Can a doctor refuse to give an Rx?

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Greetings good doctors.
Recently, a friend of mine visited his local DPM with an accessory navicular on his pronated feet. The doctor, here in NYC told him he needed orthotics and offered to cast his feet.
My friend did not wish to spend the amount the DPM would charge for the orthotic and asked for an Rx so he may shop and compare.
The DPM, told him that his orthotics were best, and that he should get them through him. The patient declined, but asked for his Rx, which he thought was his right.
The DPM became defensive and refused to give the patient his Rx stating that the patient would not get the right device for his condition, and that again, his device was best.
Is this wrong? Can a DPM refuse to give a patient an Rx because the DPM wishes to fill the Rx his/herself? What recourse does the patient have besides not going to the DPM again?
Thanks,
Spencer B. Weisbond, C.Ped.

 

Spencer:

Physicians are not required to give the patient a prescription for an orthosis or a medicine, if the physician does not feel it is indicated. In this case, there is no recourse that I know of for the patient, other than seeing another podiatrist or another physician and asking them for a prescription.

If this is a friend of yours, then I don't understand why you need a prescription to make him a pair of orthoses, other than to bill the insurance for your services.

 

Thank you Kevin.

I asked my friend to get an Rx for several reasons.

1. I am bound by the board that certified me. They state that I must have an Rx before I produce or dispense any device. I respect that rule and always ask that patients who see me have an Rx, even when actual state law says that I can do pretty much anything. However, I evaluate and create options. If the case is over my head, I refer to several skilled DPMs or MDs
(1. Thomas Novella, DPM)

2. Although I could see what this patient obviously needed, there may have been something in his case that I was unaware of, and that his DPM could have informed me via his Rx.

3. Tax purposes. I don't have to charge tax on items I fabricate if there is an Rx with it. I was trying to save him additional $.

Doctor, thank you for your timely response. I asked what my friend's recourse could have been only because he was SO adamant in finding out if he could write a letter to someone. It had nothing to do with me. Although now I can see that not too many DPM's would wish to "rat out" any another doctor. That is not the case. This case now is purely hypothetical.

Back to my original question. You said "Physicians are not required to give the patient a prescription for an orthosis or a medicine, if the physician does not feel it is indicated."

This DPM told the patient orthotics were most surely indicated, then minutes later the same DPM was refusing to issue an Rx. That is what I am really asking about. Can a DPM tell a patient that orthotics are necessary, then tell that patient that he can't have an Rx, only because that DPM wants to fill that prescription?

Here in NYC, there is somewhat of a weird relationship between DPM's and skilled orthotic fabricators like myself. The DPM in question knew that the patient was going elsewhere.

This was is a touchy situation. Since this case is months old, bad feelings have long since frozen over. The patient got a full contact, EVA mold device with bilateral high medial flanges with navicular depression and 4 degrees of extrinsic rearfoot varus post. He is comfortable, and the inflammation on the medial aspect of his affected foot has subsided.

Were my devices better than his DPM? We may never know. Will the patient find out? Never.
Any further insight you can give would be greatly appreciated. I thank you for your reply in the first place.

Sincerely,

Spencer B. Weisbond, C.Ped.
Orthotic Solutions LLC

 

Spencer:

I have been placed in the same situation with insurance companies that will approve foot orthoses but only from a brace shop that they have a contract with, instead of the orthoses that I would make for the patient. I wish I could say that the foot orthoses coming from these brace shops are the best thing for my patient, but many times they are not. Maybe the podiatrist in question just doesn't know what type of quality of orthosis you produce or maybe he doesn't want to send away business to another provider.

As you probably know, foot orthoses can range in therapeutic effectiveness from those that hurt the patient to those that positively impact their lives for many years, even though they are all still called "orthotics". The health care provider, if ethical, needs to give the patient the best advice in order to help them heal their injury and carry on positively with their lives. If the health care provider doesn't feel that the foot orthosis coming from another provider would benefit the patient, then they should let the patient know this. However, in my clinic, I will still give the patient the prescription for the orthoses, but I will do so with a warning to the patient that not all foot orthoses are alike in quality and comfort. Therefore, if they come back to me complaining that the orthoses that I reluctantly prescribed for them made them worse or no better, then I will tell them I tried to warn them of this before they made their decision to go elsewhere for their foot orthoses.

 

The DPM could perhaps also argue that the actual prescription is his "intellectual property", seeing as he has done the necessary assessments and formulated the treatment plan.

Would any other profession (think Financial Planner, Lawyer, Investment Banker, Advertising/Marketing Exec.) after they've done a client assessment, hand over every last detail of their plan, without a binding contract for completing the service in place?

Of course not.

How does Intellectual Property Rights come into play in medical practises?? Do they have a place?

 

Thank you for your view.
I understand your comparison. However, the doctor was paid for his time. He gave his opinion and when it came time to put his opinion on paper, he refused.

I do agree that the DPM can state that the proper prescription was his intellectual property but we are not talking about the cure for cancer here. When an orthopaedist prescribes a custom knee orthotic, does he argue that the Rx must be filled with his office? He may advise the patient which orthotist makes the best product.

Don't get me wrong, I do agree with your statement, and I thank you for posting it. However I feel that this situation was more a concern of lost revenue than a concern of the best care for the patient. That was just the excuse.

In the end, what did the DPM actually get? One office visit charge, and one less patient.
If he had issued a prescription, he may have had that patient forever, and enjoyed that patient's recommendations for years to come.

I sometimes get referrals from DPM's to modify their patients shoes. When the patients are in my office, I NEVER try to sell them my orthotics and I decline if the patients ask me to make their next pair of orthoses out of respect for the DPM. It would be nice if it went the other way too.

Thanks again,
Spencer B. Weisbond, C.Ped.

 

Prescription

I have many concerns with orthotics and prescriptions. First and foremost I feel they are grossly overused. There are several providers in my area who blanketly give orthotics to EVERYONE. Since I practice in an area where the majority of the businesses are self funded (have their own payment plans), these providers were found out with audits and expelled from the plans. In fact the companies came to ME PERSONALLY to monitor the orthotic benefit which is one pair per member with only a small copay.

One of these members was in with her parents a few months ago INSISTING that I gave BOTH of them orthotics on the plan. She had been to one of the expelled podiatrists and got her pair. Neither one of them had ANY foot complaints whatsoever, NONE, not even a pimple, and tried for nearly an hour to tell her they didn't need them (they don't speak english). Reluctantly I casted both of them. A month or so after they were dispensed, and they got the bill for the copay, all three of them came to the office complaining they didn't like them, and didn't want to pay the copay. In fact, the father actually threw them towards me. Luckily I kept calm about it. On a bad day there could have been an issue here. I know for a fact the original doc was waiving copays by the way. I told them they didn't need them, but they insisted, so therefore I gave them the devices. Furthermore I told them to keep the copay and to not return to the office for any reason whatsoever. Frankly I have an entire shelf of these things that patients never picked up, and if I didn't have to use them for certain things (by insurance mandate) I would never cast for another pair. By the way, I use a VERY reputable national orthotics lab.

Finally, I often write prescriptions for certain types of devices such as accomodative insoles, diabetic insoles etc. since the prosthetists stand behind their devices and will replace and or repair as needed.