Narcotics Maximus

[weezianna]

I am working a temp gig at a VA clinic.  I am being asked to refill/sign for what I believe is an extraordinary number of narcotic prescriptions.    I work in one of a number of rural clinics.  The requests are coming out of a clinic located about 2 hours from my location.

The doc in that office doesn't have a working ID card, and is unable to sign for these rx's electronically, so he is sending them all to me.  I have never seen or treated these patients, and I am getting about 10 requests a day, some for prescriptions in excess of the recommended MED.  I am very uncomfortable with this, and questioned the practice.  A pharmacist told me this practice is a no-no.  When the CBOC coordinator was informed, she sent an email stating that the Chief of Staff approved this practice as it is "like covering for someone on vacation".  

The doc in question has stated that he wants me to rx the meds as written.  He is not my supervising physician.  I am reluctant to continue to rubber stamp narcs.  I have always believed that a provider should never be forced to prescribe narcotics, but here at the VA I believe there is a lot of pressure to avoid any controversies with vets.  The doc in question can solve this problem by writing the rx's out and getting them to the VA pharmacy same day, or driving 6 hours to the main hospital to replace his ID.

Whom do I call first, the OIG or the DEA?

I appreciate your comments.

[Boatswain2PA]

Oh hell no.  Call IT and get him a working card.

[sas5814]

Big bag of nope. It doesn't matter who approved it. This is wrong, possibly malpractice, and completely indefensible if someone has a bad outcome. Let the guy who approved it do it.

[CAdamsPAC]

If it is so important that these narcs be refilled, why hasn't the physician gotten his card working? Since your name will be connected to  questionable prescriptions, you are the one who will be held responsible! I can hear the denials from the physicians at various levels and the pharmacist saying I told him not to do it when the fit hits the shan and it will someday!!! Do the right thing , practice good medicine and look out for you since it seems no one else is or will.Put your concerns in writing to the Medical Director, Medical Staff Office, Pharmacy Director along with the other appropriate governmental agencies.

[weezianna]

Thanks for your replies, confirming my thoughts.  I have already reached out to the pharmacy director; the Medical Director has actually condoned the practice.  Next step is the state medical board and the DEA and OIG.

The physician in question is supposed to get his ID card by the end of the month, but has enough time to go on vacation next week.

[rev ronin]

If someone doesn't have an ID card, how do you know that he or she is credentialed to refill narcotics?  Have you seen his/her DEA cert?

[weezianna]

The provider is credentialed with the VA, but their ID card  died, and without it, you cannot electronically sign for controlled substances.  The problem can be fixed by having them take a day or two to travel to the parent VA and get a new card.  In the interim, they could hand write the rx's and they'd be delivered by courier to the main pharmacy on a daily basis.  Patients are not going to suffer by my refusing to sign all these narcs, but they are pushing the point.  I wonder if they'd be a problem if I weren't a PA, as there are docs in the system who have refused to do this in the past.

 

[Cideous]

On 8/10/2018 at 9:02 PM, Boatswain2PA said:

Oh hell no.  Call IT and get him a working card.

Can I get an Amen here?

Hell no today and twice on Sunday.  You are under dire danger my friend especially in this climate.

Ask yourself this question....How bad do you want to be on "Action News 26!?", because that's where you are headed.

[weezianna]

2 hours ago, Cideous said:

Can I get an Amen here?

Hell no today and twice on Sunday.  You are under dire danger my friend especially in this climate.

Ask yourself this question....How bad do you want to be on "Action News 26!?", because that's where you are headed.

I feel the same way, and that's why I have refused to do this.  I have never encountered this type of mess before, and appreciate the supportive and corroborating comments.  Will let you know when the other shoe drops. 

 

[True Anomaly]

Not sure if the state medical board would have any say on this considering it's through the VA.  But your other pursuits are worthwhile.

Bottom line is that it is absolutely 100% illegal to be practicing medicine without having being delegated from a physician, or having some sort of legal relationship with a physician.  Even in Michigan, the highly-touted state where OTP is law, it still requires some sort of relationship with a physician.  If you have literally no relationship at all, on paper, with this physician, doing anything for him/her is illegal.

[ventana]

I have not worked for the VA but get my care there and have tried for 15 years to get hired there.

