First Published 4/20/2013

I realize that practice patterns differ between practices, even those treating the same condition (opioid dependence) with the same medication (buprenorphine).  Differing patient characteristics result in different regional standards of care, for example.  And some areas have access to services (e.g. group treatments or laboratory testing) that may not be as available somewhere else. Some patients pay directly for service, and some through private insurance. Some have coverage paid for by government. In all cases, who pays for health care? We ALL do. And doctors are not helping.

Physicians also have differing opinions and attitudes toward relapse and personal responsibility.  Some docs are more paternalistic than others. Some are quicker to dump ‘difficult’ patients. For most medical problems, patients are able to find doctors whose practice patterns match their personal preferences.
Shortages of buprenorphine prescribers in some parts of the country force patients onto waiting lists, and to take whatever open space comes along, whether or not they consider the physician to be personable or competent.  I resist finding fault in how other docs run their practices, as I have no way of knowing the considerations that any physician takes in regard to his/her patients.  But I sometimes hear about practice styles that make me wonder if patients need a wider range of options.

Still Going Up

A patient in my buprenorphine program is trying to find treatment for his wife.  I’m at the cap, so I can’t take more patients.  At a recent visit, he described the practice where his wife receives buprenorphine treatment.  I realize that I’m hearing only ‘his side’, but he had little to gain by misleading me…. beyond, I suppose, having an interesting story.

He said that his wife has done well on buprenorphine/Suboxone for over two years.  She hasn’t relapsed or missed appointments, and she hasn’t tested positive for any other psychotropic substances.

She is required to attend weekly psychotherapy sessions with a counselor employed by her physician.  If she misses a psychotherapy appointment, she is subject to discharge from treatment.  Even after two years of doing well, she is required to continue weekly psychotherapy.  She must attend at least one AA or NA meeting per week.  She must see the prescribing physician every month.  And every month she undergoes urine testing.

Her prescriber accepts Medicaid, so her financial burden is not all that high, other than needing to take time off from work five times per month for appointments.  But her husband described the invoices that she receives for charges to Medicaid.  The charges for doctor appointments are significantly discounted, so they make up less than half of the total bill.  But the lab bills add up.

The clinic charges Medicaid a couple hundred dollars for each ‘point of care’ urine test.  Without Medicaid, the charge is paid by the insurer or by patients themselves.  I showed her husband the kits I use that test for the presence or absence of amphetamines, cocaine, buprenorphine, THC, methadone, oxycodone, mixed opioid (e.g. heroin), and PCP.  I purchase the test kits through internet suppliers, complete with collection vials, for about $5 per test— total, for a test that measures simultaneously for all of the substances.  The $5 kits are just as sensitive and accurate as the $200 tests. The only difference is that I do the testing myself in about 3 minutes, rather than send the urine to the lab.

People with ‘indeterminate’ tests at his wife’s clinic— something that he says occurs about 30% of the time— undergo ‘quantitative’ drug testing.  I’ve written about the boondoggle of quantitative urine testing in the past, about why the tests are not an accurate reflection of blood levels of substances.  In short, blood is filter at the kidney through sieve-like structures.  That filtrate goes through a series of tubules where water is re-absorbed in varying amounts, depending on the balance between fluid intake and fluid loss through sweating, respiration, etc.  Because of the varying concentration of urine, the concentration of a drug in the urine is not directly related to the concentration of that drug in the bloodstream.  Further confounding the tests, some substances are specifically transported out of the filtrate, and others are specifically excreted into the filtrate.

Quantitative tests measure the amount of each substance in the patients’ urine, but tell little about the amount of each substance in the bloodstream.  Labs try to correct for concentration effects by measuring the specific gravity and applying a correction factor.  But the resulting value must be taken with a grain of salt (no pun intended) because of the essential flaw in using urine to determine drug levels.

I have used quantitative testing, and I understand the value in knowing, for example, the ratio between excreted buprenorphine and excreted norbuprenorphine, the chief breakdown product.  But in an era of limited resources, I cannot rationalize making a patient, insurer, or taxpayer pay the $800 – $1200 charged for EACH test!

I dropped the quantitative test company that I was using after I learned about their charges.  The reps for the company paid me a visit over lunch, and asked me why it mattered.  ‘Everybody else is using us,’ they said.  ‘Besides— the patient never even sees it.  We just take it from the insurance company, or from Medicaid.  The patients don’t really pay for it.’

Then one of them added a comment that summarizes why healthcare costs are out of control:  ‘I see your point about the problems with the test, but if you don’t use it, you could get in trouble with the state.’
To translate, the $1000 test adds very little information to the $5 test, but the people on state medical boards doesn’t necessarily understand the reasons why the tests are not worth the money, so I should order them just to make sure that I LOOK like I’m doing as much testing as everybody else.

When I was in med school (way back in the mid-1980’s), my professors at the University of Rochester made a big deal about healthcare costs.  We were taught to know the price of tests that we ordered, and to consider the value of each test, in light of the cost. With everybody bemoaning the cost of health care, seems to me that now would be a good time to get back to some of those considerations.


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