I suppose it would be more accurate to say that a war is waging; whether we decide to fight is still to be decided. At risk is who will provide drug testing for the US Department of Transportation’s (DOT) regulated industries (and other federal programs) and the vast private unregulated market. Indeed, drug testing is here to stay and it is expected to continue expanding into all avenues of our lives. Companies have determined that drug testing decreases accidents and theft and increases worker productivity and profitability. Workers have given up complaints of privacy intrusion in favor of working in a safe environment.
The DOT’s Part 40 regulations are generally considered to be the “gold standard” of drug testing programs. These regulations call for pre-employment, random, reasonable-cause, post-accident, follow-up and return-to-duty testing. When the “gold standard” is applied to the unregulated market, its easy to see why the revenue generated from the shear number of tests being performed has caused the battle lines to be drawn between health care providers.
DCs across the country have offered drug testing services in their offices for a number of years. As private industries initiate drug testing programs, there is a growing trend to require post-accident drug testing of injured workers. Physicians providing treatment of these injured workers need the ability to provide post-accident testing. Because cost conscience companies prefer “one site service,” the absence of drug testing services could eliminate a DC’s opportunity to treat worker’s compensation injuries.
Drug testing services can have a substantial impact on revenue. Not only does it provide an unending source of potential patients arriving at your office door.; unbelievably, you get paid for each visit. There are no insurance forms to fill out, no insurance companies to bill, and payment (in full) is received at the end of the month. Equally important, drug testing will set your office apart from other chiropractic offices and increase your practice diversity. Corporations have long recognized the increase in economic security through diversity of operations. Drug testing services not only offer a separate source of income, but a source not typically affected by the woes of the health care industry. Your professional reputation and recognition as an “expert” will increase. Rather than contend with other local chiropractors for patients, your office will compete with traditional health care providers who typically are not concerned with cost effectiveness.
DCs can provide three levels of drug testing services. The entry level involves extending collection services only. In this instance, your client is a company that has already developed their own policies and procedures for their drug testing program. Usually they will have already negotiated use of a laboratory facility and may have contracted a physician to review the test results. On a specific testing day, the company directs the selected donor (or applicant) to report to your office. Your office is only responsible for collecting and packing the sample for shipment to the lab. The typical charge is $10 to $20 per collection. Because office personnel can perform the collection procedure after 1-2 hours of training, the doctor’s daily routine is unaffected. A typical collection takes approximately 10 minutes.
The testing laboratory should provide all the required collection and shipping materials (except for protective gloves) and arrange for the sample’s transportation to their facility. Training for office personnel to perform the collection procedure is available through the testing laboratory. If the company does not have a designated lab or physician, you can use the laboratory of your choice. Although many local labs provide drug screening using immunoassay tests, they seldom have the equipment necessary to perform confirmation testing of positive samples. Reporting positive results without conducting confirmation tests using mass spectrometry/gas chromatography poses a high risk of litigation (most of which would be successful). Therefore local labs must send their positive samples to a larger facility when testing in the unregulated market. SAMSA-approved drug testing labs are federally regulated, have all necessary equipment, and are required by the DOT for federally regulated drug programs. The SAMSA-approved labs provide the highest level of service available at a price comparable to local labs.
There are a number of facility requirements to allow collection of urine in your office. However, almost any bathroom can be made into an appropriate collection facility, usually without any expense. Some areas of concern are: donor privacy, prevention of access to water, and control of access through doors or windows. Most of these reduce the threat of deception on the part of the donor. There are a number of cost-free fixes for these concerns. For example, you can limit access to water by removing the handles from the lavatory faucets when collecting samples.
There are several billing options available to the provider. Where a company has already made arrangements for a certain lab to be used, the collection fee is usually billed monthly directly to the company. However, if your office selects the lab, you may decide to charge a single rate for collection and testing. At the end of the month, the lab would bill your office for the tests performed.
In addition to collection services, a DC can provide a review of test results similar to a “Medical Review Officer” (MRO). The MRO designation is a DOT term for MDs and DOs providing services for federally regulated drug testing programs. Federal regulations currently require eight million workers to be enrolled in drug testing programs. Unfortunately, DOT regulations limit participation in the MRO program exclusively to MDs and DOs. However, a DC can provide these same services for the vast number of unregulated industries. Estimated as being ten times larger than the DOT regulated market, the unregulated market provides the largest potential for all physicians involved in drug testing.
The duty of a MRO in the DOT regulations (or a DC in the unregulated-regulated market) is to perform a verification (review) of test results. Negative tests results require little more than a paperwork review. However, in the case of positive results, the MRO must determine whether an alternative medical explanation is present before reporting the results to an employer. If an alternative medical explanation exits, the results are reported as negative regardless of the positive lab finding. There is a wide range of charges for MRO services. Part of this is due to the relatively low number of positive tests, and whether a MRO is contracted to review all results, or to review only the positives. For contracts that call for reviewing all results, the charges are typically in the $10 to $20 range. However, there are “pockets” such as California where competition has driven the rates down as low as $6 per test. For positive reviews only, the charge is typically more in the $40 to $60 range. This is due in part to the additional time required, but also due to the increased risk of litigation. Negative tests do not pose a significant risk of litigation.
MROs will review cases where an alternative medical explanation exists, but there is a possibility that use of a legal prescription poses a risk in safety sensitive positions. In those circumstances, the MRO should alert the company that a “fitness-for-duty” review should be performed.