 

They are one interesting backwards agency

 

This is how I would handle it

1) write a formal request for opinion to your medical director -  get them on record with a medical opinion

2) if they say it is against policy - simply stop doing it.  State that your director has said you are to no fill them

3) If this other doc tries to force you refer them to your director

4) if they director then changes stance I would then state that you are not comfortable with it and that you have a responsibility to protect your own license.  Offer to take a drive to the clinic a few times a week - in a government vehicle, on the clock, to meet with the patients before refilling.  You are showing a willingness to help, not being a D*** and trying to help the team - while not allowing yourself to be bossed around

5) if the above does not work and the director tells you to do it..... (and I would mention you need to also be consulting you SP as that is the person likely responsible for your script and in fact might even overrule the medical director as it is the practice of medicine)  Well then i would look at the regulatory bodies - but this is sort of scorched earth policy and you are likely going to be fired and black balled...

 

 

A  thought - have you just picked up the phone and called the offending doc and told them you will no refill these scripts? and why?  sometimes facing it head on helps (but have a witness as the doc might pull out the Doc v PA card and sink you)

 

 

As a final thing - yes i have refilled (on comfortably so) high dose scripts for when a doc was on vacation (for a week or so, no a month!) and it is indeed common practice in my area.  So be careful as there are more land mines out there

 

 

Finally - how old are you, how many years in practice, and how long at VA?  (no need to answer specifics but these might influence how you are treated)   ie  young, new hire you might not have much to stand on in their eyes, versus crusty old been around the block, been at the VA for 20+ years and have a solid reputation.....

 

 

 

 

and finally - going outside the chain of command might be necessary, but might end your career at the VA - same for involving regulatory agencies (and that is a step you only take in dire situations cause you would not want it done to you)  The other doc might just need remediation....

[weezianna]

Thanks, ventana for your comments.  I see the land mines here.  I am actually  VA-retiree working as a contractor at a VA.  Besides the VA hieracrchy, I will also be dealing with the company that hired me and their motivations to preserve their business interests.

Will post an update - again, thanks to all for their comments and insights.

[CAAdmission]

Someone here has problem transferral disorder. They are trying to make their problem your problem. 

You're nice if you just say no. My response would have been "F*** off!"

[Boatswain2PA]

On 8/12/2018 at 12:24 PM, weezianna said:

The provider is credentialed with the VA, but their ID card  died, and without it, you cannot electronically sign for controlled substances.  The problem can be fixed by having them take a day or two to travel to the parent VA and get a new card. 

Anyone who thinks we should have a nationalized healthcare system should reflect on this, how large of a bureaucracy would be needed to have that, how how dysfunctional that bureaucracy would be for providers and patients.

So, some time ago some Vice President of Informational Systems Security for Electronic Health Records (who makes $250k/year and will retire with a $150k pension after 15 years) thought it would be a good idea for everyone to use the VA card to rx narcotics.  Ok, makes sense.

Meanwhile, the Vice President of Informational Technology Procurement (with same pay and pension) decided that they will only issue ID cards at major VA centers.  Ok, makes sense.

Until you put the two things together....whoops!  

[EMEDPA]

6 minutes ago, Boatswain2PA said:

Anyone who thinks we should have a nationalized healthcare system should reflect on this, how large of a bureaucracy would be needed to have that, how how dysfunctional that bureaucracy would be for providers and patients.

I think many other nations have shown that this can be done well at a lower cost than pay for service options. Today many Americans are already covered under govt programs:

medicare, medicaid, IHS, Tricare/VA

So we have everyone over 65, low income folks, military members/retired military, Indian and Alaska natives. That leaves out most working people18-64 years old. I don't know if medicare for all is the answer, but consider that the US is the only developed nation without some form of centralized health care system.  France and Germany would certainly be good models. Canada and the UK are not bad, with the exception of long waits for elective procedures(this is also seen in some US systems like the VA where it can take months for something like a hip replacement).  we rank 10th or 11th out of 11 developed nations studied on most health care benchmarks:

https://www.commonwealthfund.org/chart/2017/health-care-system-performance-rankings

[Reality Check 2]

I have been watching this thread and thinking about it. I work for the VA.

