Avalon Posted February 11, 2018 Share Posted February 11, 2018 Good Morning, I was hoping to run this by a few of my colleagues this morning. I work for a gynecologic surgeon doing MIGS only. This means that for any case she completes, the maximum number of incisions would be three; one intraumbilical, and two, sub 1 cm ports in the lower abdomen. In over two years in my role with this surgeon, I have never seen a bad cosmetic outcome. Every surgical patient is offered a scar cream, made by a compounding pharmacy that is not local (and is about 80 miles away). The cream is ordered as 180 mg, with four refills, with instructions to apply several times daily for up to one year. This is charged to the insurance and the patient is informed that, if the insurance covers it, the prescription will be sent to the patient's home. The patient is told to be waiting for a call from the insurer and to state they definitely want the scar cream. In the last several months, prescriptions for this scar cream have been placed on my desk for signature. I noticed that the forms I am asked to sign from the compounding pharmacy have pre-printed stickers on them, complete with my name, my NPI number, and my state license number. I asked my staff to explain this situation to me. I was told that the surgeon had been informed by the pharmacy more than a year ago that she could no longer sign these prescriptions due to a "conflict of interest." What conflict of interest, I ask? As it turns out, our rep from the compounding pharmacy is the surgeon's daughter. The conversation between the pharmacy and my office regarding this conflict seems to have preceded my start date. Apparently, prior to my arrival, my NP colleague had pre-signed dozens such forms bearing her license and NPI number, and so there had been no need to involve me in the process. This colleague has since departed, and the pre-signed forms had all been used. There has been no conversation between the surgeon and me regarding this relevant history. The staff has apparently tried to protect me (knowing that I am kind of a by-the-book player on the team) by "forgetting" to offer the scar cream to surgical patients. The surgeon recently became quite vocal about her patients not getting the cream, and hence there is presently a bit of a pile up of such requests on my desk. I had indeed randomly signed a few of the scripts in the past, as the surgeon is out of the office most days (and indeed out of state Thursday afternoon through Tuesday morning). I just assumed there was a legitimate reason why a few scripts fell through the cracks during her absence and needed my signature. I now see a larger picture here. My thought is this: If it is conflict of interest for the surgeon to sign the scripts, then laundering them through me is equally a conflict. Alternatively, the vast majority of the patients sent to the OR with her are in fact, patients I have worked up and sent to her for surgical consult, so I am intimately involved in their care in that sense. Finally, I would point out that there is a compounding pharmacy within four miles of our office and sugi-center, so if access to scar cream is the issue, it could easily be solved by using this pharmacy. I am completely open to hearing that I am over reacting. Many thanks in advance for your perspectives on this. Link to comment Share on other sites More sharing options...
Avalon Posted February 11, 2018 Author Share Posted February 11, 2018 Yikes. Sorry for the misspelling of compounding. Haven't finished my coffee yet. Link to comment Share on other sites More sharing options...
sas5814 Posted February 11, 2018 Share Posted February 11, 2018 wow... there are several problems here but, for me, the bottom line is yes there is a conflict of interest. The old saying "the appearance of conflict of interest is conflict of interest" holds true for me. If the surgeon is your SP and he has a conflict of interest then you writing the same prescription, as a delegated authority, is also a conflict of interest. Having prescriptions pre-printed with your name and NPI creeps me out and is, in my mind, highly presumptive. I have had drug companies do that for me and I have them destroyed immediately. The simple fix, if the surgeon really feels strongly about this cream, is to find a different compounding pharmacy even if it is a mail order one, and use them. I had a similar issue several years ago with a PA who was seeing the SPs wife and routinely prescribing scheduled drugs. It wasn't a matter of whether or not the prescription was appropriate for the complaint. Here prescribing scheduled drugs for family members is a big no-no. The PA, who receives his authority from this SP, could be construed as doing the same thing. It didn't pass the sniff test. My specialty is seeing the worst case scenario. I see some kind of auditor seeing this and bad things following. Link to comment Share on other sites More sharing options...
UGoLong Posted February 11, 2018 Share Posted February 11, 2018 If the cream is really needed and the pharmacy cost is at least as inexpensive as competing pharmacies, I see no problem. If it’s cheaper locally, I’d have major problems. The fact that his daughter is the rep should not make it more likely or less likely that you would prescribe from the current pharmacy. Sent from my iPad using Tapatalk Link to comment Share on other sites More sharing options...
Miaow Posted February 12, 2018 Share Posted February 12, 2018 IANAL (Abbreviation I learned on Reddit; I am not a lawyer ), but this sounds shady to me. Like, it makes me feel icky reading it and I wouldn't be comfortable with it. I think maybe I would ask the company why they thought it was a conflict of interest for doctor (mom) to RX and then ask if there exists a similar conflict as you are technically attached to her license. I mean, sure, as a mom who doesn't want to give your daughter all your business but if you're possibly violating anti-kickback laws to do it then ... Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 12, 2018 Moderator Share Posted February 12, 2018 Solution. You write out the script(nothing prefilled), and attach a list of pharmacies where the script might be filled. Let your doc know you are doing this as you want to follow their direction, but also feel you need to allow the patients to chose their own pharmacy. Simple. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted February 12, 2018 Administrator Share Posted February 12, 2018 Is it more important that the patient get the specific compound, or that business be directed to that specific pharmacy? If the answer is the latter, then yes, there's a problem, and you've gotten some good advice above about how to deal with it. Link to comment Share on other sites More sharing options...
