated and judged by other pain management doctors, through the NCMB. That will no doubt be unnerving, but the outcome should ultimately be positive, if the doctors are taking appropriate precautions.

Only doctors failing to meet accepted standards will have action taken on them by the NCMB, and only those actions will become public.

The NCMB has a big job ahead. They will need to separate the sheep of the doctor world from the goats, and decide appropriate actions to take. I do not envy them this task.

The NCMB has already taken action against many of the pill-mill type doctors, starting over a decade ago. If the board received a complaint, investigated a prescriber, and found him or her to be engaging in worrisome prescribing practices, that practitioner either lost the license to practice medicine, or was prevented from prescribing controlled substances, or was asked to take educational courses in proper opioid (or other controlled substance) prescribing.

I have other concerns about the third criteria of the NCMB’s Safe Prescribing Initiative.

First of all, how will the NCMB know if a prescriber has had two or more patient deaths in the preceding twelve months? I suspect the only cases examined by the NCMB will be those found to be opioid poisoning per the North Carolina Office of the Chief Medical Examiner (NC OCME).

Deciding if a prescribed opioid caused a patient death can be tricky. It depends to a large degree on the tolerance of the decedent, which needs to be determined by patient history. A dose of opioids that would kill one person won’t even make another person drowsy, if they have tolerance.

That factor is particularly important with methadone. My colleagues and I bemoan the fact that when our patients die, it WILL be blamed on methadone, no matter what. One doctor grimly remarked that if one of his methadone patients got shot in the head, the cause of death would still be listed as methadone toxicity. I think he’s exaggerating, but only by a little

The problem is that the North Carolina Office of the Medical Examiner has no standard case definition of what constitutes a methadone overdose death, which inevitably leads to mistakes about cause of death. According to information on their website and what I’ve learned by speaking with them, the decision is made by the blood level of methadone in the deceased.

I’ve felt the sting of being unfairly accused of killing patients. On several occasions, I’ve called the OCME about one of my patients who died while on methadone. I wanted to provide information about the patient’s dosing history before they determined the cause of death. I felt I had important information that could help them…but it did no good.

In one case, my patient had dosed on methadone 130mg for about a year, and then started a slow and steady taper. One year later she was dosing at 60mg per day when she died suddenly and unexpectedly. At autopsy, she had cocaine in her system, and she had a history of heart trouble. I suspected a fatal cardiac arrhythmia caused by cocaine, but the OCME announced the cause of death was: “Methadone toxicity, cocaine toxicity.”

Apparently they based their decision on post-mortem blood levels, known to be inaccurate. After death, the methadone stored in the liver can leak back into the blood vessels, causing elevated readings on which their determination was made, regardless of the history I gave them about her dose.

Five or so years before, another patient of mine died of what I thought was a severe asthma attack. In fact, she called 911 herself, saying she was having an asthma attack. Sadly, by the time EMS arrived, she had stopped breathing and couldn’t be resuscitated. I called the OCME to see what they found at her autopsy. The physician who did the autopsy said he found mucus plugging and bronchial casts, classic findings of status asthmaticus, which is a severe and sustained asthma attack. I was sad about her death, and told him I had treated her for many months for opioid addiction, and that she had dosed daily on methadone 75mg for at least two months.

When the death certificate was issued months later, after the toxicology report was available, I was surprised to see the cause of death listed as “methadone toxicity.” I called the medical examiner again and asked why this was listed, and the answer was that it was based on the drug level of methadone in her system.

Thankfully those types of cases are relatively rare.

I worry much more about all the people who die from opioid overdose who are never identified as a coroner’s case. That’s a bigger issue.

Consider the ways in which a deceased person becomes a coroner’s case. Of course, all instances where foul play is suspected require autopsies. Young people with no known medical issues should be investigated. Sometimes, deaths that occur in hospitals or nursing facilities require autopsy, if unexpected. Deaths that occur in police custody always require an autopsy..

In the community, if a person dies unexpectedly, a coroner is called to come to the scene to look for foul play. If there is none, the coroner calls the person’s doctor, to see if there’s an obvious cause of death like cancer or heart disease.

If you are a doctor freely prescribing opioids and/or benzos, what would you say to a coroner? Possibly, you’d say the decedent was ill with various problems and that the death was expected. It could be convenient to describe as “cardiac arrest.” (Technically, all deaths are ultimately due to cardiac arrest, but that doesn’t tell us the cause of death) This would be less upsetting for the family, keep the doctor out of trouble, and save the cost of an autopsy to the state.

Besides, no doctor wants to think the medications he prescribed killed a patient, or even contributed to the person’s death, so that inevitably biases judgment about cause of death by the prescriber.

I wonder how many overdose deaths slip through unnoticed and unexamined. Current data shows a very high incidence of prescription opioid overdose deaths, but I fear it is even higher.