The card in question is a PIV card. An ID card with a chip in it. It has to be in the keyboard or reader thing to make your system work. They are fraught with issues and have an expiration date. You often have to rub a pencil eraser over the chip to clean it. When you write a controlled Rx - it pings the card and then you have to enter a couple of secret squirrel codes to verify yourself to get the Rx processed. Very little is on paper at the VA. 

However, there is ZERO excuse for anyone who works for the VA to not have a working PIV card. He can drive to the mothership and get a new one - they will freaking pay him to go if he is that picky. It can take a few hours.

Thankfully, my campus has a full HR dept and make their own. Ours work more than not. 

I have a lot of concerns for this situation. Currently, I CANNOT write a narcotic prescription for over 50 MEDD without a separate note in the chart or a terminal diagnosis. EVERYONE has to be on a taper to get below 50 MEDD or the pharmacy just won't fill the Rx. The pharmacy is also under federal mandate to not fill benzos and narcs together without a terminal diagnosis or some sort of blessing from psych that this is the only way things work.

I have had Rx's stopped DEAD in the pharmacy because they were over 50 MEDD or the patient has a benzo on the books. Hell, the VA will NOT give out Viagra if you have a NTG Rx in your record.

So, something here stinks to high heaven.

NO PROVIDER should have carte blanche to fill narcotics at stupid and outrageous levels. The Medical Director has NO authority to say it is ok. 

I would stop filling them. NOW. Call the actual Chief of Staff over the whole facility - who is usually a doc. 

The state board won't care - this is federal. 

But, stop signing them. Call the Chief of Staff and get someone to look at at this. It just doesn't seem possible. 

I am feeling more and more lucky to have great admin that supports us and we aren't asked to do weird stuff like this.

Stay strong!

[GetMeOuttaThisMess]

I think many other nations have shown that this can be done well at a lower cost than pay for service options. Today many Americans are already covered under govt programs:

medicare, medicaid, IHS, Tricare/VA

So we have everyone over 65, low income folks, military members/retired military, Indian and Alaska natives. That leaves out most working people18-64 years old. I don't know if medicare for all is the answer, but consider that the US is the only developed nation without some form of centralized health care system.  France and Germany would certainly be good models. Canada and the UK are not bad, with the exception of long waits for elective procedures(this is also seen in some US systems like the VA where it can take months for something like a hip replacement).  we rank 10th or 11th out of 11 developed nations studied on most health care benchmarks:

https://www.commonwealthfund.org/chart/2017/health-care-system-performance-rankings

 

My only concerns are 1) a lot fewer folks in those other countries, and 2) how to pay for it. Population is aging and fewer worker bees to pay for it. Hypothetically, if you took away the middle man and applied actuarial evaluation to see what the cost would be, I wonder how that would compare to the working class insurance premiums currently being paid by employers/working class and OOP expenses.

[EMEDPA]

we certainly would need to reign in the pharmaceutical industry. there is no valid reason that an albuerol inhaler should cost $6 in Haiti or Cuba and $65 dollars here. We also need to look at care in the last year of life, which accounts for 50% of all health care dollars spent. this may sound harsh, but if someone is 95 years old and has liver cancer metastatic to colon, lung, brain, and pelvis I am all for palliative care to involve surgery, radiation, etc, but spending $150,000 on an experimental drug that may prolong life for 3 months does not seem like an appropriate use of health care resources when we have kids not getting vaccinated and women not getting mammograms. I know someone will scream death panels, but this is really not about killing people, but focusing on keeping people healthy. If I am that 95 year old someday, please just let me die.

[GetMeOuttaThisMess]

I’ll take 80 if there’s no quality of life.

[EMEDPA]

my mom will be 90 in 2 years and has told us "no heroics". I think she will probably make 100 as her older brother, a long time smoker and drinker made it to 89(retired from the practice of law at 87),  and mom does neither and exercises every day.

[CAAdmission]

3 hours ago, EMEDPA said:

I think many other nations have shown that this can be done well at a lower cost than pay for service options. Today many Americans are already covered under govt programs:

medicare, medicaid, IHS, Tricare/VA

So we have everyone over 65, low income folks, military members/retired military, Indian and Alaska natives.

