Here We Go Again, or: More Bad Ideas about Ancillaries

I’m just about through with the magazine Medical Economics. I’ve been a devoted follower ever since residency, when I used to find the occasional dollar bill stuck somewhere in one of the back pages. But now it seems that each issue is just more of the same old stuff.

Take the cover story of the current issue: “Grow Your Practice with Ancillaries,” such as labs, x-rays, behavioral health interventions, cosmetic services, and selling stuff. All the things they suggest fit neatly into one of three categories:

1. Things you should already be doing (whether or not you’re getting paid appropriately for them)
2. Things you shouldn’t be doing, and
3. Things no one should be doing.

The behavioral intervention discussed most often in this context is obesity counseling something all doctors should already be doing. Unsurprisingly, there’s big money in it. Unfortunately, the money usually goes to other parties. “Medical Weight Loss” is big business, with various companies all set up to provide all kinds of high-powered marketing, supposedly allowing doctors to turn their practices into money machines — for low low monthly fees of course. Oh, and the training seminars of course; can’t forget those. Better hurry up and join, though, because the geographic spacing is strictly limited. Someone else in your town may sign up before you, then you’re just shit out of luck.

Here’s what obesity counseling looks like: right here. I do it every day, many times a day. I’m even getting ready to launch an online service (really; I’ll get to it, I promise; got a lot going on right now; sorry for the delay) to do it personally. Is it easy? No. Does it take time? Of course. Do I get paid for it? Good question. Correctly using the E/M guidelines usually allows me to code the visit a level higher than if I hadn’t taken the extra 10-15 minutes. Do patients pay extra out-of-pocket? No. Would they be willing to? Ah, there’s the rub. Marketing magic is what makes people willing to pay more when they think they’re getting something extra. Are they? No, not really. But they think they are, which is why weight loss services are such a seductive ancillary.

This article, by almost exactly the same title, probably appears twice a year. In between, there are articles warning about the legal hazards of over-ordering certain services just because you can get paid more for them. This is the hidden cost of those in-office labs and x-rays. If you don’t have enough patient volume to justify on-site ancillary services, adding them adding them will never “grow” your practice. Think about it: which statement are you more likely to overhear:

• You should go to my doctor. He has x-rays and labs and stress tests and all kinds of things right there in his office.
• I’m looking for a new doctor. He’s always doing some lab or x-ray or test or something every time I go in, whatever I come in with.

News flash for everyone who thinks it’s the first: it’s not. Patients catch on quicker than we realize when they are being milked for every health care dollar we can squeeze from them. It’s been shown over and over that having lab equipment in the office results in more labs being ordered. Same for x-rays, though between the much-vaunted liability for misreading films and the notoriously poor insurance payment for them, by the time you’re through paying a moon-lighting radiologist to back up your interpretations, that x-ray machine isn’t going to end up netting you much. Bottom line is that if you don’t need to perform clinical ancillaries in your office, you shouldn’t be doing them.

Then there’s the issue of selling stuff, mainly weight loss program materials (diet food and drinks) and “nutraceuticals” (basically vitamins and supplements). No, no, and hell no. Can you say “Conflict of interest”, boys and girls? I’m no great fan of the AMA, but even they come out on this subject loud and clear:

In-office sale of health-related products by physicians presents a financial conflict of interest, risks placing undue pressure on the patient, and threatens to erode patient trust and undermine the primary obligation of physicians to serve the interests of their patients before their own.

Can’t get more unambiguous than that.

Then there’s the real crap: Reiki, energy medicine, acupuncture, age management, bioidentical hormones. People who tell themselves they’re doing “research-based” versions of that stuff are fooling themselves; the research sucks. From a scientific point of view, it’s worse than useless. The better that stuff looks in the “research”, the more poorly designed the studies are. All they’re doing is parting patients from their money, and convincing themselves that it’s okay to do so because “that’s what patients want”. If they don’t realize that they’re lying to their patients, then they’re lying to themselves, something I won’t do. No one should.

Bottom line: ancillary services should be used to sustain a practice, not to grow it.