There are a number of challenging areas for MROs performing the verification process. For instance, is it acceptable to terminate an employee because he used his wife’s prescription for his recent back injury? What happens to a truck driver who buys aspirin with codeine as an over-the-counter medication in Canada, but uses it in the US? Both of these situations indicate unlawful use, but should we make decisions based on the letter of the law, or the spirit of the law? It is interesting to note that there is about a 50-50 split in the MRO community on how these issues should be resolved. Legalized marijuana is another gray area. California’s law allows marijuana use with only a “recommendation” from a physician. Although DOT’s guidance remains unchanged, should an unregulated company terminate an employee for legal use of marijuana when not at work? Fortunately, the great majority of drug testing is not nearly this complex, however these issues clearly show the need for formal training.
In addition to MRO services, a DC can provide complete “turn key” drug testing programs for industry. In addition to a review of test results, the DC can provide management of the company’s consortium of employees. This would include management and selection of random, follow-up and return-to-duty testing, as well as maintenance of records and reporting requirements. This level of service is referred to as a “Third Party Administrator” (TPA). Collection may be performed in the DC’s office, or may be done by another collection facility. Regardless of the collection site, the results of unregulated tests are sent to the DC’s office who in turn reports the verified results to the company. In the regulated market, an independent MRO receives the test results and provides the test review services. The independent MRO must first notify the company of the verified results before distributing information to the TPA. Because of the reporting requirements and mandatory use of a MRO in the regulated market, TPA services in the unregulated market are less labor intensive and more profitable for DCs.
Because of the serious repercussions of a positive drug test to the worker (loss of job, reputation, etc.) providing a review of test results without formal training is fool-hardy for DCs, MDs and DOs alike. Equally important is keeping up-to-date with the rapid changes of the testing industry. Drug testing training is not presented as part of chiropractic school. No problem, it’s not included in medical or osteopathic school either. For this reason, the DOT is considering requiring formal training for all MDs and DOs serving as MROs in the regulated market. This rule-making change is part of a review of the DOT’s Part 40 regulations which outline the federal drug testing programs. Interestingly, this presents a rare opportunity to initiate a proposal to include DCs in the MRO program. The DOT is faced with opposition from the trucking industry over MRO training requirements. The trucking industry is aware that this change will result in fewer physicians choosing to provide MRO services. The result will be less availability and higher prices. Inclusion of DCs will increase the number of participants and provide the cost controls essential to trucking interest, while improving the competency of MROs as desired by the DOT. Discussion with the American Trucking Association indicates a general support of DC inclusion in the MRO program; however, they are not willing to carry the chiropractic “flag.” Our profession will have to be it’s own flag “bearer.”
The DOT proposed rule-making change is expected to be published in the Spring of 1998. After that time, the public will have 90 days to comment. It is better to be part of the proposed change than to depend on public comments to win inclusion in the MRO program. For that reason, letters of support from DCs and local trucking companies should be sent to the DOT. However, to obtain a serious review of DC inclusion, one of the national chiropractic organizations needs to prepare a formal proposal for the DOT. The DOT views their letters with considerable interest as they represent a significant portion of the profession. Contact your association to request action.
Given that the regulated industries represent only one tenth of the drug testing market, why should we bother to be concerned with the DOT’s MRO program? The problem arises from individual state legislatures. Many states are drafting legislation to deal with the considerable amount of drug testing occurring in their state. Unfortunately, several states (with the help of medical providers) have found it easiest to follow the federal guidelines for their statues. Being excluded from the federal guidelines therefore locks DCs out of both the regulated and unregulated markets. This is particularly detrimental because of the increasing interest in expanding drug testing to work injuries, school teachers, students, and workers in nearly all occupations. There has even been discussion at the White House of requiring drug testing for teenage driver’s licenses. Check your local paper or TV news I’ll bet you’ve seen or heard something about marijuana, methamphetamine, heroine, drug abuse, or drug testing within the last month. Fortunately, DCs who are already performing drug testing (similar to an MRO) can testify to state legislatures that drug testing is part of the state scope of practice. The more DCs involved, the less likely this degradation of our scope of practice will occur in your state.
Are you looking for a way to increase your revenue? Tired of fighting insurance companies? Tired of not getting paid? Would you like to diversify your practice? Consider enlisting into the “war on drug testing.” Compared to other “practice building” techniques, nothing else even comes close.
Michael John Megehee, DC, graduated from Brigham Young University in Provo in 1976 with a Bachelor of Science degree. He worked as an engineer in the oil industry until entering Western States Chiropractic College in 1987 and graduated with honors (Cum Laude) in 1990. He has operated and practiced at the Blue Mountain Chiropractic Clinic for the past seven years and is an instructor of Anatomy and Physiology part-time at the Blue Mountain Community College in Pendleton, OR. Dr. Megehee completed the Alcohol Testing and Substance Abuse Evaluation and the Medical Review Officer Training Program from the American Association of Medical Review Board Officers. Dr. Megehee is a DOT-certified Breath Alcohol Technician (BAT) and is a certified BAT instructor for a national manufacturer of alcohol testing equipment. He owns and operates Chiropractic Occupational Services (COS), which provides State Board of Chiropractic Examiner-approved training titled, “Drug and Alcohol Testing for the Chiropractic Physician” and provides DOT-approved BAT and Screening Test Technician (STT) certification for Doctors of Chiropractic. COS provides chiropractors with a national SAMSA-approved drug testing laboratory, a contract MRO (for DOT testing) a national account with a major manufacturer of alcohol testing equipment and a monthly newsletter. Please contact COS at 541-276-1938.