They may be covered, but are we proud of the quality of care they receive? Government oversight may just mean crappy care for everyone instead of just the populations listed above.

 

2 hours ago, EMEDPA said:

we certainly would need to reign in the pharmaceutical industry. there is no valid reason that an albuerol inhaler should cost $6 in Haiti or Cuba and $65 dollars here. 

This is definitely an issue. My only concern is that if society makes a stink, they are much more likely to raise prices in Haiti than lower prices in the US!

[thinkertdm]

47 minutes ago, CJAdmission said:

This is definitely an issue. My only concern is that if society makes a stink, they are much more likely to raise prices in Haiti than lower prices in the US!

Right now, a pharmaceutical VP is considering his windfall...the only problem is that 6$ in Haiti is the same as 65$ in the US.  Probably more. 

[jmj11]

NWiH (as in "no way in hell") as a practice accident waiting to happen.

[weezianna]

10 hours ago, Reality Check 2 said:

I have been watching this thread and thinking about it. I work for the VA.

The card in question is a PIV card. An ID card with a chip in it. It has to be in the keyboard or reader thing to make your system work. They are fraught with issues and have an expiration date. You often have to rub a pencil eraser over the chip to clean it. When you write a controlled Rx - it pings the card and then you have to enter a couple of secret squirrel codes to verify yourself to get the Rx processed. Very little is on paper at the VA. 

However, there is ZERO excuse for anyone who works for the VA to not have a working PIV card. He can drive to the mothership and get a new one - they will freaking pay him to go if he is that picky. It can take a few hours.

Thankfully, my campus has a full HR dept and make their own. Ours work more than not. 

I have a lot of concerns for this situation. Currently, I CANNOT write a narcotic prescription for over 50 MEDD without a separate note in the chart or a terminal diagnosis. EVERYONE has to be on a taper to get below 50 MEDD or the pharmacy just won't fill the Rx. The pharmacy is also under federal mandate to not fill benzos and narcs together without a terminal diagnosis or some sort of blessing from psych that this is the only way things work.

I have had Rx's stopped DEAD in the pharmacy because they were over 50 MEDD or the patient has a benzo on the books. Hell, the VA will NOT give out Viagra if you have a NTG Rx in your record.

So, something here stinks to high heaven.

NO PROVIDER should have carte blanche to fill narcotics at stupid and outrageous levels. The Medical Director has NO authority to say it is ok. 

I would stop filling them. NOW. Call the actual Chief of Staff over the whole facility - who is usually a doc. 

The state board won't care - this is federal. 

But, stop signing them. Call the Chief of Staff and get someone to look at at this. It just doesn't seem possible. 

I am feeling more and more lucky to have great admin that supports us and we aren't asked to do weird stuff like this.

Stay strong!

I've worked at different VAs and administrations range from pretty good to abysmal.  At this location, pharmacy hasn't batted an eye when a patient was rx'd 180 MEDD.

You get the PIV card issue.  It should be an easy fix - just take the day or two off and go and get it.  I don't know why they're dragging their heels on this.   This doc seems very fixed on making sure that there are no veteran complaints and I wonder if someone is putting pressure on him.  He is away this weekend and an NP who fills in from time to time is signing all his narcotic requests

I received an email from the medical director saying that there should be no problems signing for someone else's narcs, as it's "just like someone was on vacation". so it is indeed possible.   

A piece of the puzzle is missing and I will find out what it is.

[CAdamsPAC]

10 hours ago, EMEDPA said:

we certainly would need to reign in the pharmaceutical industry. there is no valid reason that an albuerol inhaler should cost $6 in Haiti or Cuba and $65 dollars here. We also need to look at care in the last year of life, which accounts for 50% of all health care dollars spent. this may sound harsh, but if someone is 95 years old and has liver cancer metastatic to colon, lung, brain, and pelvis I am all for palliative care to involve surgery, radiation, etc, but spending $150,000 on an experimental drug that may prolong life for 3 months does not seem like an appropriate use of health care resources when we have kids not getting vaccinated and women not getting mammograms. I know someone will scream death panels, but this is really not about killing people, but focusing on keeping people healthy. If I am that 95 year old someday, please just let me die.

Why are pts with "End Stage" anything being admitted to the ICU?