Ethical Question - How Wouuld Have Handled This?

[jmj11]

Okay, this isn't a big deal as I'm loosing no sleep over it, but I'm just curious how you would see the case I'm about to present. It is also resolved, over, finished . . . so I'm not looking for advice now . . . just what you would have done.

 

Background: Oxygen inhalation is the mainstay 1st treatment for cluster headache attacks, but it still works only in about 50-60% of patients. It rarely works in migraine and I think for many of the migraine sufferers who claim it helps, it is more of a placebo. We have no clue how it works in cluster headache (or even if it works in migraine headache) but it has absolutely nothing to do with O2 sats.

 

I saw a new, out of town patient a few weeks ago. I love seeing patients like her. She has a horrible migraine problem and has been followed by several headache clinics without success . . . but she is highly motivated and has a positive attitude. She mentioned during our first visit that once before she had found oxygen inhalation helpful to abort attacks (when we combine it with self-injection of DHE 45). While I'm dubious about O2 in migraine, it wouldn't hurt and possibly could help. So I wrote an order for O2 in the same way I do for my cluster headache patients.

 

So, a few days later I get a fax from her oxygen supply center with an order that they want me to sign for overnight oximetery . I refused to sign in and wrote back, "Low oxygen sats have NOTHING TO DO with aborting a headache with oxygen. It is not indicated."

 

I got a fax back that the insurance won't pay for the oxygen if a overnight oximetery isn't done first. I wrote back, "Then forget it because the insurance company is an idiot (my words). I'm not ordering a test that has no value at all for what I'm doing."

 

I got a fax back from the oxygen supply company stating, "We know that most headaches are caused by low night time O2 sats and you must sign this order." I wrote back that the statement is total crap. I asked them to show me one study in the entire world saying that low O2 sats "cause migraine." And even if it did, it still would have nothing to do with using O2 to abort a migraine. It doesn't work by bringing low sats up to normal.

 

I saw the patient back yesterday. She is very reasonable. It turns out that the oxygen supply place actually did the overnight oximetery the first day she went in, and then were trying to cover their tails for the $200 procedure that they wanted to bill the insurance company for. They told the patient that I was being somewhat of a prick about it. Finally they called the patient's PCP and got the order signed by her.

 

I made my point to the patient and she understood. I was sorry about making things difficult but I see me signing off on a test that was billed to the insurance, a test that has NO VALUE, would be fraud on my end, even if it might have made things easier for the patient. How do you see it?

[rcdavis]

You did the right thing.

 

The PCP May have done an acceptable thing.. Thinking that , well, maybe she did desaturated... Sort of a true, true, and not related situation.

 

The insurance company, again, are the the "heavy", saying that they aren't going to pay for a drug for which their is no proven benefit, ( and which DOES have side effects). And ignoring your and the patient's observations that "hey.. The drug works for me".

 

The oxygen supply company is the unethical one.. For pushing for a test to justify the patient using their drug, when the test has no effect on the reason for the drug, other that the insurance company's requirements.

 

I am curious.. If she does not desaturated.. And does not have clusters, does " the fact that it works" fly with the insurance company?

 

If physassist and his ilk (" evidenced based medicine and protocols from on high") are correct... Never, never, never will a clinician like you be able to again try something which is out of the mainstream or unusual to help their patient...

 

Bad specialist PA, bad, bad.

 

You acted ethically.

[jmj11]

The oxygen supply place, in one of their letters, said that if they could show a low over night sats, they could get it approved for cluster or migraine. But it is stupid is stupid do (Forest Gump). It is like saying, if we can prove that you have PFO with an echo, we will pay for the Cleocin T Gel . . . totally unrelated.

[cupojava]

I also believe you did the right/ethical/legal thing.

If the PCP has other indication to do a nighttime oximetry (snoring, morning HA or possible sleep apnea) then that's his call. Often times, we are placed in this situation and there have been instances of PAs who have fraudulently involved with DME suppliers. Just read the news. I hope PA students and other readers learn from this.

[physasst]

You did the right thing.

 

The PCP May have done an acceptable thing.. Thinking that , well, maybe she did desaturated... Sort of a true, true, and not related situation.

 

The insurance company, again, are the the "heavy", saying that they aren't going to pay for a drug for which their is no proven benefit, ( and which DOES have side effects). And ignoring your and the patient's observations that "hey.. The drug works for me".

 

The oxygen supply company is the unethical one.. For pushing for a test to justify the patient using their drug, when the test has no effect on the reason for the drug, other that the insurance company's requirements.

 

I am curious.. If she does not desaturated.. And does not have clusters, does " the fact that it works" fly with the insurance company?

 

If physassist and his ilk (" evidenced based medicine and protocols from on high") are correct... Never, never, never will a clinician like you be able to again try something which is out of the mainstream or unusual to help their patient...

 

Bad specialist PA, bad, bad.

 

You acted ethically.

 

Not at all. Are there defined "best practices" for refractory migraines that have failed other treatments? Is there a defined decision tool or aid? Protocols and EBM work great in disorders that have defined best practices. But many disorders do not. Some do. What I have said, is that where there are best practice, EBM guidelines (think Ottawa Ankle), providers need to follow them.

 

To somehow extend that to say that ALL disorders need to be treated by protocol is a textbook definition of reductio ad absurdum....

[jmj11]

Another point I wanted to make, regarding the other discussion between rcdavis and phyasst is, as we all know, there is a big contrast between good evidence in evidence-based medicine and FDA approval. For FDA approval you need good evidence + 500 Million dollars (or more) for the required studies and hoops. So, there are still many things out there, such as O2 in cluster headache, that has good evidence-based medicine support . . . but will never get FDA approval because oxygen is not trademarked (man I wish I had the patent on oxygen and all you jokers had to pay me for each breath you take :=D: ) and no one has a financial incentive to do the big studies to get FDA approval.

 

Many insurers though, base their coverage on FDA approval, which takes away from our arsenal good treatment options . . . which brings us back to this case.