Guest ral Posted February 12, 2018 Share Posted February 12, 2018 Ral's Fact #37: You can write a prescription for two kicks to the head if you want. You are not allowed to say who does the kicking. Compounding pharmacies compound. Unless the one your patients are being directed to has some superior proprietary ingredient list, I would say you are skating on very thin ice. Had a local compounding pharmacy rep visit the clinic a couple of weeks ago. I asked if they make Newman's Nipple Cream. "We do, except I think ours is called Triple Nipple." "That'll work.", says I. Link to comment Share on other sites More sharing options...
BruceBanner Posted February 12, 2018 Share Posted February 12, 2018 No one "needs" scar cream. No one needs anything made by a compounding pharmacy IMO. Not that compounded topicals cant be useful, but I cant ever think of an instance where they were medically necessary. I've had quite a bit of experience with compounding pharmacies and they are---at best---semi-shady operations. Think about it: they use cheap Chinese substrate to compound a variety of controlled and non-controlled drugs (mostly topicals) and market themselves to practices who either give them a recurring prescription stream or "partner" with with practices where an arrangement is mutually beneficial. Occ Med groups, Derm groups, pain groups, etc. This is 100% conflict of interest and you are being used to launder these scripts. As far as the legality goes, I'm not sure, but your signature is no doubt generating revenue for the surgeon's daughter. Sticky situation. Link to comment Share on other sites More sharing options...
sas5814 Posted February 12, 2018 Share Posted February 12, 2018 Brucebanner I generally agree about compounding pharmacies, because there are a lot of shady ones making a lot of nonsense stuff, BUT there are some narrow exceptions in my experience. Trimix for ED...mostly used for prostatectomy patients and the like, has been a real quality of life drug for some of my patients. I used to have triamcinolone and eucerin cream compounded a long time ago...useful for a lot of things. Like most things it can be good or bad and which is which is usually a process of the do-er. Link to comment Share on other sites More sharing options...
lkth487 Posted February 13, 2018 Share Posted February 13, 2018 There's some pediatric specialty stuff that also needs a compounding pharmacy. To the OP, don't do it. I think it's ethically very dubious even if it was legal (and I'm not sure if it would be). If shit hits the fan, the surgeon may try to throw you under the bus and it's going to be your license on the line. Link to comment Share on other sites More sharing options...
Avalon Posted February 13, 2018 Author Share Posted February 13, 2018 Thanks to all for your thoughtful replies. I do appreciate it. I left the stack of unsigned scripts that had accumulated on her desk yesterday, with a note asking for a meeting and an explanation of why she could not sign them herself. This should force the conversation she has never found the need to have with me about the history and the ethics of the situation. During this meeting I can now use the wisdom, expertise, and solutions offered above by my colleagues. I'll let you know how it goes. Link to comment Share on other sites More sharing options...
BruceBanner Posted February 13, 2018 Share Posted February 13, 2018 20 hours ago, sas5814 said: Brucebanner I generally agree about compounding pharmacies, because there are a lot of shady ones making a lot of nonsense stuff, BUT there are some narrow exceptions in my experience. Trimix for ED...mostly used for prostatectomy patients and the like, has been a real quality of life drug for some of my patients. I used to have triamcinolone and eucerin cream compounded a long time ago...useful for a lot of things. Like most things it can be good or bad and which is which is usually a process of the do-er. I used to write for topical compounds all the time for chronic MSK pain patients. I've used them for ED as well. I once interviewed for a men's clinic that used Trimix almost exclusively; they had it compounded and sold it to patients for an incredible markup. Pure profit. Definitely some useful stuff can be made by them and it's another tool to have in the toolbox, if people can pay for it. Link to comment Share on other sites More sharing options...
camoman1234 Posted February 13, 2018 Share Posted February 13, 2018 Smells fishy, I would run fast and far. You might be digging your own grave with a possible litigation. Take the high road, it will not be worth it if your face to face to a judge try to explain yourself. Good luck! Link to comment Share on other sites More sharing options...
thinkertdm Posted February 13, 2018 Share Posted February 13, 2018 My favorite compound: (I actually compound it myself). Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 13, 2018 Moderator Share Posted February 13, 2018 On 2/12/2018 at 9:52 AM, BruceBanner said: No one "needs" scar cream. No one needs anything made by a compounding pharmacy IMO. Not that compounded topicals cant be useful, but I cant ever think of an instance where they were medically necessary. I've had quite a bit of experience with compounding pharmacies and they are---at best---semi-shady operations. Think about it: they use cheap Chinese substrate to compound a variety of controlled and non-controlled drugs (mostly topicals) and market themselves to practices who either give them a recurring prescription stream or "partner" with with practices where an arrangement is mutually beneficial. Occ Med groups, Derm groups, pain groups, etc. This is 100% conflict of interest and you are being used to launder these scripts. As far as the legality goes, I'm not sure, but your signature is no doubt generating revenue for the surgeon's daughter. Sticky situation. ionto and phonophoresis needs meds from a compounding pharmacy.... and they work..... just saying there is a few times when compounding is needed. Link to comment Share on other sites More sharing options...
cbrsmurf Posted February 13, 2018 Share Posted February 13, 2018 Compounding pharmacies are useful in ENT for medicated rinses. Pre-printed forms with your name and info are not unusual. It's common and convenient. There is an ethical issue with being patients being referred to a family-owned/related business. There may be a legal issue as well. I'm sure you can bring it up if you want, but you may be threatening your own employment. Link to comment Share on other sites More sharing options...
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